By E. Sanford. Ohio Northern University. 2018.
In short buy cytotec 200 mcg with amex, there is nothing as practical as a good the- ory purchase cytotec 200 mcg visa, as GCT illustrates buy cytotec 100 mcg online. This way buy 200 mcg cytotec with mastercard, micro-level processes, for example, changes in heart rate, are nested in those at a macro level—for example, stereotypic profes- sional views about people with chronic back pain. Consequently, changes at a micro level can have macro-level effects, and vice versa. Because bio- logical processes connected with pain are commonly at the micro level, and psychological and social processes are more likely to be macro-level phenomena, it requires commitment to multidisciplinary thinking to be able to select and use this diverse multivariate information appropriately and effectively in problem solving. Work to date on biopsychosocial mod- els already points to the urgent need to understand and address all three components in these models, if we are to create successful treatments (Taylor, 1999). We argue here that pain researchers have been very successful with the application of biological approaches to pain relief (McQuay & Moore, 1998), and to some extent with psychological approaches, such as cognitive be- havior therapy. But the contribution of social factors to the study of pain is poorly defined, weakly elaborated, and infrequently conducted, compared to other types of research on pain. It will be necessary to show which social factors directly and significantly affect and exacerbate pain if this approach is to gain acceptance as an important, independent, and equal contributor to the biopsychosocial triad. Important social factors will need to be prop- erly evaluated for their potential to generate new types of treatment or styles of management. On the basis of existing evidence about the effective- ness of the model, it is increasingly clear that an integration of sociocultural factors is essential to achieving positive outcomes, relieving suffering, and diffusing action from the narrow medicalization of pain, in ongoing pro- grams of care. A MODEL OF THE PSYCHOSOCIAL FACTORS IMPLICATED IN THE ETIOLOGY AND MAINTENANCE OF CHRONICALLY PAINFUL ILLNESS Although health professionals who work in pain research and practice have become pioneers in the design and running of smoothly functioning multi- disciplinary teams, it is arguable that when examining the key social influ- ences that affect pain and pain behavior, we have been slow to draw on contributions from the wider range of social science disciplines available, and to extend and apply them to improve our understanding of the pain re- sponse and its management. SOCIAL INFLUENCES ON PAIN RESPONSE 183 the social factors that affect pain, illness, and treatments, with the aim of il- luminating the inherently complex interaction between a pain sufferer and their psychosocial environment. Furthermore, it is not possible to do this properly without taking a multidisciplinary approach but within the per- spective of a different but overlapping set of disciplines. The model developed by Skevington (1995) proposes four levels of un- derstanding that provide a framework within which the social aspects of chronic pain may be better appreciated, and this is shown in Fig. Level 1 defines the individual processes affected by social influences, such as per- ceived bodily sensations. In contrast, Level 2 characterizes salient interper- sonal behaviors, in particular, that person’s relationship with significant others. Level 3 defines group and intergroup behaviors such as group be- liefs, experience, and influences, whereas Level 4 encompasses some of the higher order factors that affect sociopsychological processing, such as health ideology and health politics. Although reductionist, this model aims to understand the processes within each level and the relationships be- tween levels, rather than assuming that each level can be better explained by looking at the level below. The model broadens our conceptualization of chronic pain by removing the individual from his or her social and cultural “black box. The aim here is to extend the model and elab- orate it through a discussion of individual differences. Level 1: Individual Behaviors Affected by Social Processes Individual behaviors affected by social processes include a multitude of subjective factors including perceived bodily sensations, the perceived se- verity of symptoms, lifetime personal and social schema, social and per- sonal emotions, individual representations, and personal motivation. This level of analysis is probably most familiar to those who work on chronic pain, and with pain patients where internal biological and psychological fac- tors have been investigated at a micro level. Although sensations superfi- cially appear to be physiologically determined, there is now extensive cross-cultural evidence to show that pain thresholds and pain tolerance lev- els are influenced by a wide variety of different social and cultural factors (Bates, 1987; McCracken, Matthews, Tang, & Cuba, 2001; Nayak, Shiflett, Eshun, & Levine, 2000; Zborowski, 1969; also see chap. For instance, in the Hispanic culture, stoicism is highly prized (Juarez, Ferrell, & Bornemann, 1998), whereas in other cultures describing the pain in a vivid and extended detail is much more the norm (Zborowski, 1969). Reporting symptoms is known to be unreliable (Pennebaker, 1982), even when allow- ing for familial and social biasing influences that further explain the cross- F I G. M o d e l o f t h e p s y c h o s o c i a l p r o c e s s e s a n d s o c i a l f a c t o r s i m p l i c a t e d i n t h e g e n e r a t i o n a n d m a i n t e n a n c e o f a c h r o n i c a l l y p a i n f u l i l l n e s s. Mechanic (1986) underscored this view when he suggested that sociocultural and sociopsychological factors affect the reporting of pain and illness. Indeed, according to Mechanic, cultural differ- ences cannot be explained by learning and personality alone, but also re- quire an appreciation of the sector of society to which people belong.
