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The neurosignature 32 MELZACK AND KATZ pattern is also modulated by sensory inputs and by cognitive events discount tadapox 80 mg visa, such as psychological stress buy tadapox 80mg amex. Furthermore, stressors, physical as well as psycho- logical, act on stress-regulation systems, which may produce lesions of muscle, bone, and nerve tissue, thereby contributing to the neurosignature patterns that give rise to chronic pain. In short, the neuromatrix, as a result of homeostasis-regulation patterns that have failed, may produce the de- structive conditions that give rise to many of the chronic pains that so far have been resistant to treatments developed primarily to manage pains that are triggered by sensory inputs. The stress regulation system, with its complex, delicately balanced interactions, is an integral part of the multiple contributions that give rise to chronic pain. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury or other tissue pathology and to- ward the concept of pain as a multidimensional experience produced by multiple influences. These influences range from the existing synaptic ar- chitecture of the neuromatrix to influences from within the body and from other areas in the brain. Genetic influences on synaptic architecture may determine—or predispose toward—the development of chronic pain syn- dromes. Multiple inputs act on the neuromatrix programs and contribute to the output neurosignature. They include (a) sensory inputs (cutaneous, vis- ceral, and other somatic receptors); (b) visual and other sensory inputs that influence the cognitive interpretation of the situation; (c) phasic and tonic cognitive and emotional inputs from other areas of the brain; (d) in- trinsic neural inhibitory modulation inherent in all brain function; and (e) the activity of the body’s stress regulation systems, including cytokines as well as the endocrine, autonomic, immune, and opioid systems. We have traveled a long way from the psychophysical concept that seeks a simple one-to-one relationship between injury and pain. We now have a theoretical framework in which a genetically determined template for the body-self is modulated by the powerful stress system and the cognitive functions of the brain, in addition to the traditional sensory inputs. Phantom limb pain in amputees during the first 12 months following limb amputation, after preoperative lumbar epidural blockade. Contribution of central neuro- plasticity to pathological pain: Review of clinical and experimental evidence. Changes in the effects of stimula- tion of locus coeruleus and nucleus raphe magnus following dorsal rhizotomy. Pre-emptive lumbar epidural anaesthesia reduces postoperative pain and patient- controlled morphine consumption after lower abdominal surgery. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Pre- emptive analgesia: Clinical evidence of neuroplasticity contributing to postoperative pain. Characteristics of the bursting pattern of action potential that occurs in the thalamus of patients with central pain. Abnormal single-unit activity recorded in the somatosensory thalamus of a quadri- plegic patient with central pain. Spread of saphaneous somatotopic projec- tion map in spinal cord and hypersensitivity of the foot after chronic sciatic denervation in adult rat. Post-operative orthopaedic pain—The effect of opiate premedication and local anaesthetic blocks. Prolonged relief of pain by brief, intense transcutaneous somatic stimula- tion. The gate control theory 25 years later: New perspectives on phantom limb pain. Sensory, motivational and central control determinants of pain: A new conceptual model. Phantom limbs in people with congenital limb deficiency or amputation in early childhood. Phantom body pain in paraplegics: Evidence for a central “pat- tern generating mechanism” for pain. Effects of discrete brainstem lesions in cats on perception of noxious stimulation. Philosophical Transactions of the Royal Society of London, 308, 219–226. A map of serotonergic structures involved in stimulation produced analgesia in unrestrained freely moving cats. Surgery in the rat during electrical analgesia induced by focal brain stim- ulation. Analgesia produced by electrical stimulation of catecholamine nuclei in the rat brain. Postoperative pain after inguinal hemiorraphy with different types of anesthesia. The effect of peripheral nerve injury on dorsal root potentials and on transmission of afferent signals into the spinal cord. Chronic peripheral nerve section diminishes the primary affer- ent A fibre mediated inhibition of rat dorsal horn neurons. Asmundson Faculty of Kinesiology and Health Studies and Department of Psychology, University of Regina Kristi D. Wright Department of Psychology, University of Regina If we liken models of pain to facial displays of emotion, it becomes readily apparent that many expressions have evolved. Indeed, over the years there have been a large number of models proffered by individuals from varying intellectual traditions. Most of these models can be grouped within one of several general categories—traditional biomedical, psychodynamic, and biopsychosocial. The intent of all models, without exception, has been to address the enduring questions of “What is pain? To date, there have been a number of reviews written on biopsycho- social approaches to pain (e. Nonetheless, the face of pain, or at least the way we as clinical and research psychologists view it, is constantly chang- ing. Indeed, many of the earlier models have proven inadequate for patient care, and more recent research has superseded initial formulations.
