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By: Rasheed Adebayo Gbadegesin, MBBS

  • Professor of Pediatrics
  • Professor in Medicine
  • Affiliate of Duke Molecular Physiology Institute

https://medicine.duke.edu/faculty/rasheed-adebayo-gbadegesin-mbbs

Evidence for effectiveness on function and disability menopause the musical las vegas discount 50mg clomid overnight delivery, cost menopause hot flashes relief purchase clomid discount, risk and perceived improvement is mixed women's health issues in third world countries buy generic clomid 25mg on line. The overall strength of evidence to menstrual cramps 9 days before period purchase generic clomid online support recommendation of the use of the lateral glide for cervicobrachial pain in clinical practice is low menstruation hives order clomid 100mg overnight delivery. This study is the only one that evaluates the value of the lateral glide as a specific mobilisation technique over a prolonged period of time women's health issues in thrombosis and haemostasis buy generic clomid online. In doing so, pragmatic problems were encountered including a large number of participants receiving additional treatment which had the potential to introduce a confounding effect at longterm analysis. Evaluation of intervention effects in the short, medium and long-term and a cost analysis is appropriate to inform health policy; however different methods to evaluate effectiveness might need to be considered for different time-frames to identify the true effects of an intervention. Randomised controlled trials are considered the gold standard in research design (Silverman, 2009). A well-designed longitudinal observational study 235 might identify clinically important differences among therapeutic options for specific sub-groups of patients with a condition. This method might be considered a more appropriate way of providing data on long-term intervention effectiveness and safety (Silverman, 2009), and thus more effectively lead to the development of clinical practice guidelines. Study title Study to investigate the effectiveness of a lateral glide cervical spine mobilisation on cervicobrachial (neck and arm) pain. Before you decide it is important to understand why the research is being done and what it will involve. Ask us if there is anything that is not clear or it you would like more information. Cervicobrachial pain is the name for symptoms in the arm which originate from the neck. Symptoms usually include pain and sometimes include pins and needles (tingling), numbness and weakness in the arm. Physiotherapy often aims to help these problems by using advice, exercises and a variety of other treatments. This study will aim to establish if one commonly used treatment for this condition is better than another. You have symptoms affecting your neck and arm which have been identified as suitable to receive physiotherapy. If you do, you will be given this information sheet to keep and be asked to sign a consent form. A decision to withdraw at any time, or a decision not to take part, will not affect the standard of care you receive. We put people into groups and give each group a different treatment; the results are compared to see if one group is better. To try to make sure the groups are the same to start with, each patient is put into a group by chance (randomly). You will be randomised to either manual therapy with standard physiotherapy or standard physiotherapy alone and this allocation will not be changed. However, we would like to ask whether you do have a preference so that we can explore this in relation to treatment. Treatment will occur at weekly intervals (approximately) for between 1 to 6 weeks which is normal for treatment in a physiotherapy department. In each appointment the physiotherapist will ask you about your symptoms and perform some physical tests on your neck and arm. If you are in the standard physiotherapy group you will receive an up to date booklet consisting of self treatments and advice which the physiotherapist will go through with you so you are clear about what you need to do. If you are in the manual therapy with standard physiotherapy group, you will also receive the booklet, but in addition have small pressures applied to the bottom of your neck whilst lying down. You will need to be able to attend the physiotherapy department at the hospital for up to six weekly attendances once your treatment has started as would be expected for your normal physiotherapy care. Additional requirements that are not part of standard physiotherapy practice include the following: 248 You will be asked to sign the consent form (attached to the back of this paper). It is best to fill this in by yourself rather than having your friends, relatives or the physiotherapist help, to ensure that we have your view of your problems rather than someone elses. These appointments are important for us to evaluate how the treatment you previously received has affected your problem over a period of time. At each of these follow up appointments, you will be required to fill in another questionnaire (very similar to this first one) and have measurements taken of how much you can move your neck and the physiotherapist will measure how much she can move your arm. If you do not attend these appointments we will contact you by phone to arrange an alternative appointment time, unless you ask us not to. All information that is collected about you during the course of the research will be kept strictly confidential. Any information about you that leaves the hospital will have your name and address removed so that you cannot be recognised from it. In the unlikely event that you are harmed by taking part in this research project, there are no special compensation arrangements. If you wish to complain about any aspect of the way you have been approached or managed relating to the study, please contact Dr Brendan Laverty 0121 414 7618 (email: b. They will be presented within the university, and used for conference presentations or publication in academic journals. It is hoped that this work will contribute to a better understanding of how physiotherapists can effectively treat cervicobrachial (neck and arm) syndrome. Please contact either Emma Salt or Sue Kelly on the contact numbers below if you would like to obtain a summary of the studies findings. Keep the original copy of the consent form in the patient notes and place one copy into the completed data folder for the researcher and give the other copy to the participant. When you return to the cubicle, check the participant has completed the questionnaire. You should then fill in details recorded by the Trial Physiotherapist pre intervention form (demographic data). If symptoms are worse, further details should be recorded such as any additional symptoms or development of red flags. For self management with lateral glide group, For the self-management group, treatment involves going through the self treatment involves going through management for neck and arm pain booklet in the self management for neck detail, and then applying a lateral glide and arm pain booklet in detail. Repeat this for a further two sets of treatment with an interval of one minute between each set to provide three sets of treatment in total. Re-assess myotomes, dermatomes and reflexes Record assessment and treatment in standard format in the patient notes. Record time and any comments on participant comments Book a further appointment for the participant to return for a second treatment session (try and make within one week later or as soon to one week as possible). Ask the participant to bring the booklet with them to all further appointments 268 nd th Flow diagram for Trial Physiotherapists 2 6 treatment pathway Participant returns for appointment Clinical assessment involves: An outline of the participants symptoms to establish if there has been any change from their symptom presentation at last appointment. Repeat the lateral glide treatment that was given on their initial treatment session (same dose, grade etc) Re-assess myotomes, dermatomes and reflexes and record treatment in standard way No Give the participant a follow-up appointment with the Assessment Physiotherapist. Is the participant still within five weeks from (This should be six weeks from commencing treatment Yes Ensure all the participant trial data (with the exception of the Is the participant wishing to return for a original consent form) is now further session of treatment Yes Book a further appointment for the participant to return for a subsequent