This tests the patient’s serratus ante- rior muscle buy cytotec 100 mcg without a prescription, which is innervated by the long thoracic nerve (C5–C7) buy 200mcg cytotec with amex. If the serratus anterior muscle is weak order 200 mcg cytotec, medial scapular winging will be 26 Musculoskeletal Diagnosis Photo 9 buy 100 mcg cytotec visa. If the trapezius is weak, there may be lateral scapular winging evident. Table 1 lists the movements of the shoulder, along with the involved muscles and their innervation. Shoulder Pain 27 Table 1 Primary Muscles and Root Level of Innervation for Shoulder and Scapular Movement Major muscle Primary muscles movement involved Primary innervation Shoulder flexion 1. To test specifically for an anterior impingement syndrome, perform the Neer and Yocum tests. The Neer test is performed by internally rotat- ing and passively flexing the patient’s shoulder while keeping the arm in 28 Musculoskeletal Diagnosis Photo 11. This maneuver reduces the space between the acromion and greater tuberosity and may elicit pain in rotator cuff tendonitis. In the Yocum test, the patient’s shoulder is abducted to 90°, and the elbow is flexed to about 60°. Using the hand and elbow as a ful- crum, the arm is forcibly put into internal rotation (Photo 12). This maneuver jams the supraspinatus tendon into the anterior surface of the coracoacromial ligament and acromion process. In this test, the patient is instructed to supinate the arm, and the examiner resists the patient’s shoulder flexion. In this test, the patient flexes the elbow to 90° while simultaneously inter- nally rotating the shoulder and supinating the forearm against resist- ance. This test is positive and indicates a biceps injury if the maneuver elicits pain over the long head of the biceps tendon (Photo 14). To test more specifically for a SLAP lesion, and to differentiate it from an AC joint injury, the O’Brien test is performed. In this test, the patient stands with the shoulder flexed to 90° and the elbow in full extension. With the patient’s hand supinated, the examiner puts an inferiorly directed force on the patient’s hand. When the maneuver elicits pain inside the shoulder when the hand is in supination, but not when the hand is in pronation, a SLAP lesion is suspected. Therefore, if this maneuver elicits pain in the AC joint, pathology should be suspected in the AC joint and not in the labrum. To test for a supraspinatus tear, perform the empty can test or the drop-arm test. To perform the empty can test, the patient is instructed to abduct the arm to 90° and flex the shoulder to 30°. The patient then internally rotates the arm so that the patient’s thumbs are pointing down (as if emptying a can). Then the examiner pushes down (trying to adduct) the patient’s arms (Photo 16). If there is weakness or pain with this maneuver, the patient may have a tear in the supraspinatus tendon or muscle, or a suprascapular neuropathy. To perform the drop-arm test, passively abduct the patient’s shoul- der to 90° and have the patient slowly lower the arm. If the patient is unable to slowly and smoothly lower the arm without pain, the patient may have a weak or torn supraspinatus tendon or muscle. In this test, the patient is instructed to put the hand behind the back with the dorsum of the hand against the lumbar spine.