Although the flexion contracture can be surgically corrected by an extending osteotomy or an arthrolysis procedure buy generic tadapox 80mg line, it has been clearly shown that the b range of motion is not thereby improved cheap 80mg tadapox visa. The 4th/5th digits on the right have already little finger can also prove troublesome. Syndactylies on adjacent fingers should never be separated Clinodactyly during the same operation as this would jeopardize the circulation Clinodactyly involves a deviation of the finger in the fron- tal, i. While the little finger is usually affected, a triphalangeal thumb is also often present. If pronounced angulation is present the condition is described as a delta phalanx. This is the result of abnormal epiphyses, which are rotated around the metaphysis in a C-shape, and is clearly visible on an x-ray. In the event of marked deviation, an osteotomy can restore the normal anatomical configuration. Tendovaginitis stenosans (»trigger finger«) Tendovaginitis stenosans almost always affects the thumb and involves a narrowing of the tendon sheath (or pulley) of the flexor pollicis muscle. This produces thickening of the tendon, which can only be drawn through the pulley after overcoming a certain resistance. Weakness or hypoplasia of the extensor pollicis muscle is also fre- quently present however. A flexion contracture of the metacarpophalangeal joint is also occasionally observed. The condition can be left untreated during the 1st year of life since 30% of the contractures resolve spontaneously. Radioulnar synostosis in severe pronation in a 6-year old In the other cases, simple surgical opening of the pulley boy (annular ligament release) will suffice. Function must be carefully ever, physiotherapy may be needed to stretch the finger. The mobility may be worse in never occur after an annular ligament release, although a one of the two partners than the other. The radiographic reduction in interphalangeal mobility remains in approx. The risks of this procedure include the development incidence in the white population of approx. The frequency in the black population (particularly of the postaxial form) is roughly ⊡ Table 3. A Brazilian (According to Wassel) study calculated a prevalence of 143:100,000 in a popula- tion with a relatively high proportion of black individuals Type Characteristic features Frequency. The duplication of the little finger is usually inherited I Split distal phalanx 2% as an autosomal-recessive condition and is often part of a syndrome. The duplication of the thumb, on the other II Bipartite distal phalanx 15% hand, is not usually hereditary, although familial oc- III Split proximal phalanx 6% currence has been described. IV Bifid proximal phalanx 43% Classification V Split metacarpal 4% The traditional classification is as follows: VI Bifid metacarpal 20% ▬ Preaxial: Duplication on the side of the thumb ▬ Central or axial: Duplication in the area of the 2nd– 4th fingers ▬ Postaxial: Duplication on the side of the little finger The commonest forms of polydactyly are postaxial. Pre- axial duplications are slightly less common, while the axial type is extremely rare. Classification according to Blauth Classification in two directions: longitudinal and trans- verse: ▬ The transverse axis refers to the affected (1st, 2nd, 3rd, 4th, 5th). Classification of radial duplication according to Wassel ⊡ Table 3. Clinical features, diagnosis During the clinical examination we note the size of the supernumerary finger, which is usually smaller than the other fingers (⊡ Fig. In the common type IV the ulnar The condition can be classified on the basis of the cli- thumb should normally be left in place and the radial nical examination. Central duplications are rare presence of any hypoplasia of the bony structures. This can The treatment is based on the degree of the defor- conceal the actual polydactyly, in which case an accurate mity: diagnosis may occasionally be reached only after an x- Grade I: No treatment required 3 ray has been recorded. The supernumerary phalanx is Grade II: Release and deepening of the 1st web usually resected, taking care to preserve the tendons and space, opponensplasty, stabilization of the metacar- nerves. Sometimes a deviation of the »normal« phalan- pophalangeal joint, exploration of the flexor and ges has to be corrected. The opponensplasty uses the ring finger flexor digitorum superficialis or abductor digiti minimi 3. If more than one finger is affected, the two affected fingers Madelung deformity are always supplied by the same nerve (normally by the Madelung deformity is an autosomal-dominant inherited median nerve). The cause of the macrodactyly is usu- disorder involving the inadequate development of the ally neurogenic. Occasionally a neurofibromatosis is also epiphyseal plate of the distal radius. Tendons and blood vessels yet visible at birth, and the diagnosis is usually not made are configured normally. In this form surface in the ulnar direction of more than 20° the difference in size increases gradually over this period. Ulna: Dorsal subluxation, enlargement of the ulnar The diagnosis is based on clinical examination. The dif- head ference in length should be measured and the function Carpus: Wedge-shaped deformity. Radiological documentation is also nous ligament known as Vickers ligament extends important. Treatment either involves partial amputation between the radius and the ulnar section of the carpus of the finger or a reduction in its size, although the latter (⊡ Fig.