treatment session 269 Missed appointments and cancellations In instances where treatment appointments are missed or cancelled, further appointments will be made based on usual departmental protocols. It is important for the Trial Physiotherapist to be able to arrange the 6 week re-assessment, and complete the participant data post-intervention form regardless of whether the participant has attended all agreed treatment sessions or not. The research lead will be responsible for overseeing that all participants have been contacted for their follow-up appointments. Indications for participants who discontinue the trial If a participant decides not to continue with being part of the trial, they are at liberty to do so. In these instances participants will not be required to attend the follow-up assessments, however, please make sure you still fill in the Details recorded by the Trial Physiotherapist post intervention form and make sure it is clear that they received alternative treatment and if possible, the reasons for this. We are now looking to evaluate how you felt about being involved in the trial to inform us what measures we need to address before involving other patients in future research trials. I would be very grateful if you could spend a few minutes to complete the survey and return it by post in the pre-paid envelope. Alternatively, you can contact the research lead, Emma Salt either by phone or email. Did you feel you were given enough information about what to expect from being involved in the research trial Please comment on how useful you found the information booklet you received. If you received any mobilisation (manipulation) treatment, please comment on how you found this. Were you aware that you were free to withdraw from the trial at any point in time Based on your experience of this trial, would you be happy to participate in another health research trial The test was considered positive if any of the following criteria are positive: 1) symptoms reproduced 2) side to side differences of >10 degrees elbow extension 3) contralateral neck side-bending increased symptoms or ipsilateral side-bending decreased symptoms when in upper limb tensioned position. Flexion Extension Right side bend Left side bend Right rotation Left rotation 275 To be completed by the participant this questionnaire is divided into four parts. The first part asks what the severity of your pain is in the neck and arm and any additional symptoms you may be suffering with. The third part aims to establish how your symptoms are affecting your function and the last part asks if there have been any changes since you started your physiotherapy treatment. The Severity of your pain the following scales help to identify the severity of your pain. For example if you were feeling moderately high severity of pain/discomfort you would indicate it on the line below with an x as such: example: no pain worst pain x imaginable However if you were only feeling moderately low pain/discomfort you would indicate it on the line like this: no pain worst pain x imaginable On the scale below mark an x to indicate the average pain in your neck and arm over the last week no pain worst pain imaginable On the scale below mark an x to indicate the worst pain in your neck and arm over the last week no pain worst pain imaginable 276 Below are 7 questions about any additional symptoms you may have. Does the painful area change colour (perhaps looks mottled or more red) when the pain is particularly bad Getting unpleasant sensations or pain when lightly stroking the skin might describe this. Does your pain come on suddenly and in bursts for no apparent reason when you are completely still In the area where you have pain, does your skin feel unusually hot like a burning pain Gently rub the painful area with your index finger and then rub a non-painful area (for example, an area of skin further away or on the opposite side from the painful area). Gently press on the painful area with your finger tip then gently press in the same way onto a non-painful area (the same non-painful area that you chose in the last question). For example, circle number 1 if you have no difficulty performing the activity, or circle number 7 if you are unable to do the activity, or circle any of the numbers in between depending on the amount of difficulty you have with the activity or situation in the question. If you did not have the opportunity to perform a certain activity in the past week, please make your best estimate on which response would be the most accurate. If you do not have a job and were not working at the time of your symptoms starting, answer not applicable to these questions. Note that section B (questions 12 to 20), the numbers 1 to 7 refer to how frequently you experience the situation in the question. Since the last time you completed this form, have you needed to take medications for the neck and arm pain We would be extremely grateful if you could answer the enclosed short questionnaire so that we are able to compare how you are now with when you joined the study. Once completed, please return the questionnaire in the stamped addressed envelope provided. Your participation is very important so that the results provide physiotherapists with a better understanding of how to help people who have neck and arm pain. To achieve this goal, it is essential that we find out how people respond in the long-term to different physiotherapy treatments. If you have any queries about the questionnaire or any other aspects of the trial, please contact Emma Salt on 01283 566 333 x5255 or by email: emma. Example: For example if you were feeling moderately high severity of pain/discomfort you would indicate it on the line below with an x as such: no pain worst pain x imaginable However if you were only feeling moderately low pain/discomfort you would indicate it on the line like this: no pain worst pain x imaginable On the scale below mark an x to indicate the average pain in your neck and arm over the last week no pain worst pain imaginable On the scale below mark an x to indicate the worst pain in your neck and arm over the last week no pain worst pain imaginable Please turn over page 287 Since the last time you completed a trial form, would you say your pain has become: A very great deal better A great deal better A good deal better Moderately better Somewhat better A little better Almost the same, hardly any worse or better at all A little worse Somewhat worse Moderately worse A good deal worse A great deal worse A very great deal worse Please mark x in the box which describes your situation the best. Since the last time you completed a trial form, have you needed further treatment for your neck and arm pain If both minimum and maximum recorded values are within the limits for all outcome measures, then, proceed. If one or both extremes are outside the theoretical limits for one or more outcome measures: i. If errors are still present, and there are no other data with which to cross check values, set data outside the limits to missing (a blank in Excel). If yes, for that participant, set the score on the subscale to missing in the Excel database ii. If no, for that participant, set the score on the subscale to the mean score across answered items on that subscale (as recommended by developers of the outcome measure). Does any outcome measure have more than 50% unanswered/missing items for any participant If yes, for that participant, set the score on the outcome measure to missing in the Excel database. If no, for that participant, set the score on the outcome measure to the mean score across answered items or use weightings as specified by the developers of that outcome measure. These non-applicable items should correspond to items within outcome measures that do not necessarily apply to all participants. Following completion of the above checks, compute participant scores for each outcome measure following rules specified by the developers (or, latest published criteria, as appropriate) Independent person to check a sample of data. Follow-up time points were also identified as Random factors to model variation around the planned follow-up time points the model was built in three phases: 1) Analysis across time the dependent variable. Non-significant covarites were not included in the model, so that only significant covaraiates were taken forward to stage three of the modelling. This approach was recommended by Field (2009) and compared the profile of change across the intervention groups, with adjustment for time and important covariates.