However buy cytotec 200mcg without a prescription, as maintenance agents volatile anes- thetics have predictable wash-in and wash-out kinetics and are a useful adjunct to other agents when titrated to hemodynamic and ventilatory parameters generic cytotec 200mcg with amex. Of the volatile agents discount cytotec 100mcg with mastercard, nitrous oxide has the least impact on cardiovascular and respira- tory function and can serve as a useful component of a balanced anesthetic if the patient’s oxygen requirements permit purchase cytotec 100 mcg with visa. Opioids are important analgesic agents for burn patients throughout the acute phase of injury and for postoperative analgesia during reconstructive proce- dures. The spectrum of opioids currently available provides a wide range of potencies, durations of action, and effects on the cardiopulmonary system. Burn patients experience intense pain in the absence of movement or procedures. Opioids provide the mainstay of analgesia in the acute phase of burn management. However, acute burn patients usually become tolerant to opioids because they receive continuous and prolonged administration of these drugs. Therefore, opioids should be titrated to effect in the acute burn patient. Most opioids have little effect on cardiovascular function, but they are potent respiratory depressants. Therefore, the ventilatory status of patients receiving opioids, particularly those with compromised airways, should be monitored closely. Regional anesthesia can be used effectively in patients with small burns or who are undergoing reconstructive procedures. In pediatric or adult patients undergoing procedures confined to the lower extremities, lumbar epidural or caudal anesthesia can provide a useful adjunct for control of postoperative pain. In cooperative adult patients with injuries confined to the lower extremities, epi- dural or subarachnoid anesthesia may be used if contraindications do not exist. For upper extremity procedures, brachial plexus has been used both as primary anesthetic and to control postoperative pain. Topical anesthesia has also been used successfully for acute burn surgery. Elderly and debilitated patients requiring full-thickness grafts have been cared 126 Woodson for successfully under topical anesthesia with EMLA cream (eutectic mixture of local anesthetics, lidocaine, and prilocaine). Fluid Management End points used to titrate fluid administration intraoperatively are similar to those used during resuscitation of acute burns. In fact, because of the nature of surgical trauma associated with burn wound excision, management of anesthesia for these procedures is largely a resuscitation effort. This involves continuous assessment of volume status, titration of fluids to various physiological end points, and assess- ment of tissue perfusion. Evaluation of the effectiveness of intraoperative volume replacement is much the same as assessment of effectiveness of resuscitation of the acute burn. For extensive wound excisions expected to involve substantial blood loss, it is prudent to minimize the volume of crystalloid fluids administered intraopera- tively. In the early phase of the hospital course, a large amount of edema fluid from the initial resuscitation will be present. In addition, the surgeons will fre- quently inject dilute crystalloid solution subcutaneously (clysis solution) to facili- tate debridement or harvest of split-thickness skin for autografts. Limiting crystalloid used for volume replacement can minimize the volume of extra fluid needed to be eliminated after these procedures. Large amounts of normal saline administered intrave- nously, however, have been associated with hyperchloremic metabolic acidosis. By itself this metabolic derangement is relatively benign, but during resuscitation from major blood loss it can confuse assessment and/or exacerbate effects of acidosis due to poor tissue perfusion. Lactated Ringer’s solution is not associated with such problems, but there is theoretical concern regarding diluting packed red blood cells with lactated Ringer’s solution because of the latter’s calcium content and the potential for formation of thrombi. In our practice, blood loss during burn wound excision is replaced with packed red blood cells reconstituted with plasma. Plasmalyte is added as needed to reduce the viscosity of administered blood or when additional volume is needed but not more oxygen-carrying capacity. This minimizes crystalloid load and helps to prevent coagulopathy due to dilution of coagulation factors.
