By N. Ford. Sherman College of Straight Chiropractic.

But pain must be appreciated as a psychological phenomenon buy estradiol 1 mg with mastercard menstrual extraction abortion, rather than a purely physiological phenomenon buy estradiol 1 mg without prescription menopause 3 months no period. Specifically, it represents a perceptual process associated with conscious awareness, selective abstraction, ascribed meaning, appraisal, and learning (Melzack & Casey, 1968). Emotional and motivational states are central to understand- ing its nature (Price, 2000). Pain requires central integration and modula- tion of a number of afferent and central processes (i. This formulation acknowledges the importance of various levels of anal- ysis of pain. The biological sciences (molecular biology, genetics, neuro- physiology, pharmacological sciences, etc. Ultimately, however, a unified theory of pain must integrate this understanding with the product of work in the behavioral and social sciences, as well as the hu- manities, because pain cannot be understood solely at the level of gene ex- pression, neuronal firing, and brain circuitry. Many of the serious problems in understanding and controlling pain must be understood at the psycho- logical and social level of analysis. What accounts for some people reacting dispassionately and others with great distress to what appears to be the same degree of tis- sue damage? The discipline of psychology must play a central role in the study, as- sessment, and management of pain. It is not surprising that Ronald Melzack, one of the developers of the most influential theory in the field of pain, is a psychologist. Nor is it unexpected that at least 2 of the 10 most influential clinicians and researchers in the field of pain (as assessed by survey of a random sample of members of the International Association for the Study of Pain [IASP]) are psychologists (Asmundson, Hadjistavropoulos, & Anto- nishyn, 2001). These two individuals (Ronald Melzack and Dennis Turk) are contributors to this volume. In this book we have tried to capture major features of the psychology of pain and the most influential contributions of psychologists to pain re- search and management. We are primarily interested in the ultimate impact of advances in understanding and controlling pain. Hence, although much of the volume covers applied issues, basic processes are also given careful consideration. FROM DESCARTES TO THE NEUROMATRIX Historical trends demonstrate the importance of psychological mechanisms. Descartes’s (1644/1985) early mechanistic conceptions of pain resulted in the biomedical specificity theory that proposed that a specific pain system transmits messages from receptors to the brain. This theory is sometimes referred to as “the alarm bell” or “push button” theory (Melzack, 1973), INTRODUCTION 3 because of its apparent simplicity. Descartes’s early views were refined substantially over the years, and more complex mechanistic views gradu- ally emerged as investigators struggled to incorporate in their models of pain the complexities and puzzles of pain that dismayed patients and clini- cians struggling with pain control. Nevertheless, biomedical specificity theory continued to exert an enormous influence through the first half of the 20th century. There was little room for recognition of the importance of psychological processes such as emotion, attention, past experience, and cognitive processes in the study of pain. Patients suffering from pain without a pathophysiological basis or signs often were considered “crocks” (Melzack, 1993). Despite dominance of sensory specificity and biomedical models of pain, clinicians were increasingly finding emotional and motivational processes to be important in understanding pain. Merskey (1998) observed that psy- chological explanations about motives for complaints about pain and psy- chodynamic theories gradually became popular during the early and mid- dle parts of the 20th century (e. Early investigation of psychiatric patients with pain had led to the erroneous conclusion that physical and psychological factors in pain were mutually exclusive and that pain is either physical or psychologi- cal (IASP Ad Hoc Subcommittee for Psychology Curriculum, 1997). Persis- tent pain with no identifiable causes was frequently labeled as psychogenic, a regrettable construct because it perpetuates mind/body dualistic thinking (Liebeskind & Paul, 1977) and fails to recognize that biological mechanisms are integral to all psychological phenomena, including pain. Freud (1893–1895) viewed pain as a common conversion symptom and favored the position that pains encountered in hysteria were originally of somatic origin.

