By A. Kippler. University of the Sciences in Philadelphia.
To this end depakote 250mg low price, the concepts presented herein provide an important piece of the foundation on which the assessment and treatment approaches described in other chapters of this volume are built. Our intent in this chapter is to provide an overview and critical analysis of the traditional biomedical and psychodynamic models, summarize ele- ments of the gate control theory that strongly influenced current conceptu- alizations of pain, and review important details of models that fall under the biopsychosocial rubric. Within the context of the latter, we include discus- sion of some of the most influential behavioral, cognitive, and cognitive- behavioral models and associated empirical findings. We conclude by posit- ing a synthesis of the various iterations of the biopsychosocial approach, place this in the context of a comprehensive diathesis–stress model (i. TRADITIONAL BIOMEDICAL MODEL The traditional biomedical model of pain dates back hundreds of years. Descartes (1596–1650) modernized it in the 17th century (Bonica, 1990; Turk, 1996a), and in that form it held considerable influence through to the mid 20th century. The model holds, in essence, that pain is a sensory experi- ence that results from stimulation of specific noxious receptors, usually from physical damage due to injury or disease (see Fig. Consider the case of Jamie, a middle-aged person with strained muscles in the low back. BIOPSYCHOSOCIAL APPROACHES TO PAIN 37 diagnosing and subsequently treating Jamie should be, for all practical pur- poses (and notwithstanding availability of adequate diagnostic, surgical, and pharmacologic technology), straightforward. Jamie’s physical pathol- ogy would be confirmed by data obtained from objective tests of physical damage and, if thorough, tests of impairment. Medical interventions would then be directed toward rectifying the muscle strain. The impact of the strain on Jamie’s social, psychological, and behavioral functioning would not be given much weight in any intervention. Indeed, other symptoms re- ported by Jamie, such as depressed mood, hypervigilance to somatic sensa- tions, and pain, would not be viewed as significant but, rather, as secondary reactions to (or symptoms of) the muscle strain. In Jamie’s case, intervention was targeted at healing the muscle strain and all symptoms subsided within 5 weeks. But, for every Jamie there is an- other person for whom application of an identical intervention does not re- solve pain and other symptoms, including disability, despite eventual heal- ing of physical pathology. As becomes evident in this chapter, the reductionistic and exclusionary assumptions of the biomedical models have not been upheld.
It is thought that during coping discount 500 mg depakote with amex, individu- als constantly reassess the stressful episode and their resources and alternatives for dealing with it. A combination of the best of several therapies: Rolfing, Trager, pulsation therapy, psychotherapy, and cran- iosacral therapy. The function is to permit the action of the group of syner- gists to reinforce one another while eliminating the action of the antagonistic muscles that would oppose the particular movement, either slowing the movement or preventing it. For instance, reciprocity between states for licensing of therapists whereby one state accepts the licensing qual- ifications of another state. The restoration of a disabled individual to maximum independence com- mensurate with his/her limitations. Reichian release: Manipulation of the musculoskeletal system is used to release emotional blockages from the body. This energy healing method involves placing the hands on or just above the body in order to align chakras and bring healing energy to organs and glands. In behav- ior therapy, reinforcement is provided to encourage specific activities, strengthened by fear of punishment or anticipation of reward. In diagnosis, refers to the probability that several therapists will apply the same label to a given individual. One RM = maximum that can be lifted 1 time; two RM = maximum weight that can be lifted twice, etc. Decrease in resonance is called dullness; absence of resonance is called flatness. The processes by which a living organism or cell takes in oxygen from the air or water, distributes and utilizes it in oxidation, and gives off products of oxidation, esp. It is a combination of amma, acupressure, shiatsu, lomi lomi, herbology, reflexolo- gy, and Western massage.
Once the planned donor sites that are accessible anteriorly are taken purchase depakote 250 mg on-line, the donor site dressings should be applied and secured. In general, the large areas such as the chest/ abdomen and anterior thighs and legs are attended to first. The excision is best accomplished with traction on the eschar coming through the knife. Sometimes, this layer may be in the fat, but the color is red instead of glistening yellow. In this case, the excision should be extended further until good yellow glistening fat is reached (the mne- monic being red is dead). On occasion, it may be necessary to extend the excision down to the level of the fascia for very deep wounds. It also may be necessary to go to this level should invasive wound infection occur in a previously excised bed. I try to avoid fascial excisions, because this causes problems in the reconstructive phase due to contour difficulties. In addition, if a fascial excision is carried out unnecessarily early in the course of treatment or if invasive infection ensues, options for exci- sional treatment are very limited (i. Once it is confirmed that the proper layer has been reached for all the anterior areas, hemostasis can begin. I do this by applying dry laparotomy sponges to the wound beds and applying pressure if possible with elastic bandages (e. I then make the sponges damp with dilute epinephrine solution (1:400,000 concentration). The sponges are then carefully removed beginning at the edge of the excised area, and the electrocautery pen is used to cauterize large vessels. After this is completed, apply gauze sponges again with elastic dressings, if possible, in preparation to move the patient to the prone position. Before the patient can be moved to the prone position, some monitors must be disconnected so that that they are not lost.
