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Recognizing aberrant drug-related behavior can assist in effectively screening patients for addiction in pain treatment settings purchase female viagra 100 mg mastercard. To refine the concept of addiction in the context of chronic pain discount female viagra 50mg mastercard, the American Society of Addiction Medicine, the American Pain Society, and the American Academy of Pain Medicine agreed on the following definition that supports our neurobiologic and psychologic understanding of addiction: ‘[Addiction is] a primary, chronic, neurobiologic disease with genetic, psy- chosocial, and environmental factors influencing its development and manifes- tations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, continued use despite harm, com- pulsive use, and craving’. In order to treat pain effectively, aberrant drug-related behavior should be noted, and addiction should be addressed concurrently. In assessing for addiction during opioid use, the clinician should collect the patient’s personal and family history of substance abuse as well as relevant objective information from the physical examination, observation, and labora- tory tests. The clinician should also use appropriate screening instruments, such as the CAGE-AID. When treating patients with opioids for long periods of time, it is impor- tant to follow them regularly and identify behavior suggestive of addiction. Behavior that should prompt investigation includes: continued use of drugs despite adverse consequences or harm secondary to use, loss of control over drug use, and preoccupation with use due to craving. A pattern of such behav- ior, rather than intermittent manifestation of one or two of these actions, warrants further assessment. Further examination into each behavior will assist in identifying key features of aberrant behavior. The beneficial effects of opioids may be hindered by the phenomenon of tolerance. Patients deriving benefit from opioids should experience a reduction in pain and maintenance or improvement of function in areas such as rela- tionships, work, sleep, and mood. When using opioids improperly, however, Opioids in Chronic Pain 129 patients tend to develop impaired psychosocial functioning. For instance, addicted patients tend to lose function in critical aspects of life relating to their jobs, friendships, mood, and familial relationships. Consequently, patients being treated with opioids who persist in their disability or experience deterio- ration in the functional activities of living despite rehabilitative support may suffer from addiction or substance abuse. Likewise, changes in mental status or intoxication from opioids may reflect a desire for the euphoric reward of the medication rather than a need for its analgesic benefit. Tolerance to the anal- gesic effects of opioids does not develop quickly in patients receiving the med- ication properly for pain. Tolerance to opioid-induced euphoria, however, does develop rapidly, necessitating higher doses to achieve the same effect. Patients with active addiction thus tend to escalate the dose of opioid to attain this euphoric state. This pattern of behavior probably highlights an addic- tive response to the opioid in a way that promotes continued use of the drug despite adverse consequences. Of course, pain specialists should consider other possible causes of aber- rant behavior such as pseudoaddiction, i.

A general principle applies: Doses of Green-emitting screens will only achieve the desired ef- 2 ionizing radiation used in humans should be kept as low fect in combination with green-sensitive films order female viagra 50 mg with amex. The specific radia- tion protection measures will be discussed in detail in the Gonad protection relevant x-ray investigations purchase 50mg female viagra free shipping. Gonad protection is always used provided it does not con- ceal any diagnostically important structures, i. A few generally valid guidelines of relevance to orthopae- Parts of this chapter (primarily concerning radiation pro- dic diagnostics are mentioned below. Field size This is the most important dose-increasing factor in References infants and small children. Greenspan A (2000) Orthopedic Radiology, Lippincott, Williams & Wilkins, Philad.. Schneider K (1996) Strahlenschutz und Qualitätssicherung in der dosage, the smaller the initial field. Our radiology technicians always strive therefore Technical Report Series 757, Geneva to frame a prescribed x-ray with the smallest possible field size. In all developed countries, mass screening programs are Additional filtering on the x-ray tube conducted to detect abnormalities and illnesses at an early An additional 0. In the past, such programs focused on the detec- portion of »soft« radiation such that the absorbed dose tion of infectious diseases such as tuberculosis, hence the not contributing to the imaging process is lowered by routine use in many places of imaging investigations. A disadvantage is a reduction in image contrast, recent years these investigations have almost completely although this is generally acceptable. Apart Anti-scatter grid from eyesight and hearing tests, medical examinations in The purpose of this grid is to reduce the scatter radia- schools focus primarily on the detection of abnormalities tion, and thus improve image definition, when large body of the musculoskeletal system. The objective of medical screening programs in patients, however, the scatter radiation is so low that the schools is always to detect problems at an early image quality is hardly affected. Dispensing with grid stage so that appropriate treatment can be initiat- x-rays for the infant pelvis reduces the dose by a factor ed before they reach the stage where much more of 2. Intensifying screens As well as recording the public health status and at- These screens produce a change in the sensitivity of the tempting to avoid serious complications in later life, film-foil system between 200 and 1,600 units. A system such programs must also consider not least the eco- with a relative sensitivity of 400 units is generally rec- nomic aspect. Exceptions are detailed views program should be cheaper than the subsequent expen- of bone with a recommended 200 units and follow-up sive treatments. Clearly ▬ leg length discrepancies, visible gait disorders such as an equine gait are also read- ▬ axial deviation of the lower extremities, ily discernible.