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On the one hand discount 1mg estradiol with mastercard women's health center el paso tx, the be paid to indirect signs: low mobility of the affected osteomyelitis can heal spontaneously without any type of extremity with evasive movements (»Pseudoparalysis«) buy 2 mg estradiol with amex women's health issues bleeding, late sequelae. On the other, it may lead to multifocal in- sensitivity to touch, stretch position, diminished general flammatory metastases and a chronic course without any condition, swelling and redness usually indicate that pus detectable pathogen. Because of the anatomi- around 30% of cases of chronic unifocal osteomyelitis, cal circumstances in the neonate, extensive destruction, and their spectrum roughly corresponds to that of acute penetration of pus into the joints with definitive damage hematogenous osteomyelitis. The spectrum of the pathogens is much more variable in Clinical features, diagnosis the neonate than in older children. The clinical features of primary chronic osteomyelitis are highly variable and fairly non-specific. A »pseudo« Spondylodiscitis or mini-trauma will often draw attention to the sub- The diagnosis of purulent spondylitis or spondylodiscitis threshold pain that had already been present. Abdominal signs and symptoms can be the onset is usually insidious, occurring over several misinterpreted as appendicitis, and hip and thigh pain weeks or even months. Except in cases with spontaneous or difficulties in walking can also occur as predominant healing, the symptoms usually increase steadily, but not features. Localized pain on percussion and tenderness and dramatically, which often means that diagnostic inves- an extended spinal posture are indicative of the condition. As with Further details on diagnosis and treatment can be found acute hematogenous osteomyelitis, the primary chronic in chapter 3. Since a generalized re- Chronically progressing bacterial inflammation of the action of the body to the illness is usually lacking, the bone, which is not based on external causes and which diagnosis focuses primarily on local factors. This consists of immobilization, possibly ▬ Brodie abscess (= metaphyseal intraosseous accompanied by the administration of anti-inflammatory abscess formation without any preceding acute drugs. If an osteolytic focus is discovered then primary chronic osteomyelitis) a biopsy is indicated – as if a pathological change had ▼ already been visible initially. If there is the least suspi- otic treatment may be supplemented by an opera- cion of a malignant tumor on the basis of the radiographic tion. In primary chronic osteomyelitis the reverse findings, the usual tumor investigations with CT, MRI and is the case. The preoperative laboratory tests (differential blood count, ESR, C-reactive Follow-up management protein, immunoserology) supplement the diagnosis but Every child will require functional follow-up manage- are not specific. During the biopsy material should also ment, possibly with a dynamic splint. If the lesion is be taken for bacteriological investigation, both in respect located in the lower extremities, the patient is mobilized 4 of aerobic and anaerobic organisms. In view of the low on crutches without weight-bearing on the affected side. Sometimes the bacterial DNA can be gradually increasing weight-bearing can start within the detected by the PCR method (polymerase chain reaction). If the necrotic tissue was not completely Possible conditions to be considered in the differential removed in the primary procedure, the bone defect will diagnosis of osteolytic foci with and without an additional become superinfected, resulting in subsequent local ir- periosteal reaction include not only Langerhans cell his- ritation or abscess formation, which will then require tiocytosis, non-ossifying fibromas, enchondromas and immediate revision and radical resection of the necrosis unicameral bone cysts, but also malignant tumors (e. Here, too, irrigation with Lavasept is ap- Ewing sarcoma or leukemia), which must be considered propriate and we do not use suction/irrigation drains or especially if there is erosion of the cortical bone and peri- antibiotic-impregnated methyl methacrylate chains. Follow-up controls, postinfectious deformities Treatment Subsequent clinical and radiological controls after 6–8 weeks are designed to ensure that the bone defect is not! Objective: To achieve a definitive cure for the disease superinfected and gradually fills up spontaneously. If the as soon as possible without cosmetic or functional focus has diminished in size, full weight-bearing may long-term sequelae. This requires adequate surgical begin immediately depending in each case on the extent treatment. Further x-rays may then be required after a The treatment of primary chronic osteomyelitis involves a further 6–8 weeks, and possibly again after 6–12 months, biopsy combined with a radical clearance of the focus. The in order to document the subsequent spontaneous closure clearance may be performed in the same session only if of the defect. We do not consider follow-up bone scans to the imaging investigations or exposure of the site rule out be necessary since the regeneration process can continue the presence of a possible malignant tumor. Otherwise the for a long time, which means that increased uptake may surgeon must await the result of the histological investiga- still be observed after 6–12 months and should not be con- tion.