Please direct questions about this Bulletin to women's health clinic ucla buy clomid with paypal Kirsten Jensen women's health clinic waco tx generic 25 mg clomid otc, Director of the Division of Benefits and Coverage women's health clinic in midland tx cheap 50mg clomid, at kirsten pregnancy 36 weeks purchase clomid with mastercard. Apply knowledge of the incidence pregnancy 6 days before ovulation generic 50 mg clomid mastercard, etiologies mensis cheap clomid 25mg with mastercard, and assessment of pain to the treatment of critically ill patients. Develop evidence-based pain management strategies that include both nonpharmacologic and pharmacologic interven tions and that account for transitions of care. Evaluate short and long-term outcomes associated with pain management, and develop methods to improve quality of care. Unrelieved pain is associated with both short and long-term physical and psychological consequences and should be the focus of evi dence-based assessment, treatment, and prevention. Pain management is extremely complex because pain pres ents in different ways. This chapter discusses these challenges and others asso ciated with analgosedation in the critically ill population. Somatic nociception is associated with peripheral tissue injury and is character Physiology, Etiology, and Causes ized by sharp, stabbing, or dull pain that can be localized. Pain is defned by the International Association for the Study Visceral nociception is associated with organ injury, is typi of Pain as an unpleasant sensory and emotional experi cally difcult to localize, and is characterized in vague terms ence associated with actual or potential tissue damage, or such as cramping. Peripheral neu pain is a multidimensional issue with both emotional and ropathic pain is caused by neuronal lesions related to trauma, physical components that are characterized as pain distress infections. Of interest, patients per with the following: ceived procedures performed by nurses as less painful than General knowledge of medications commonly used those done by other caregivers and physicians. Investigators for analgesia hypothesize that anxiety and its associated increase in pain Adverse drug effects of analgesic agents perception were limited because nurses provide reassurance, Pharmacologic properties of opioids compassion, and pre-procedural education and often include family members (Puntillo 2014). These tools have common features, but they are not in practice exist and suggest that assessments be performed useful for measuring pain intensity and cannot discriminate and documented at least four times per nursing shift, before between pain types. Compared with patient self-report, surrogates correctly Self-report identify the presence of pain 74% of the time and the severity Individual pain tolerance is widely appreciated, but cultural of pain 53% of the time, with a tendency to overestimate pain differences may not be. Although consideration of family Chinese, and Japanese origins have very few expressions concerns is important, it remains the responsibility of health for pain in their vernacular, which may impair their ability to care providers to evaluate pain and the need for interventions. In contrast, the English Agreement of pain severity between nurse report and language includes 16 categories of pain described by at least patient report is around 75%. To self-report, a patient cannot be deeply sedated and the importance of providing light sedation to allow patients must be able to interact in a meaningful way with caregivers. Analgesic Trial the presence of an endotracheal tube or a tracheostomy Occasionally, despite the use of evaluative strategies, there should not preclude pain assessments. If patient behaviors seem to respond to tool with a numeric format that includes body locations where an analgesic trial, consideration of continued administration is pain is felt, together with words to describe the qualitative indicated. Overall, vital signs should not be used as the sole pain at the site of injury and medical patients usually having indicator of pain. Behavioral Pain Scales Relevance: Acute and Long-term Physical and In an effort to improve pain evaluations in noncommunicative Psychological Consequences patients, assessment tools based on behavioral pain indicators the stress response from painful stimuli activates the. These factors may lead tive pain management can make this approach difcult to to hypercatabolic states, tachypnea, tachycardia, increased implement. A comprehensive educational approach is recom oxygen demand, ischemic injury, impaired wound healing and mended to enhance caregiver understanding of the benefts response to infections, and hyperglycemia (Sigakis 2015). Pain also interferes with sleep, may hinder effec titration, and adverse drug reactions. These the primary goal of pain management is to acutely provide data are consistent with a multicenter observational study patient comfort and safety; secondary goals are to prevent that found that pain assessment tools were used for only 28% the immediate and long-term complications of pain. The of mechanically ventilated patients, and that analgesia was complexity of pain management mandates a comprehensive provided without pain assessment in most patients (Payen systematic multidisciplinary approach. Caregiver personal and cultural biases may infuence should be routinely performed and documented (at least four pain management as well, especially if they have strongly held times per nursing shift and within 30 minutes of administer views about the potential for opioid overuse. Efforts should include the health care system may play a role in suboptimal preemptive strategies initiated before painful procedures, pain management by not mandating quality improvement identifcation of outpatient issues such as chronic pain or his processes or not insisting on caregiver responsibility and tory of substance abuse and tolerance with a low threshold to accountability for pain relief. All of these can easily be exacerbated logic or nonpharmacologic interventions that consider the by issues related to inadequate nurse stafng. The exact level of pain relief should illness, or not vocalize the extent of their pain as a means of be patient-specifc because some patients prefer to tolerate a avoiding adverse drug events. Comprehensive Interventions pain management strategies should include prevention and Data suggest that less than one-half of patients are assessed aggressive management of adverse drug events. Examples for pain while undergoing a potentially painful procedure, and include initiating bowel regimens for most patients treated less than one-fourth actually receive procedural pain treatment with opioids and providing a tapered dosing schedule for de (Payen 2009). The general application of deep breathing, and ice therapy) have been studied; all pro an analgosedation approach in the United States should be tem duced conficting results (Joffe 2013; Gelinas 2012). Despite pered by an appreciation that almost all data supporting this these uncertainties, preemptive interventions for known pain approach were generated in Europe, where 1:1 nurse-to-patient ful procedures should be provided because they are low cost ratios were common and sitters were available. Furthermore, and low risk and have the potential to complement pharmaco data on the infuence of analgosedation on outcomes such as logic options as part of a multimodal approach to analgesia delirium, pneumonia, mortality, and long-term cognitive impair (Barr 2013; Czarnecki 2011). The route of administration of analgesia is an impor treat pain and ease the harshness of life (Chu 2008). Intermittent intravenous administration is signals, ultimately to dampen the excitability of nociceptors. Regional or neuraxial strate Fentanyl gies may be useful in the settings of thoracic, abdominal, Fentanyl is one of the most widely used opioids in the criti vascular, and orthopedic surgery. Because it is a substrate for this enzyme of action and promise to improve analgesia while limiting system, fentanyl may interact with inhibitors such as the exposure to opioids. In addi recommendation for the consideration of non-opioids to be tion, fentanyl competes with midazolam for clearance by administered in addition to standard opioid therapy. In addition, an analgesia-frst or analgosedation approach Some tertiary sources suggest that fentanyl doses should has been advocated because surveys show that unrelieved pain be adjusted in the setting of kidney disease. Methadone has a complex pharmacokinetic profle: its not signifcantly affected by renal dysfunction, though they half-life varies from 15 to 60 hours and depends on hepatic are strongly infuenced by hepatic disease, heart failure, and metabolism and the presence of interacting substances body mass (Choi 2016). Fentanyl, which has 5-hydroxytryptamine 1A agonist prop It has been suggested