Goalies are additionally American Academy of Orthopedic Surgeons have rec- required to wear chest and throat protectors order 80mg tadapox overnight delivery. Many players also wear rib ACL functional braces are available for players with protector vests cheap 80mg tadapox fast delivery. Custom-fit braces have not been shown to perform better or offer more protection than off-the-shelf braces (Wojtys and Huston, 2001). RACQUET SPORTS Some clubs require eye protection for badminton, BASEBALL/SOFTBALL squash, and racquetball players. When a lens in a sports frame is struck, it proj- coaches, and on-deck hitters. This recommendation was Mouth guards are recommended, but not mandatory, originally made in 1984 by the Sports Eye Safety Com- to reduce risk of dental trauma. ICE HOCKEY The NCAA mandates the use of helmets with fastened WRESTLING chin straps, face masks, and an internal mouthpiece. Shin guards should pro- vical spine injuries (Reynen and Clancy, Jr, 1994). CHAPTER 17 PLAYING SURFACE AND PROTECTIVE EQUIPMENT 105 Mouth guards are recommended, especially for goal- natural grass and tartan turf. Am J Sports Med 8(1):43–47, keepers, to protect against not only dental injury but 1980. Kulund DN, Athletic injuries to the head, face, and neck, in Kulund DN (ed. Naftulin S, McKeag DB: Protective equipment: Baseball, soft- ball, hockey, wrestling, and lacrosse, in Morris MB (ed. Nicola TL: Tennis, in Mellion MB, Walsh WM, Shelton GL Albright JP, Powell JW, Smith W, et al: Medial collateral liga- (eds. Philadelphia, ment knee sprains in college football: Effectiveness of preven- PA, Hanley & Belfus, 1997, pp 816–827. Powell JW, Schootman M: A multivariate risk analysis of American Academy of Pediatrics Committee on Sports selected playing surfaces in the National Football League: Medicine: Knee brace use by athletes. Am J Barret JR, Tanji JL, Drake C, et al: High- versus low-top shoes for Sports Med 20(6):686–694, 1992. A prospec- Reynen PD, Clancy WG, Jr: Cervical spine injury, hockey hel- tive randomized study. Benson BW, Mohtadi NG, Rose MS, et al: Head and neck Rovere GD, Haupt HA, Yates CS: Prophylactic knee bracing in injuries among ice hockey players wearing full face shields vs college football. Sitler M, Ryan J, Hopkinson W, et al: The efficacy of a prophy- Cantu RC, Mueller FO: Brain injury related fatalities in American lactic knee brace to reduce knee injuries in football. Am J Sports Med Gaulrapp H, Siebert C, Rosemeyer B: Injury and exertion pat- 18(3):310–315, 1990. Sportverletz Sportschaden Sitler M, Ryan J, Wheeler B, et al: The efficacy of a semirigid 13(4):102–106, 1999. A Gieck JH, Saliba EN: The Athletic Trainer and Rehabilitation, in randomized clinical study at West Point. Surve I, Schwellnus MP, Noakes T, et al: A fivefold reduction in Grippo A: NFL Injury study 1969–1972. Final Project Report the incidence of recurrent ankle sprains in soccer players using (SRI-MSD 1961). Keene JS, Narechania RG, Sachtjen KM: Tartan turf on trial: A Wojtys EM, Huston LJ: Custom fit versus off the shelf ACL func- comparison of intercollegiate football injuries occurring on tional braces. Section 2 EVALUATION OF THE INJURED ATHLETE radiography (at the cost of loosing some of fine bone 18 DIAGNOSTIC IMAGING details), the ability of radiography to depict soft tissue Leanne L Seeger, MD, FACR pathology remains inferior to cross sectional imaging Kambiz Motamedi, MD (MRI, CT, and ultrasound). Disadvantages include availability of INTRODUCTION the physician, radiation exposure, and subjectivity of the amount of stress needed. In some cases, it may There are several modalities available for the imaging exacerbate underlying pathology. The strengths and weak- Conventional arthrography delineates the synovial nesses of each modality, along with their specific indi- space and intra-articular structures by joint disten- cations are discussed in this chapter. MRI or CT, coordination is needed for scheduling scanner time to immediately follow the procedure. Arthrography may be contraindicated in patients