Marfan syndrome is characterized by tall stature buy 500 mg depakote with mastercard, particularly with elongation of the distal segments of the limbs. This disproportionate growth of the limbs produces a reduced upper segment to lower segment ratio and a span that is greater than the height. Genetic disorders of the musculoskeletal system 156 The term dolichostenomelia refers to these long, slender limb bones. Arachnodactyly is a term that has been applied to the long, spindly ﬁngers and toes. Weakness and redundancy of joint capsule and ligaments and tendons may result in joint hypermobility, patellar subluxation, hip dislocation, hyperpronated ﬂat feet (ﬂexible ﬂatfeet), scoliosis, and kyphoscoliosis. Overgrowth or undergrowth of the ribs and sternum commonly produces pectus carinatum or pectus excavatum. The connective tissue defects result in an evolving pattern of cardiovascular manifestations. Weakness of the aortic wall frequently results in progressive dilatation of the aortic root that may ultimately produce an aneurysm of the ascending aorta. Other ophthalmologic ﬁndings include myopia, glaucoma, and retinal detachment. Homocystinuria shares some of the phenotypic characteristics seen in Marfan syndrome. In contrast to Marfan syndrome however, it is an autosomal recessive disorder due to cystathionine B-synthetase deﬁciency. Elevated levels of homocystine, homocystine metabolites and methionine accumulate in blood and urine. The urinary excess of these substances may be identiﬁed by a positive cyanide nitroprusside test, but the diagnosis is based upon urine and plasma amino acid analysis. The diagnosis may be further conﬁrmed by studies of cystathionine B-synthetase activity in a liver biopsy specimen. Similar to Marfan syndrome, major manifestations of homocystinuria are found in the skeletal system, the vascular system, and the eye. Additionally, between one-third and three-quarters of untreated homocystinurics have mild to moderate mental retardation.
The pes calcaneus results from a weakness ioning develops from the longitudinal foot arch cheap depakote 500mg visa. The main load is transferred to the heel the heel and the ball of the foot are overloaded particularly and the lower leg stands in a forward lean. By way of during walking, leading to increased callusing and sub- compensation, the knees and hip must be held in flexion sequently to local painful conditions. Symptoms are rare, to ensure that the whole sole strikes the ground, other- therefore, for as long as the pes cavus remains mobile. Without inserts, the foot is functionally stretched and flexed dur- The triceps surae muscle normally acts to stabilize the ing walking and thus remains mobile. Inserts, on the ankle and thereby prevent the lower leg from sinking 437 3 3. Functional deformities in primarily flaccid locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Pes calcaneus – Crouch gait Functional orthosis (muscle transfer) position Arthrodesis Functional Compensates for in- Walking/standing Functional orthosis abducted pes creased internal rota- aggravated Cast correction planovalgus tion of the leg Risk of dislocation in the Lengthening of the triceps surae and/or peroneal muscles tarsal bones (pain) Lengthening of lateral column of foot Arthrodesis forward during standing and walking. A precondition appears to be suffer a loss of power during a paresis or myopathy (the adequately free plantar flexion, which is no longer present same symptoms are also observed after excessive tendon in most cases. The affected patients have to stand on their heels only to offset this weakness. But since the Functional abducted pes planovalgus resulting ground contact area is too small and the stabil- > Definition ity inadequate, some patients will sink forward with the The foot gives way under load as a result of the absent, foot and lower leg, causing them to stand and walk in a or insufficient, activity of the muscles that stabilize the crouch position, i. The arches are flattened out, the heel is in a valgus sition requires more power and energy for walking and position and the forefoot is abducted. The skeleton is standing, and the flexed positions of the joints become normal when the foot is not weight-bearing. The ability to walk and For the functional form of abducted pes planovalgus in stand is then jeopardized with increasing age, weight muscle weakness due to a paresis or myopathy, the same and height. The orthosis must be of a can be achieved only by means of an external appliance rigid design since it has to replace the absent muscle activ- (orthosis) or a surgical procedure. During walking, the orthosis prevents the premature throdesis of the lower ankles (usually an extra-articular forward movement of the tibia in relation to the foot in Grice operation) is performed to stop the foot from going contact with the ground and ensures adequate knee exten- over.