that, when methadone is used to erties, has been associated with serotonin syndrome, but the treat chronic pain patients with opioid tolerance or who are clinical signifcance of this is uncertain because the data switching from an alternative opioid, initial daily dosages are based largely on animal studies and a few case reports should not exceed 3040 mg, and dose titration should in humans when fentanyl had been used in combination with not exceed 10 mg daily at 5 to 7-day intervals (Chou 2014). Recent data suggest that with the combination of fentanyl and serotonergic agents methadone represents the second most common cause from January 2012 to December 2013. The American Pain Society practice guide tanyl patch therapy, and one received intravenous fentanyl. Despite these potential drawbacks, methadone offers Hydromorphone potential advantages because it may restore analgesia in Hydromorphone is a semisynthetic opioid derived from mor patients who have become tolerant to standard opioids or phine. Issues with this drug stem from an underappreciation when hyperalgesia is suspected. This strategy is known as opioid rotation, and supporting Remifentanil data are largely derived from the oncology literature. A trial of Remifentanil is an ultrashort-acting synthetic opioid (half 12 mg of intravenous hydromorphone can be used and con life 310 minutes), which may offer an advantage for patients tinued if the patient responds favorably. For example, it is vital that sonable to consider this mode of administration for short-term the pharmacist and nurse work closely to avoid disruptions use in patients until they can tolerate enteral medications. Hyperalgesia, which is thought to be mediated who abuse ethanol, have liver disease, or have malnutrition. The maximal total daily dose by any route of administra Nonetheless, the potential for hyperalgesia should be tion is 4000 mg. These agents exert their analgesic properties principally by inhibiting the enzyme cyclo-oxygenase, resulting in a reduc Buprenorphine tion in the synthesis of mediators of the acute infammatory Buprenorphine is a partial opioid receptor agonist with response, including prostaglandin synthesis in the spinal antagonist properties at the opioid receptor with a mean cord. It is available as a single agent or in com thus, choice of agent can be based on local preference and bination with naloxone and is increasingly used for patients costs. These agents offer analgesia that is equivalent to with opioid dependence and chronic pain. Higher doses of standard with kidney disease, and in those concomitantly using diuret opioids may be required for buprenorphine-treated patients ics. It is converted in the liver to an active metabolite, offers a clinical advantage in patients with asthma because O-desmethyltramadol, which is a opioid agonist. No consistently decreases opioid requirements by as much as other sedatives or analgesics were used. Cumulative mor 20% when used in a multimodal capacity, but the clinical cor phine exposure was signifcantly less in the ketamine group relation of a reduction in opioid-related adverse events is not (58 mg) than in placebo (80 mg) (p<0. These limited data support further study of ket the approach to dosing has been remarkably inconsistent, amine in this patient population (Patanwala 2015). Hemodynamic monitoring have consistently been less than 5 mcg/mL, and documented using a pulmonary artery catheter showed that ketamine toxicity has been limited to hemodynamically stable arrhyth was associated with a 21% decrease in cardiac index, a 20% mias and bradycardia (McCarthy 2010). More study is needed increase in pulmonary capillary wedge pressure, and a 38% to defne the benefts and burdens of intravenous lidocaine increase in systemic vascular resistance (Patanwala 2015). Intravenous lidocaine should be avoided in Ketamine should be avoided in this population until the risk is patients with arrhythmias, sinus bradycardia, heart block, further defned by a well-powered trial. Adverse effects of ketamine include hypertension, Lidocaine is also available for topical use as a 5% patch. The neuro this formulation may be useful as an adjunct to standard opi psychiatric adverse effects of ketamine on discontinuation oid therapy in the management of pain related to rib fractures (emergence phenomenon) seem to occur infrequently with (Oyler 2015). Carbamazepine treats pain by Dexmedetomidine and Clonidine inhibiting sodium channels. The gabapentinoids, which are sedation without affecting respiratory drive, and data suggest renally eliminated, require dose adjustment in the setting of that they are opioid sparing as well (Oyler 2015). Clonidine and kidney disease, whereas carbamazepine is noted for its abil dexmedetomidine are similar, but they can be distinguished ity to induce hepatic enzymes, leading to signifcant drug by their degree of -receptor specifcity (dexmedetomidine2 interactions. Cost is a signifcant limitation for dexmedetomi Regional anesthesia is an established effective means of dine, but this may be overcome by rapid transition to enteral pain control. This strategy promises to avoid respiratory clonidine in selected patients (Gagnon 2015). Both agents complications, allow less sedation, promote greater mean may cause central sympatholysis by blocking the release of ingful patient interactions, facilitate early mobility efforts, norepinephrine and lead to bradycardia and hypotension. The use of indwelling catheters has limitations Lidocaine dictated by the expertise of available personnel and by Lidocaine is widely used as a local anesthetic, for regional patient-specifc relative contraindications. Furthermore, epidural anesthetics are asso lidocaine use is associated with lower pain scores, less opi ciated with hypotension. This technique for chest duced constipation, which often gives rise to discomfort, trauma patients improves lung mechanics, which may agitation, and a delay in meeting nutritional goals. If opioid-induced constipa Opioid-associated adverse drug events are very common tion is refractory to standard interventions, the peripherally and account for as much as 16% of all inpatient adverse drug active opioid antagonists methylnaltrexone and naloxe reactions. Methylnaltrexone is administered subcutaneously, and cial implications of adverse events are signifcant because the weight-based dose should be adjusted in renal disease. Respiratory Depression and Oversedation Opioid-associated respiratory depression is sometimes used Withdrawal clinically to aid in oxygenation by facilitating patient syn Few data describe the risk factors, characteristics, and man chrony with mechanical ventilation. The a barrier to successful liberation from mechanical ventilation, most commonly described symptoms are nonspecifc. The incidence of the Joint Commission has identifed risk factors for respi opioid withdrawal is not well defned but may approach 30% in ratory depression and oversedation, including age older than mechanically ventilated patients receiving high-dose opioids 60 years, opioid naivety, excessive opioid exposure, morbid for a week or more (Cammarano 1998). With Nausea and Vomiting few exceptions, these risk factors are not modifable, but Opioid-induced nausea and vomiting may be related to direct strategies to limit the adverse effect include the systematic stimulation of chemoreceptor trigger zone. Treatment options evaluation of pain; the use of a multimodal approach, when are similar to those for postoperative patients. Pain assessment and management may be particularly administered during that observation period. One autoregulatory cerebral vasodilatation that follows (Roberts high-quality double-blind randomized trial compared dex 2011). No medetomidine with morphine in cardiac surgery patients; no frm guidance on the choice of agents exists, but fentanyl and between-group differences were found in the incidence of remifentanil may be preferred because they seem to minimally delirium, but the duration of delirium was longer in patients alter cerebral perfusion and minimally interfere with hemody receiving morphine (Shehabi 2009). In discomfort, providing a close observation of all the vari addition, typical pain-related behaviors are often absent; there ants of patient behaviors related to pain, and administering fore, caregivers need to be aware of other fndings associated an analgesic trial when uncertainty about pain is present. The most common causes of pain in patients for nonverbal patients and updated tools, guidelines, and with dementia have their origins in musculoskeletal disorders, forms to facilitate bedside application. These data suggest that a Until recently, the ability to evaluate pain in patients with delir self-report pain assessment strategy should be tried frst and ium was unknown because this group of patients was excluded in a serial fashion because the ability to self-report waxes and from validation studies. When