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The aim is to > Definition keep the length range over which the muscle can pro- Structural deformity of the foot caused by spastic duce its power within the range of motion of the joint muscle activity order female viagra 50 mg mastercard. The procedure can either be performed openly with Z-plasty lengthening or percutaneously by Structurally fixed equinus foot an incomplete transverse incision of the Achilles tendon at various levels discount female viagra 100 mg. As the dorsiflexors have been stretched > Definition out for a long time in these feet, a dropfoot may result. The cause is structural shortening (contracture) of the tri- To overcome this dorsiflexor weakness we have started to ceps surae muscle. In structural equinus foot, dorsiflexion add a shortening of the tibialis anterior at its distal inser- to the neutral position is not possible, even if the triceps tion, with favorable initial results. Equinus foot overcorrections are not infrequently ob- As with the functional form, the weight-bearing area is re- served after tendon lengthening procedures. These can duced in structural equinus foot, resulting in dynamic in- result in muscle insufficiency with a pes calcaneus posi- stability. In contrast with a purely functional equinus foot, tion that ultimately causes the patient to end up with the foot drops during weight-bearing while standing, but poorer function than with the equinus foot position. In not onto the heel and without any additional deformation the operation according to Strayer the efficiency of the in the form of an abducted pes planovalgus or a clubfoot. It must likewise be followed by muscle, this operation produces a functionally positive orthotic management. In fact, orthotic treatment over sev- result and overcorrections are rare. The intramuscular division A surgical option is the Achilles tendon lengthening of the aponeurosis can stretch the muscle belly and thus procedure in which the tendinous portion is lengthened lengthen its tendon, which was not shortened in the first ⊡ Table 3. Structural deformities in primarily spastic locomotor disorders Deformity Functional benefit Functional drawbacks Treatment Equinus foot (Knee extension) Dynamic instability due to small Functional orthosis (in equinus foot) weight-bearing area Cast correction Deformation of the feet Lengthening Clubfoot – Dynamic instability in the stance Functional orthosis phase Calcaneal osteotomy (Dwyer) Skin problems Cuneiform/cuboid osteotomy Arthrodesis Abducted pes Compensates for in- Dislocation in the tarsal bones Functional orthosis planovalgus creased internal rotation Hyperactivity of the peroneal Cast correction of the leg muscles Arthrodesis Instability of leg in stance Orthoses, cast correction Surgical lengthening of lateral column of foot Pes cavus – Overloading due to stiffness Padded insert Release of the plantar fascia Corrective osteotomy 435 3 3. The foot is then immobilized for 2 trocnemius muscles, the soleus muscle or at both sites. Although the effect of this subsequent cuboid osteotomy is an appropriate procedure procedure is usually inferior to that of the tendon length- for correcting the adduction position ( Chapter 3. While the risk of recur- proved effective for severe deformities that have been rence is high, the operation can be repeated if necessary. When a position of slight The triceps surae muscle can also be lengthened by overcorrection has been reached, the fixator is removed means of an external fixator (Ilizarov-type apparatus) that and the corresponding corrective osteotomies performed. If no os- consuming and mentally stressful but, on the other hand, teotomy is performed, the abnormal position will recur does produce good correction of the length relationships within a short period. Here too, the risk of recurrence other hand, require a corrective arthrodesis of various is high. This method is only recommended for previously joints in order to place the foot in a plantigrade position. Since such patients had previously been reliant, usually permanently, on a rigid, functional orthosis for walking! All lengthening measures, both conservative and and standing, and have therefore become accustomed surgical, are associated with a high risk of recur- to rigid foot joints, they suffer no functional deficit as a rence, particularly during growth.