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On a subject as potentially contentious as ethnic or racial differences cheap estradiol 1 mg with amex womens health garcinia cambogia article, it seems best to err on the side of caution buy estradiol 1 mg line women's health issues globally. Only one investigation compared both experimental and endogenous pain in the same individuals, ischemic pain tolerance in African American and White pain clinic patients (Edwards, Doleys, Fillingim, & Lowery, 2001). It is essential to go beyond pain threshold and tolerance measures and look 172 ROLLMAN into other measures of pain reactivity and inhibition (Gracely, Petzke, Wolf, & Clauw, 2002; Lautenbacher & Rollman, 1997; Lautenbacher, Rollman, & McCain, 1994; McDermid, Rollman, & McCain, 1996; Staud, Vierck, Cannon, Mauderli, & Price, 2001; Yang, Clark, & Janal, 1991) across ethnic groups. Many factors, such as the subjects’ education, psychological status, and assignment to ethnic categories, varied considerably, as did the train- ing of the interviewers and quality of the assessment tools. The McGill Pain Questionnaire has been carefully validated in numerous languages (e. Much remains to be learned about the process of acculturation or cul- tural diffusion and how it affects cognitions and behaviors. Bates’s (Bates & Edwards, 1992) Ethnicity and Pain Questionnaire, which assesses an individ- ual’s ties to his or her ethnic group, indicates that later generations of fami- lies that came to the United States from abroad are likely to have accultur- ated to the culture of the majority group. In her New England sample, Central American, Italian, and Polish groups had the greatest heritage con- sistency, whereas Irish, French Canadians, and, especially, Anglo-Ameri- cans were more assimilated. Over 80% of the Central American participants reported an external locus of control, in contrast to the Polish group, where only 10% did so. Other studies have also suggested that there may be im- portant cultural differences in responsibility, blame, and other attributional styles which moderate pain expression and suffering (Bachiocco, Credico, & Tiengo, 2002; Eccleston, Williams, & Rogers, 1997). We assume that pain and emotion mean the same thing in all cultures, but we do not well understand the interaction between semantics and cul- ture. We cannot answer the question, “Even if an Anglo-American has a headache, is the meaning the same as when a Chinese person says he or she has a headache? Shioiri, Someya, Helmeste, and Tang (1999) found that Japanese subjects experienced difficulties in recog- nizing some emotional facial expressions and misunderstood others. Rus- sell (1991) provided a detailed review of the literature that indicates both similarities and differences in how emotions are categorized in different lan- guages and cultures. We should not assume that stoicism is good and expressiveness is bad, although that impression is often taken away from many of the studies reviewed here. One can easily argue the opposite and note that what- ever cultural differences exist are not limited to pain or negative affect 6. ETHNOCULTURAL VARIATIONS IN PAIN 173 and that societies that openly express pain also seem to openly express joy or happiness. We have not clarified the definitions of race and ethnicity, often using them interchangeably. Many scholars challenge the concept of “race-as- biology,” arguing that it is, in fact, a social construct (Goodman, 2000). No genetic signature identifies individuals as members of a particular race, and even the term ethnicity leads to confusions (Dimsdale, 2000; Morris, 2001). A twin study of laboratory pain sensitivity (MacGregor, Griffiths, Baker, & Spector, 1997) found equally high correlations between both monozygotic and dizygotic twins, leading to the conclusion that “there is no significant genetic contribution to the strong correlation in pressure pain threshold that is observed in twin pairs. These findings reinforce the view that learned patterns of behavior within families are an important determinant of perceived sensitivity to pain” (p. A recent investigation by Raber and Devor (2002) showed that in rats the characteristics of a cagemate can largely override genetic predispositions to pain behavior, possibly through the influence of stress. They concluded: Can the presence of social partners affect pain behavior without actually al- tering felt pain? In animals, we have no direct access to information of pain ex- perience except as reflected in behavior. Could genotype or social convention (including the presence of specific others) change outward pain behavior without actually affecting the “raw feel” of the pain? In humans, the answer is clearly yes, although intuitively one imagines that rodents are less bound by social context (innate or learned), and that pain behavior should therefore more faithfully reflect actual pain sensation. Black, and White, and Asian groups within a single society such as the United States may have enormous differences in child-rearing practices, modeling, and behavioral reinforcement, in addition to whatever genetic factors might distinguish them. One cannot legitimately lump together individuals from China, Japan, Thailand, the Philippines, Singapore, Korea, Indonesia, and so on and pre- tend that they share a single cultural identity that can be labeled “Asian. This is not to say that there are no differences between racial or ethnic groups.

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