self-report is impossible, behavioral pain scales in a select group of patients with delirium without cognitive can be considered as long as motor function is intact. No such difference was seen with the United Kingdom Medicines Information Pharmacists nonpainful procedures (Kanji 2016). Group website has a comprehensive document on the safe use of opioids in the setting of renal impairment. Subarachnoid HemorrhageRelated Headache Headaches in patients with subarachnoid hemorrhage occur Palliative Care with a prevalence of 75% during hospitalization; these can be the incidence of moderate to severe pain in the fnal 3 days severe and persist for as long as 29 years. Data suggest that of life in hospitalized patients is about 40% and represents headache is a leading cause of 30-day hospital readmission the greatest fear for this population. Provision of intermittent bolus medication for except in the setting of acute respiratory distress syndrome breakthrough pain should also be offered. Other agents that may have utility include glu assume that signifcant pain is present and to offer analgose cocorticoids, transdermal lidocaine, antidepressants, and dation as a baseline strategy to ensure comfort (May 2015). Morphine is metabolized to morphine-3-glucuronide (55%) continuation of their analgesia. Consideration for using fen and morphine-6-glucuronide (10%), both of which are renally tanyl patches, methadone, and oral opioids typically within cleared. Morphine-3-glucuronide has no analgesic the risk specifc to the inadvertent continuation of anal activity, but it is reported in animal studies to be neurotoxic. Pharmacists can play an important role in limiting this held notion that the clearance of fentanyl (an opioid without occurrence by medication reconciliation efforts as patients active metabolites) is signifcantly affected by kidney function. The central aspects of renal disease, but associated adverse reactions have not of any process improvement effort include the prompt rec been characterized. The American Society for Pain Management and the American Association of Critical-Care Nurses have suggested a hier Patient Satisfaction archy of pain assessment techniques that begin with using There are fnancial incentives for improving patient satisfac patient self-report; identifying potential causes of pain such tion from effective pain management.

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Mobi-C Cervical DiscSurgical Technique Guide 7 Surgery Approach and Procedure Decompress the foramen bilaterally menopause baby order genuine clomid line. The Mobi-C surgical approach is identical to menstruation 4 days buy 100 mg clomid otc that Establish a normal the women's health big book of yoga pdf order 100mg clomid with visa, healthy disc height of a traditional anterior cervical discectomy and (no overstufng) breast cancer 49ers purchase clomid with paypal. However menopause 35 cheapest clomid, the Mobi-C surgical Place the implant in the center of the vertebral procedure emphasizes aspects that may difer from a bodies for optimal biomechanical success menopause the musical san francisco buy clomid 25 mg. The operating surgeon will want to: Considerations for a Two-level Surgery Center the exposure on midline. It may distractor to open the posterior aspect of the be easier to complete the most diseased level frst disc space. Caspar pins are available sterile packed from the inferior edge of the superior vertebral body. Use midline placement of the caspar pin as a visual reference for midline device placement. The extent of decompression is left to surgeon discretion based on patient pathology and history. Width gauges correspond to the 15 mm in depth and can be used to estimate trial depth. Note: the center reference point, located on the width gauge, confrms location of the vertebral midline; Use the paddle distractor to create parallel distraction. When the desired height is obtained, lock the caspar distractor to hold distraction. Use the caspar distractor to maintain the parallel distraction achieved by the paddle distractor. The trial will Caspar pin depth (12 mm and 14 mm) determine the fnal implant height to be used as well Paddle distractor depth (15 mm) as implant footprint (width and depth). Trialing should Important: It is extremely important to choose a size begin with the smallest height frst (5 mm) and should that achieves complete A/P coverage. Important: Confrm the complete anterior-posterior and medial-lateral endplate coverage of the selected footprint. Mobi-C Cervical DiscSurgical Technique Guide 13 Release the caspar distractor to assess the tension and ft. Once released, take a lateral X-ray to validate height and depth selection and an A/P X-ray to assess central placement and width. The holes in the trial, front and side facilitate verifcation of position (center and rotation). In assessing the trial ft: Start with a 5 mm trial (over 85% of implanted Mobi-Cs are 5 mm, rarely a 7 mm). Note: If the inferior endplate of the superior vertebra is fat, use a curette to prepare room for the dome of the device. Note: the trial implant holder can be removed to take an unobstructed A/P X-ray, then re-engaged for trial removal. A zero this position can be verifed visually; the groove on setting will place the anterior edge of the implant the implant inserter should align with midline. It is important to set the correct axial stop collar, there is a tactile feel of the ball detent rotation before impacting the device into the dropping into a groove. Axial rotation maneuvers of the device should be avoided once the device is in the disc space. Release the into the disc space by tapping lightly on the implant caspar distractor to permit the vertebral endplates to inserters impaction knob with a mallet until the align in parallel. The implant should be centered, If necessary, the posterior position of the device in the regardless of endplate coverage. Adjust the Note: Take care to center the device on the implant inserters depth stop knob. The implant During and after insertion, avoid lateral and rotational should be centered. Carefully remove the caspar distractor is released, apply initial compression implant inserter in a straight line. Take care not to with caspar distractor to set the lateral implant teeth move the implant. In a two-level case, screw is required for cleaning and in two-level cases perform compression at each level separately. Place bone wax as needed in the holes created by the pins to reduce bleeding and on any anterior bone surfaces exposed during osteophyte removal. Remove the over distract when adjusting the height for inferior plate and mobile insert together, taking care implant removal. The inner contact surfaces of the superior and inferior spinal plates are spherical and fat, Warnings respectively. The the Mobi-C Cervical Disc should only be used by two lateral stops of the inferior plate are designed to control surgeons who are experienced with anterior cervical and limit the mobility of the mobile insert. The spinal plates, spinal procedures and have undergone hands-on both superior and inferior, feature two rows of teeth which training in the use of this device. Only surgeons who are are designed to aid in initial and long term fxation and familiar with the implant components, instruments, stability. Indications Correct selection of the appropriate implant size is the Mobi-C Cervical Disc Prosthesis is indicated in extremely important to assure the placement and skeletally mature patients for reconstruction of the disc function of the device. Information regarding proper from C3 to C7 following discectomy at one level or two implant size selection, implant site preparation, and the contiguous levels for intractable radiculopathy (arm pain use of the instrumentation before, during and after and/or neurological defcit) with or without neck pain, Mobi-C surgery is provided in the Mobi-C Surgical or myelopathy due to abnormality localized to the level of the Technique Manual and the Mobi-C Instrument System disc space and at least one of the following conditions Instructions for Use. The Mobi-C Cervical Disc Due to of the proximity of vascular and neurological Prosthesis is implanted using an anterior approach. Care must be taken to despite nonoperative treatment prior to implantation of the identify and protect these structures. Carefully inspect each Prior fusion at an adjacent vertebral level; component and its packaging for any signs of damage, Neck pain alone; including damage to the sterile barrier. Do not use Mobi-C implants if the packaging is damaged or the Rheumatoid arthritis or other autoimmune disease; implant shows signs of damage. Visual inspection of the prosthesis assembly is recommended prior to implanting the device. Preoperative If any part of the assembly appears damaged or not fully Patient selection is extremely important. Even though the device appears undamaged, it may have