with IMAGING MODALITIES coagulopathy. With acute or subacute injuries, soft tissue or radiography (with or without applied stress), conven- marrow edema is seen. With chronic injuries, struc- tional arthrography, magnetic resonance imaging tural abnormalities may be seen. It is of limited value (MRI), which may be combined with arthrography for evaluating bone cortex and soft tissue calcifica- (referred to as MRA), computed tomography (CT), tion. There are several relative and absolute con- which may be combined with arthrography, ultra- traindications to MRI, including claustrophobia, sonography, and radionuclide bone scans. Because of the popularity of MRI, there may be a prolonged MODALITY STRENGTHS AND wait time for obtaining an examination. WEAKNESSES CT is superior to other modalities for fine bone detail, and is an important tool for depicting the anatomy of Plain radiography is widely available, relatively inex- complex fractures. Three-dimensional CT reforma- pensive, and provides excellent detail of bony struc- tions are extremely useful in the management of tures and soft tissue calcifications. This is especially true with the newer tissue resolution has slightly improved with digital generation (multislice) scanners that significantly 107 Copyright © 2005 by The McGraw-Hill Companies, Inc. CT is often utilized as a surrogate for retear of a repaired knee meniscus, and detection of MRI, in cases where MRI is contraindicated. With CT is indicated for demonstrating the extent and exception of anatomic areas where various position- anatomy of fractures. It is also useful for evaluation complex elbow with older generation scanners.
Cross-excitation in dorsal root ganglia of nerve-injured and intact rats 80mg tadapox. Peripheral nerve It is not at present clear to what degree some or all of injury triggers central sprouting of myelinated afferents safe 80mg tadapox. Increased uptake and transport of cholera toxin B-subunit in It is clear, for example, that not all post-nerve injury dorsal root ganglion neurons after peripheral axotomy: pos- states possess a sensitivity to sympathetic blockade. NMDA receptors as targets for drug action in Similarly, it seems certain that after nerve injury a neuropathic pain. Subunit characterization of NMDA recep- occur in humans as well as animals. The spinal phospholipase–cyclooxy- least some human states have mechanisms that appear genase–prostanoid cascade in nociceptive processing. Beyond neurons: Evidence that immune and glial cells contribute to pathological pain states [review]. Pharmacology and toxi- REFERENCES cology of astrocyte–neuron glutamate transport and cycling. The clini- rones in the rat spinal dorsal horn with particular emphasis cal picture of neuropathic pain. Adv Exp Med of activity in rat dorsal root ganglion neurons changes over Biol. A-fibers mediate mechanical hyperesthe- tive loss of GABAergic inhibition in the superficial dorsal sia and allodynia and C-fibers mediate thermal hyperalgesia horn of the spinal cord. An experimental model for peripheral rats with peripheral nerve injury and promotion of recovery neuropathy produced by segmental spinal nerve ligation in by adrenal medullary grafts. Excitatory actions of gaba during development: Lynch III C, Zapol WM, Maze M, Biebuyck JF, Saidman LJ, The nature of the nurture. Section III EVALUATION OF THE PAIN PATIENT HISTORY OF PRESENT ILLNESS 4 HISTORY AND PHYSICAL EXAMINATION A thorough history should document and characterize the potential pain symptoms3: Brian J. Character and severity of the pain: achy, allodynia (due to nonnoxious stimuli), burning, dull, dyses- INITIAL UNDERSTANDING thesia (unpleasant abnormal sensation), electrical, hyperalgesia (increased response to a painful stim- The importance of the initial evaluation in increas- uli), lancinating, paresthesia (abnormal sensation), ing successful outcomes in pain management neuralgia (pain in a distribution of a nerve), sharp. Include changes in mobility, cognition, and activities of daily living; household arrangements; and