The prevalence of articular joint pain more than doubles in adults over 65 years (Barberger-Gateau et al discount 50 mg female viagra overnight delivery. Foot and leg pain have also been reported to increase with advancing age well into the ninth decade of life (Benvenuti cheap female viagra 100mg otc, Ferrucci, Gural- nik, Gagnermi, & Baroni, 1995; Herr, Mobily, Wallace, & Chung, 1991; Leveille, Gurlanik, Ferrucci, Hirsch, Simonsick, & Hochberg, 1998). Studies of age- specific rates of back pain are more mixed with some reports of a progres- sive increase over the life span (Harkins et al. Another useful source of information on age differences in the pain expe- rience involves a review of symptom presentation in those clinical disease states that are known to have pain as a usual component. The majority of studies in this area focused on visceral pain complaints and particularly myocardial pain, abdominal pain associated with acute infection, and differ- ent forms of malignancy. Variations in the classic presentations of “crush- ing” myocardial pain in the chest, left arm, and jaw are known to be much more common in older adults. Remarkably, approximately 35–42% of adults over the age of 65 years experience apparently silent or painless heart at- tack (Konu, 1977; MacDonald, Baillie, & Williams, 1983). This represents a striking example of tissue damage without pain signaling the obvious threat, although the level of nociceptive input is seldom known with clinical 128 GIBSON AND CHAMBERS pain states. Nonetheless, attempts to address this issue by using more con- trolled and quantitative examples of cardiac pain have been recently under- taken. For many patients with coronary artery disease, strenuous physical exercise will induce myocardial ischemia as indexed by a 1-mm drop in the ST segment of the electrocardiogram. By comparing the onset and degree of exertion-induced ischemia with subjective pain report, it is possible to provide an experimentally controlled evaluation of myocardial pain across the adult life span. Several studies have documented a significant age- related delay between the onset of ischemia and the report of chest pain (Ambepitiya, Iyengar, & Roberts, 1993; Ambepitiya, Roberts, & Ranjada- yalan, 1994; Miller, Sheps, & Bragdon, 1990). Adults over 70 years take al- most 3 times as long as young adults to first report the presence of pain (Ambepitiya et al. Moreover, the severity of pain report is re- duced even after controlling for variations in the extent of ischemia. Collec- tively, these findings provide strong support for the view that myocardial pain may be somewhat muted in adults of advanced age. The presentation of clinical pain associated with abdominal complaints such as peritonitis, peptic ulcer, and intestinal obstruction show a similar pattern of age-related change. Pain symptoms become more occult after the age of 60 years and in marked contrast to young adults, the collection of clinical symptoms (nausea, fever, tachycardia) with the highest diagnostic accuracy does not even include abdominal pain (Albano, Zielinski, & Organ, 1975; Wroblewski & Mikulowski, 1991). With regard to pain associated with various types of malignancy, a recent retrospective review of more than 1,500 cases revealed a marked difference in the incidence of pain between younger adults (55% with pain), middle-aged adults (35% with pain), and older adults (26% with pain). With one exception (Vigano, Bruera, & Suarex- Almazor, 1998), most studies also note a significant decline in the intensity of cancer pain symptoms in adults of advanced age (70+ years; Brescia, Portenoy, Ryan, Krasnoff, & Gray, 1992; Caraceni & Portenoy, 1999; McMillan, 1989). It remains somewhat unclear as to whether the apparent decline in pain reflects some age difference in disease severity, in the will- ingness to report pain as a symptom, or an actual age-related change in the pain experience itself. Other reports of atypical pain presentation have been documented for pneumonia, pneumothorax, and postoperative pain. For instance, several studies suggest that older adults report a lower intensity of pain in the post- operative recovery period even after matching for the type of surgical pro- cedure and the extent of tissue damage (Gagliese, Wowk, Sandler, & Katz, 1999; Meier, Morrison, & Ahronheim, 1996; Oberle, Paul, & Wry, 1990; Thomas, Robinson, & Champion, 1998).

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