small defects and internal stress patterns that can lead to early breakage. It is important any dissatisfaction in the product quality, identity, to remove all anterior and posterior osteophytes on the durability, reliability, safety, efectiveness and/or superior and inferior vertebral endplates. To prevent weakening of of the implanted system component(s) ever malfunctions, the endplates, use of a burr is discouraged during. Use the caspar retractor as or otherwise does not perform as intended), or may have needed to maintain or modify distraction. In the repetitive bending, and prolonged or strenuous activity event that the Mobi-C device requires removal for any reason, initially and for a period of weeks to months depending follow the instructions provided below in the device on the individual patients progress and the stability and retrieval section. Please refer to the Mobi-C Cervical Artifcial Disc Surgical Technique for step-by-step Non-clinical testing has demonstrated instructions on the required surgical technique for device that the Mobi-C Cervical Disc retrieval. Disclaimer: this document is intended exclusively for physicians and is not intended for laypersons. Information on the products and procedures contained in this document is of a general nature and does not represent and does not constitute medical advice or recommendations. Because this information does not purport to constitute any diagnostic or therapeutic statement with regard to any individual medical case, each patient must be examined and advised individually, and this document does not replace the need for such examination and/or advice in whole or in part. Please refer to the package inserts for important product information, including, but not limited to, indications, contraindications, warnings, precautions, adverse effects, and patient counseling information. All content herein is protected by copyright, trademarks and other intellectual property rights, as applicable, owned by or licensed to Zimmer Biomet Spine, Inc. This material is intended for health care professionals, the Zimmer Biomet Spine sales force and authorized representatives. So terrible are these headaches that I can do nothing but lie on the couch and try to dull the pain by sniffing ether. Todays specialists on the psychology of pain would argue that Maupassants catastrophic thinking about his pain likely played a role in heightening the intensity of the pain he experienced. In order to grasp the essence of current conceptualizations of catastrophizing, it is useful to consider four papers that have provided a foundation for the literature on catastrophizing (Chaves and Brown, 1978; Spanos et al, 1979; Rosenstiel and Keefe, 1983; Sullivan et al. In an early study, John Chaves and Judith Brown (1978) asked dental patients to report thoughts and images they experienced, or the strategies they engaged in, during a stressful dental procedure. Chaves and Brown (1978) noted that individuals differed markedly in the thoughts they experienced during the dental procedure. They found that individuals who engaged catastrophic thoughts were particularly likely to experience high levels of distress during the dental procedure. Catastrophizers were described as individuals who had a tendency to magnify or exaggerate the threat value or seriousness of the pain sensations. Nicholas Spanos and his colleagues from Carleton University were also interested in the psychological factors that influenced the experience of pain (Spanos el al. In their research, they asked university 3 students to immerse one arm in a container of very cold water and to report the degree of pain they experienced. The procedure is referred to as a cold pressor procedure and can induce significant pain without causing any tissue damage. Spanos et al (1979) interviewed their subjects about their pain experience following participation in the cold pressor procedure. Individuals who reported thought content reflecting worry, fear, and the inability to divert attention away from pain were classified as catastrophizers. Similar to the findings of Chaves and Brown (1978) individuals who engaged in catastrophic thinking reported the highest levels of pain. Frank Keefe and his colleagues from Duke University (Rosenstiel and Keefe, 1983; Keefe et al. The items on the catastrophizing subscale reflect elements of helplessness and pessimism in relation to ones ability to deal with the pain experience. It has been translated into several languages and has been incorporated in the assessment protocol of pain clinics and rehabilitation centres throughout North America and Europe. Catastrophizing is currently defined as: an exaggerated negative mental set brought to bear during actual or anticipated painful experience (Sullivan et al. Prior knowledge of a patients level of catastrophic thinking, in addition to other pain-related variables, enables treatment plans to be more individually tailored. The percentile scores are derived from a sample of injured workers who had initiated a time loss claim with the Nova Scotia Workers Compensation Board. General characteristics of the sample are as follows: Sample size: 851 Sex distribution 438 men, 413 women Age: 42. In other words, catastrophizing not only contributes to heightened levels of pain and emotional distress, but also increases the probability that the pain condition will persist over an extended period of time. Janet Pavlin and her colleagues from the University of Washington (Pavlin et al, 2004) found that high scores on a measure of catastrophizing predicted the degree of pain that individuals experienced following surgery, and contributed to a higher level of disability in the weeks that immediately followed surgery. Their study showed that individuals who obtained high scores on a measure of catastrophizing had a higher probability of experiencing persistent knee pain and disability two years following their surgery. A number of recent investigations have shown that catastrophizing, assessed shortly following occupational injury, predicted the development of chronic pain and disability (Picavet et al. Findings such as these suggest that if catastrophic 7 thinking can be minimized, then the probability of the persistence of pain and disability might be reduced. Individuals th who score above the 75 percentile would be considered at high risk for the development of chronicity. A Determinant of Pain-Related Outcomes Research has supported a multidimensional conceptualization of catastrophizing comprising elements of rumination, magnification, and helplessness (Sullivan et al. Individuals who score high on measures of pain catastrophizing report more intense pain (Sullivan et al. To date, nearly 600 studies have been published documenting a relation between catastrophizing and pain. A significant relation between catastrophizing and pain-related outcomes has been observed in numerous pain samples. A relation between catastrophizing and pain-related outcomes has been observed in children as young as 7 years (Crombez et al. The relation between catastrophizing and pain appears to emerge early in life, has been observed across a wide range of clinical and experimental pain-eliciting situations, and shows a remarkable consistency. Implicit in this work is the view that catastrophizing is causally related to pain, and the pattern of findings appears to support the causal or, at least, antecedent status of catastrophizing. For example, catastrophizing, assessed while individuals are in a pain-free state, prospectively predicts 8 pain ratings made in response to aversive stimulation. Catastrophizing scores obtained one week (Sullivan and Neish, 1999) or 10 weeks (Sullivan et al. Catastrophizing prospectively predicted pain ratings in arthritis patients 6 months later, even when controlling for initial pain ratings (Keefe et al. Reductions in catastrophizing have been shown to prospectively predict reductions in pain and disability (Sullivan et al. Theory and Mechanisms It is not clear when the term catastrophizing was first used in the psychological literature, but there are references to catastrophizing in psychological writings dating back to the beginning of this century. In the 1960s, the term catastrophizing was used to describe the excessively negative thinking of individuals with depression. For example, Beck (1967) described catastrophizing as a cognitive distortion that could contribute to the development or exacerbation of symptoms of depression. The term catastrophizing has also been used to describe the mental set of individuals suffering from various anxiety disorders (Beck and Emery, 1985). It is possible that the essential features of catastrophizing in depression and anxiety may be similar to those of catastrophizing as discussed in the pain literature (Turner and Aaron, 2001). Catastrophizing in the literature on depression and anxiety has been characterized in rather pathological terms.