community and vocational activities. PSYCHOSOCIAL HISTORY Factors in the work environment that are associated with the potential for delayed recovery include job The psychosocial history provides vital information satisfaction; monotonous, boring, or repetitious work; necessary for understanding how pain is affecting the new employment; and recent poor job rating by a supervisor. Roles may change and new stressors may alter family dynamics, which may influence the outcome of any treatment program. Proper identifica- Obtain a complete list of prescribed and over-the- tion of substance abuse issues allows the proper counter medications and “home remedies” that are treatment of pain symptoms and facilitates future being taken or were taken to manage the pain symp- counseling. Return to these activities should be a goal of a treatment and rehabilitation program. Feasible sub- FAMILY HISTORY stitute hobbies should be identified in the interim. The stress of a new pain condition or injury can trigger a recur- rence of a previous psychiatric problem. Supportive REVIEW OF SYSTEMS psychotherapy or psychiatric medications can prevent or treat problems that could interfere with successful A comprehensive review of systems may uncover pain management. Early identification of such issues can inquire about problems in all systems of the body and facilitate a referral to a social worker as appropriate. VOCATIONAL HISTORY AND BACK PAIN Constitutional symptoms, such as unexpected weight loss, night pain, and night sweats, require further In a study by Suter, the risk of back injury was greater investigation. Mark painful areas as Please rate the intensity of your pain by making a mark on this scale follows: 000 = pins and needles /// = "lightning" or "shooting" pain TTT = throbbing NO PAIN WORST xxx = sharp pain AAA = aching pain PAIN IMAGINABLE FIGURE 4–2 Visual analog scale. Right Left Left Right tation, immediate and short- and long-term memory, comprehension, and cognition. JOINT EXAMINATION Always examine both sides of the patient when appro- priate to detect any asymmetries. Be sure to test all myotomal levels to help distinguish peripheral nerve, plexus, or root injuries (Tables 4–1 and 4–2). PHYSICAL EXAMINATION GENERAL GRADE DEFINITION 5 Complete joint range of motion against gravity with The patient should be appropriately gowned to allow full resistance proper visualization of any pertinent areas during the 4 Complete joint range of motion against gravity with examination. In addition, look for bony malalignments or areas of muscle atrophy, fascicula- tions, discoloration, and/or edema. SENSORY EXAMINATION A thorough sensory exam requires testing light MENTAL STATUS touch, pin prick, vibration, and joint position, as certain fibers or columns may be preferentially A thorough mental status evaluation should include a affected. OTHER NEUROLOGIC EXAMINATIONS hypochondriasis, hysteria, and depression in patients with three of the five signs. These five signs help Evaluate cranial nerves I through XII, especially in indicate when factors other than anatomic concerns the setting of cervical or facial pain and headaches. Clonus requires more than ness four muscle contractions following a stimulus. Nonanatomic (regional) motor or sensory impair- Check for the presence of Babinski’s plantar reflex ment and Hoffman’s thumb reflex, both of which may be Excessive verbalization of pain or gesturing (over- present in an upper motor neuron syndrome. Prevalence of neous areas supplied by individual peripheral nerves (right). Philadelphia: potential generated by a muscle when its supplying Lippincott–Raven; 1997:143. Adapted from Members of the Department of Neurology, tion of multiple motor unit action potentials (see Mayo Clinic and Mayo Clinic Foundation for Medical below). Clinical Examination in Fibrillation potential: a type of spontaneous activity. A review of psychological risk factors in back Motor unit action potential (MUAP): the potential and neck pain.
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