For example buy generic cytotec 100 mcg online, providing a sensory focus intervention to a Blunter would be considered a mismatched intervention order 200mcg cytotec with mastercard, whereas a relaxing imag- ery strategy would be considered a matched intervention for such an indi- vidual (Fanurick et al cheap cytotec 200 mcg visa. Laboratory acute pain studies have provided some evidence indicating that interventions matched to preferred coping style result in more effective reductions in acute pain responsiveness (e generic cytotec 100mcg without a prescription. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 261 Clinical studies regarding this issue are mixed, but generally negative. Although there were no interaction ef- fects regarding pain experienced during the procedures, Monitors were found to experience less distress in the information provision condition whereas Blunters experienced greater distress (Shipley et al. Studies performed in the context of more severe acute clinical pain, on the other hand, are more negative. In a study of general surgery patients, efficacy of information pro- vision, relaxation, and no intervention was compared as a function of Moni- toring and Blunting coping styles (Scott & Clum, 1984). Blunters reported less pain and used less analgesics when provided with no intervention, which appear at least not inconsistent with the matching hypothesis. How- ever, contrary to the matching hypothesis, Monitors appeared to do best with breathing relaxation as opposed to information provision (Scott & Clum, 1984). Work by Wilson (1981) also in general surgery patients found that Blunters did not experience exacerbated pain following an information provision intervention, again failing to support the matching hypothesis. More recent work in surgical patients also indicated that efficacy of a relax- ation intervention did not differ depending on the degree to which patients preferred a Monitoring coping style (Miro & Raich, 1999). Differences in the measures used to assess coping style, types of interventions employed, and other procedural details make comparisons across studies more difficult. However, clinical support for a coping style by intervention type matching hypothesis is at best weak. Moreover, the absence of validated clinical pro- cedures for determining preferred coping style for purposes of selection of intervention type (e. Other Potential Moderators As noted previously, there is evidence from several studies that interven- tions including sensory focus, breathing relaxation, and use of control- enhancing statements reduce the discomfort of dental procedures only among those with a high desire for control and a low level of perceived con- trol prior to intervention (Baron et al. Given the importance of perceived control in determining satisfaction with acute pain management (Pellino & Ward, 1998), these findings suggest that if resources for providing psychological acute pain interventions are lim- ited, it may be most appropriate to focus these resources on individuals who express a desire for greater control over the acute pain experience. Laboratory acute pain research has indicated that imagery, analgesia suggestions, and distraction were effec- tive for reducing acute pain only among individuals high in hypnotizability (Farthing et al. This might not be considered surprising given that individuals high in hypnotizability may be more capable of developing vivid mental imagery (Farthing et al. As with coping style, validated clini- cal criteria for making treatment decisions based on assessment of hypno- tizability are not available. Therefore, the practical clinical utility of this moderator variable is questionable. BARRIERS TO EFFECTIVE CLINICAL USE OF PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN If psychological interventions for acute pain can be clinically useful in some circumstances, as appears to be the case, what are the barriers to their use? A study by Jiang and colleagues (Jiang, Lagasse, Ciccone, Jakubowski, & Kitain, 2001) of hospital acute pain management practices indicated wide- spread underutilization of nonpharmacological techniques. A primary fac- tor contributing to this underutilization was resource availability (Jiang et al. With the current focus on reduction of health care costs nation- wide, cost containment becomes a major barrier to providing the trained personnel and staff time to implement many psychological pain manage- ment strategies in situations in which they have proven effective. Clearly, as described earlier, there are potential risks associated with inadequate control of acute post-surgical pain (e. Provision of psychologically based interventions in the context of an overall program for management of postsurgical pain may therefore be cost-effective in the long term. However, the short-term nature of the dis- tress and pain associated with brief but painful medical and dental proce- dures may simply not be viewed as justifying the time and personnel costs needed to implement many psychological interventions for acute pain (Lud- wick-Rosenthal & Neufeld, 1988). Moreover, the absence of a psychiatric di- agnosis to justify provision of a psychological intervention, which is typi- cally a requirement for purposes of insurance reimbursement, may be a practical barrier to having psychological acute pain interventions be ad- ministered by psychologically trained staff. Brief and simple techniques that can be implemented quickly either through automated procedures (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 263 a memory-based positive emotion induction requiring less than 5 minutes of time has been shown to diminish acute pain sensitivity and pain-related physiological arousal, and could be carried out by nursing staff with limited training (Bruehl et al. Distraction techniques also require little effort to implement, and therefore may be more widely useful.
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