Although some states allow the legal use of marijuana for medicinal purposes pregnancy meal plan buy discount clomid 25mg online, which may or may not include pain women's health clinic london ontario purchase clomid in india, there is no high-level scientific research supporting the long-term use of marijuana for chronic pain menstrual and ovulation calculator generic clomid 25 mg with amex. In fact pregnancy resource center order clomid 25 mg on-line, there is good evidence that excessive smoking of marijuana can be harmful (especially in young people) menstruation jelly like generic 100 mg clomid with visa. American Chronic Pain Association Copyright 2018 146 However womens health np discount clomid 100 mg with mastercard, in January 2017, the National Academies of Sciences, Engineering and Medicine published a paper that concluded after studying 10,000 scientific abstracts published since 1999 that found evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience a significant reduction in pain symptoms 8. That means there is now a disagreement within the federal government whether marijuana can help manage pain (or even be considered medicinal). More frequent marijuana smoking is associated with an increased risk of severe respiratory illnesses, especially chronic bronchitis. Other potential delivery methods include oils, tinctures, vaporizers, and edibles. Use also leads to reduced workplace productivity, as well as impaired judgment, even hours after use. Marijuana intoxication impairs cognitive and psychomotor performance with complex, demanding tasks. Individuals who have used marijuana over long periods of time demonstrate impaired performance on a variety of neuropsychological tests. A recent review of the existing medical literature concluded that the use of marijuana at a young age increased the risk of schizophrenia or a schizophrenia-like psychotic illness by approximately three-fold. Emerging evidence suggests a link between more frequent, or severe, marijuana use and anxiety symptoms and disorders. Patients using opioids need to be aware of all prescribed and non-prescribed medications that affect the central nervous system, including marijuana and alcohol, because there may be a synergistic effect that may cause respiratory depression and death. People who are self-medicating with marijuana may not recognize the presence of marijuana withdrawal symptoms. Marijuana causes physical dependence, and withdrawal symptoms can start as early as hours after smoking marijuana and last for up to a month and include sleep disturbances, substantial anxiety (which can worsen pain), discomfort, lack of appetite, and commonly trigger marijuana craving. Despite some states allowing medicinal marijuana, it is a federal crime for a health care professional to prescribe a scheduled drug to a person known to be using the drug illegally. It is also important to remember that possessing marijuana when traveling through a state where medicinal marijuana is not allowed could result in being charged with possession of an illegal substance, even if the person is using the drug under the supervision of a physician and has the proper home state documentation. Additionally, an individual can be denied employment or fired if the employer or prospective employer conducts drug screenings as a part of the hiring process or has a no-drug tolerance policy. American Chronic Pain Association Copyright 2018 147 Illegal Drugs Regarding chronic pain treatment (excluding cancer and end-of-life care), health care professionals will not prescribe opioids and other medications to individuals who are known to use illegal street drugs (heroin, methamphetamines, cocaine, and others) or to be irresponsible with prescription pain medication. The American Chronic Pain Association website can be a great source of information theacpa. This and other pain management programs include ways to track daily pain and activity and can be a useful vehicle to easily summarize progress over time. They can be especially helpful when starting an exercise routine by tracking progress based on frequency and duration of the exercises. These programs can also suggest warm-up and cool-down stretching routines catered for each individuals pain problem. They also can be useful for monitoring medication use and giving helpful reminders throughout the day. Smart phone applications (apps) are in development specifically for persons with chronic pain. These programs are useful in identifying important information about the pain, summarizing progress for the health care professional, and offering daily tips and recommendations for improving pain management. When you understand what makes your pain worse, you can begin to work on ways to reduce or deal with your pain triggers. Being in better control can help you be less afraid and better able to manage your pain. We encourage you to fill out a chart at the end of each day or several times a week. It can help you talk more openly with your health care provider so that together you can find ways to improve your quality of life. This tool can help you create a detailed picture of your pain-where it is, how it feels, how much it hurts, and what triggers it. Patient to Person: First Steps Topics include: Understanding Chronic Pain Knowing Yourself Learning to Live with Others Helping Your Body store. It is important for the person with pain, family members, and others to avoid quick judgments based on what they hear or read about any particular treatment or medication. The best place to get advice about treatments and medications is from the health care professional assisting the person with pain. Families need to be good reportersobservant, truthful, and honest about what they see in the person who is provided a certain treatment or who is taking medication. Sometimes the person provided the treatment or taking the medication does not realize the changes that are produced. There is no question that there are many treatment approaches (tools) in the tool chest of the treating health care professional or therapist, but they should be used judiciously. Benefit should be based on less pain, more function, and return to everyday activities with the least, manageable side effects possible. The best source of information is health care professionals and therapists who understand the treatment and medication options available to people with chronic pain. Choosing Nonopioid Analgesics for Osteoarthritis: Clinician Summary Guide: Available at informahealth care. The image on the cover shows a network of the nerve cells which carry sensory information from the external world to the spinal cord and brain. The image was captured at the Bosch Institute Advanced Microscopy Facility, University of Sydney and is used with permission from: Dr. Michael Lovelace and Professor Tailoi Chan-Ling, Retinal and Developmental Neurobiology Laboratory, Discipline of Anatomy and Histology, University of Sydney; Professor Patricia Armati and Dr. Roberta Chow, Brain and Mind Science Research Institute and Nerve Research Foundation, University of Sydney. Cognitive Behavioral Therapy for Chronic Pain Among Veterans Therapist Manual Suggested Citation: Murphy, J. The authors thank the following individuals for their contributions to this manual: Michael O. Miller, PhD assisted in reviewing and providing feedback in the development of this manual. Samantha Outcalt, PhD assisted with writing several sessions in the frst draft of the manual. Phillips, PhD provided the majority of content for the case examples used in this manual. John Otis, PhD reviewed a frst draft of the manual and provided feedback for development. Evangelia Banou, PhD and Nicolle Angeli, PhD offered their review and editorial input on the materials used to accompany