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By X. Porgan. Gallaudet University.

An information provision intervention- (sensory and procedural) delivered in person to patients undergoing gyne- cological laparoscopic surgery did not reduce pain levels postsurgically compared to no-intervention controls (Reading buy vardenafil 10 mg free shipping, 1982) cheap vardenafil 20 mg mastercard. Despite this lack of effect on pain reports, a behavioral effect was observed, with intervention- group patients requesting significantly fewer analgesic medications (Read- ing, 1982). More recently, Doering and colleagues examined the efficacy of a procedural information videotape intervention in patients undergoing hip replacement surgery (Doering et al. Results of this RCT also revealed no significant effects on pain intensity ratings, although like the Reading (1982) study, significant reductions in analgesic requirements were ob- served (Doering et al. Results of studies such as these indicate some potential postsurgical benefit of information provision interventions. Clinical Trials in Children Although not a primary focus of this chapter, it is important to note that psychological interventions appear to have benefit in the control of acute pain associated with medical procedures in children as well as adults. A meta-analysis (total of 19 studies) of the effects of techniques including dis- traction, relaxation, and imagery on acute pain experienced during medical procedures in children indicated a significant overall clinical effect, with children receiving interventions on average reporting pain levels 0. Children required to undergo repeated lumbar punctures or bone-mar- row aspirations as part of cancer treatment have been the focus of a num- ber of the available RCTs. These studies indicate the efficacy of combined interventions, including breathing relaxation, imagery, and distraction, for 258 BRUEHL AND CHUNG reducing the pain associated with such procedures (Jay, Elliott, Katz, & Siegel, 1987; Jay, Elliott, Woody, & Siegel, 1991; Jay, Elliott, Fitzgibbons, Woody, & Siegel, 1995; Kazak et al. These pain reductions appear to be clinically meaningful: Children receiving such a combined intervention reported 25% less pain than children in an attentional control group (Jay et al. Psychological interventions may also be effective for less intense but more common sources of acute clinical pain in children. For example, a sim- ple distraction intervention (use of a kaleidoscope) resulted in significantly reduced pain and distress associated with venipuncture relative to a group given simple comforting responses by clinicians (Vessey, Carlson, & McGill, 1994). Despite positive results such as these, other studies examining dis- traction and controlled breathing interventions for venipuncture pain indi- cate selective effects, reducing emotional distress during venipuncture but not affecting pain intensity significantly (Blount et al. As a whole, controlled trials in children do suggest some benefit to the use of psychological interventions for acute pain. COMPARISONS WITH PHARMACOLOGICAL PAIN MANAGEMENT The results of several of the outcome studies just reviewed indicate that psychological interventions used in conjunction with pharmacological ap- proaches may reduce the amount of such analgesic medications required (Ashton et al. Direct comparisons of psychological to pharmaco- logical techniques for acute pain management are rare and frequently suf- fer from methodological limitations, making interpretation difficult (Geden, Beck, Anderson, Kennish, & Mueller-Heinze, 1986; Kolk, van Hoof, & Dop, 2000; Schiff, Holtz, Peterson, & Rakusan, 2001). In the context of relatively mild acute pain associated with venipuncture, evidence for the benefits of distraction interventions compared to topical anesthetic interventions is mixed. A similar study also suggested no specific benefit (in terms of pain ratings) for a distraction intervention compared to a “standard care” condition, which frequently included EMLA cream (Kleiber, Craft-Rosenberg, & Harper, 2001).

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The femoral neck is capital femoral epiphysis and can occur safe 20 mg vardenafil, for example buy cheap vardenafil 10 mg on-line, narrowed slightly depending on the anatomical configura- if force is used to reduce a chronic case. The advantage of the wedge osteotomy is performed open reduction can also cause this complica- the much reduced risk of femoral head necrosis compared tion. When faced with evidence of a chronic process on that associated with open reduction. If a rotation deformi- the x-ray, the surgeon therefore has to decide whether a ty remains, this can, if necessary, be corrected secondarily reduction can be performed at all, or should only be fixed by an intertrochanteric osteotomy. Otherwise, the subcapital osteotomy represents a in only a third of cases. Of course, a chronically dislocated femoral infection rate in slipped capital femoral epiphysis is no head should not be returned to its original position with higher than for other interventions involving metal im- force, otherwise the risk of femoral head necrosis be- plants. Metal breakage only occurs if excessively thin nails comes much greater. If the history is not clear, we also always attempt a (gentle) reduction since, in the majority of diagnosed cases, Metal removal an acute slippage has already been complicated by a chroni- On completion of growth we generally remove nails and cally dislocated position. Normal screws are difficult to remove as they can particularly important with open reductions. In two cases we have found that the head was avascular even before Correction of the deformity (after completion of the reduction. However, we also have to report two cases of Subcapital wedge osteotomy iatrogenic femoral head necrosis in our own hospital. If the femoral head has slipped by more than 40°, a correc- The surgical technique described by Leunig et al. Although the wedge oste- implement this as close as possible to the deformity, i. Nevertheless, we currently prefer to flexion-valgus osteotomy for the correction of the defor- implement corrections close to the joint. After Southwick described the same opera- Contouring of the femoral neck tion in the English literature in 1967, the technique If ventral protrusion of the femoral neck and resulting is more commonly associated with the name »Southwick« impingement has occurred after only slight slippage, the in the English-speaking world than with the name »Im- impingement can be eliminated by appropriate contour- häuser« (⊡ Fig. This operation represents an alter- ing of the femoral neck (bump resection«). If a relevant native to the subcapital wedge osteotomy, and the risk of labrum lesion is already present (which can be visualized femoral head necrosis is slightly reduced. As a rule, it can by arthro-MRI), the contouring can be performed in also be performed during puberty, even in the florid stage connection with a surgical hip dislocation.

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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 order 20 mg vardenafil free shipping, independent quality vardenafil 20 mg, 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.

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