sessions. Gimeno helped signifcantly in compiling the fnal reference list used in this manual. Josephine DeMarce, PhD, lead author of the Cognitive Behavioral Therapy for Substance Use Disorders Therapist Manual (DeMarce, Gnys, Raffa, & Karlin, 2014) provided helpful guidance in the organization and structure of this manual. Information contained in the sleep session was informed by the Cognitive Behavioral Therapy for Insomnia Therapist Manual (Manber et al. In addition, the resources below were used while researching material for this manual: Caudill, M. Therapist Manual 7 Preface In an effort to promote the availability of effective psychological treatments, the U. Program evaluation results indicate that the training in and implementation of these therapies have signifcantly enhanced therapist skills and Veteran outcomes. Therapist and Veteran forms and worksheets are described in the text and provided in the Appendices. Treatments based on cognitive behavioral theory have been successfully applied to the management of chronic pain, either delivered alone or as a component of an integrated, multimodal, and interdisciplinary pain management program. The frst part focuses on foundational information regarding pain, especially chronic pain, including common conditions and treatments. The content and specifc issues are presented with this particular population in mind. As many as 50% of male and 75% of female Veterans report pain in a primary care setting (Haskell Heapy, Reid, Papas, & Kerns, 2006; Kerns, Otis, Rosernber, & Reid, 2003). Among those returning from Iraq and Afghanistan, as many as 45% endorse clinically signifcant pain levels (Gironda, Clark, Massengale, & Walker, 2006). In addition, chronic pain and mental health disorders often co-occur (Gatchel, 2004). Veterans with chronic pain seen in mental health settings report a variety of pain complaints and, in many cases, a history of numerous pain management interventions. Accordingly, the following section provides an introduction to common pain conditions and treatments. The goal of this section is to familiarize mental health providers with basic information regarding pain in order to enhance understanding of their patients experiences. In addition, possessing pain-related knowledge can help in understanding the patients condition and history, conceptualizing the best approach to treatment, and establishing credibility with the Veteran to assist in the formation of a therapeutic alliance. For this reason, another popular defnition of pain is that it is whatever the experiencing person says it is, existing whenever he (or she) says it does (McCaffrey& Pasero, 1999). One of the most important distinctions in understanding and treating pain is between acute and chronic pain. Some of the most important differences are highlighted below: Less than 3 months More than 3 months Is a symptom Is a condition May develop after incident; may have Identifed cause; bodys response to injury known or unknown cause Diminishes with healing and responds Persists beyond expected healing time to treatment and/or despite treatment Acute pain typically occurs following an identifable incident where an injury is sustained, such as a broken arm or sprained ankle. It is adaptive because it results in focused attention on a situation that is threatening. Acute pain is time-limited, diminishes with healing, and the cause usually is known. Chronic pain, on the other hand, persists beyond the expected time and indicated point of healing, and is typically defned as longer than 3 months duration. While pain is present and may feel identical to acute pain, the experience does not have the same meaning. More recent understandings of chronic pain suggest that when pain continues in the absence of ongoing tissue damage, the nervous system itself is misfring pain signals. Chronic pain, therefore, is best understood as a chronic disease to be managed versus an acute symptom to be cured. Therapist Manual 11 Types and Locations of Pain Chronic pain can affect any part of the body. Because of the complexity of chronic pain, it is often diffcult to categorize conditions into clear and simplistic categories. It is useful, however, to be familiar with the most commonly used classifcations, nociceptive and neuropathic pain: Nociceptive Pain Pain that is caused by damage to body tissue and is based on input by specialized nerves called nociceptors Nociceptors sense danger to soft tissues such as muscles, bones, ligaments, and tendons Most nociceptive pain is musculoskeletal, and is often described as aching or deep Neuropathic Pain Pain that occurs when there is nerve damage that typically involves either the peripheral or central nerves It is often described as burning, shooting, tingling, or electric Headache pain does not fall into either of the above classes but is another large category of painful conditions: Headache Pain Pain that involves disturbance of sensitive structures around the brain Sensation is usually in the forehead, eyes, or upper back/neck areas Pain is often described as a tight band, pounding, throbbing, or dull the evaluation of a patient who has chronic pain can be a complex process and various factors must be considered. It is not uncommon for someone to have low back pain related to degenerative disc disease (nociceptive) as well as diabetic neuropathy creating foot pain and numbness (neuropathic). Furthermore, the etiology of a specifc pain complaint may be unknown; while some Veterans have an identifed precipitating event or trauma demarcating the onset of their pain issues, others do not. There may also be a lack of clarity regarding a specifc diagnosis, something that can be frustrating for the Veteran. As in the lower area of the back, pain is most often related to muscle sprain or overuse, herniated discs, or arthritic processes. It is generally caused by activities that strain the neck such as poor posture or sleeping, muscle tightness, or whiplash from a motor vehicle accident. The most common areas of the body affected include hands, feet, neck, low back, knees, and hips. Progression of the disease can lead to destruction of cartilage, ligaments, and tendons. Tendonitis and bursitis involve infammation of one of the tendons and bursae, respectively. Tendons are thick cords that join muscles to bones and infammation causes pain and tenderness in the joints. Tendonitis is commonly associated with sports involving repetitive motion such as swimming or throwing a ball but can result from any repetitive movement involving the joints. Bursae are fuid-flled sacs found in joints that surround areas where tendons, skin, and muscle tissues meet. Pelvic foor disorders occur when the area that supports the pelvic organs becomes weak or damaged. These may result in urinary or fecal incontinence, as well as persistent pain in the pelvic walls. Some of the common causes are endometriosis, pelvic foor tension myalgia, pelvic infammatory disease, fbroids, surgeries, and irritable bowel syndrome. Pelvic pain is much more common among women, with one in seven experiencing some form of this chronic condition. Gout is a type of arthritis that is characterized by infammation, tenderness, and stiffness in joints. Symptoms are episodic and fare-ups are typically associated with increased levels of uric acid. Uric acid levels are infuenced by genetic factors but also by diet and lifestyle (Gheita, El-Fishwawy, Nasrallah, & Hussein 2012). It involves microvascular lesions in small blood vessels and its development is often associated with high blood sugar secondary to diabetes. Pain quality is often described as numb and tingling, pins and needles, electric, or burning, as opposed to being characterized as pain.

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