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By D. Ortega. Mountain State University.

Letterer–Siwe disease is the acute disseminated progressive life-threatening form of this histiocytosis 8mg reminyl free shipping, with both visceral and bony involvement generic 4mg reminyl with mastercard. Hand–Schuller–Christian disease is the more chronic disseminated form of histiocytosis X, with minimal or moderate visceral involvement, and bone involvement. The diagnosis and management of these two conditions will be left for more appropriate medical textbooks. Computed tomography image showing a large cortical nidus of bone is a histiocytic granuloma that affects osteoid osteoma. The most common location for involvement is the skull, with the next most common site being the femur. The most common presenting symptom is localized pain in the area of bone involvement. The expansile nature of the lesion may weaken the surrounding bone and lead to fracture. Characteristically the radiographic appearance is that of a radiolucent “punched out” appearance with very little, if any, bony reaction to the lesion unless a fracture is present. A skeletal survey is recommended in nearly all cases to evaluate a more systemic distribution. Progressive involvement of the skull to an advanced degree gives the 145 Malignant soft tissue and bone lesions appearance known as the “geographic” skull. Involvement of the vertebra can produce a lesion known as verterbra plana (Figure 6. In the vertebra, the lesion produces intraosseous collapse, but does not appear to affect the adjacent disc spaces (“coin-shaped” vertebra) (Figure 6. In the long bones, the lesions involve the diaphysis as well as the metaphysis and produce their damage by expansion and erosion from within. A radiographic skeletal survey is indicated, and generally provides more information than radionuclide imaging, as many of the lesions are “cold” on scanning. Treatment consists of closed or open biopsy, and histologic documentation of the nature of the lesion. Eosinophilic granuloma of bone is a benign lesion that generally will undergo spontaneous healing, whether treated or untreated. Decisions to proceed with wide curettage and grafting, intralesional injection of steroids, or simple biopsy and observation, are arrived at by the location within the bone and the Figure 6. Lateral radiograph of the thoracic spine with a characteristic subsequent potential damage from the lesion “coin-shaped” vertebrae associated with vertebra plana (eosinophilic (fracture potential). Lateral cervical radiograph demonstrating vertebra plana seen in histologic diagnosis, proceed to orthopedic eosinophilic granuloma. Malignant soft tissue and bone lesions The basic characteristic of malignant soft tissue lesions is an enlarging, firm, painful mass. Malignant bone lesions are often painful in contrast to benign processes. Persistent growth and increasing firmness of a soft tissue mass are hallmarks of malignancy. Lesions deep to the fascia and greater than 5 cm deserve particular attention. Night pain, loss of motion, and radiographic image evidence of a soft tissue component to a bone lesion increase the index of suspicion for malignancy. Standard radiographic examination of the affected portion of the body is always indicated. If a diagnosis cannot be established on clinical assessment and standard radiographs, Miscellaneous disorders 146 magnetic resonance imaging is almost always the best means of evaluation. Computed tomography scanning and bone scanning are of little use in soft tissue malignancies. Ultrasonography may be preferable to magnetic resonance imaging in popliteal soft tissue masses for popliteal cysts.

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Indeed generic reminyl 8 mg with amex, many of the earlier models have proven inadequate for patient care safe 4mg reminyl, and more recent research has superseded initial formulations. Take, for example, the advancement of the original conceptualizations of the gate control theory (Melzack & Casey, 1968; Melzack & Wall, 1965, 1982)—the first to integrate physiological and psychological mechanisms of pain—to the current neuromatrix model as described by Melzack and Katz in chapter 1 of this volume. Similar progress has occurred in the context of biopsy- chosocial approaches that have emerged from postulates of the gate con- 35 36 ASMUNDSON AND WRIGHT trol theory, such that our answers to the “what” and “how” questions just posed are, in our opinion, becoming more clear. To this end, the concepts presented herein provide an important piece of the foundation on which the assessment and treatment approaches described in other chapters of this volume are built. Our intent in this chapter is to provide an overview and critical analysis of the traditional biomedical and psychodynamic models, summarize ele- ments of the gate control theory that strongly influenced current conceptu- alizations of pain, and review important details of models that fall under the biopsychosocial rubric. Within the context of the latter, we include discus- sion of some of the most influential behavioral, cognitive, and cognitive- behavioral models and associated empirical findings. We conclude by posit- ing a synthesis of the various iterations of the biopsychosocial approach, place this in the context of a comprehensive diathesis–stress model (i. TRADITIONAL BIOMEDICAL MODEL The traditional biomedical model of pain dates back hundreds of years. Descartes (1596–1650) modernized it in the 17th century (Bonica, 1990; Turk, 1996a), and in that form it held considerable influence through to the mid 20th century. The model holds, in essence, that pain is a sensory experi- ence that results from stimulation of specific noxious receptors, usually from physical damage due to injury or disease (see Fig. Consider the case of Jamie, a middle-aged person with strained muscles in the low back. BIOPSYCHOSOCIAL APPROACHES TO PAIN 37 diagnosing and subsequently treating Jamie should be, for all practical pur- poses (and notwithstanding availability of adequate diagnostic, surgical, and pharmacologic technology), straightforward. Jamie’s physical pathol- ogy would be confirmed by data obtained from objective tests of physical damage and, if thorough, tests of impairment. Medical interventions would then be directed toward rectifying the muscle strain. The impact of the strain on Jamie’s social, psychological, and behavioral functioning would not be given much weight in any intervention. Indeed, other symptoms re- ported by Jamie, such as depressed mood, hypervigilance to somatic sensa- tions, and pain, would not be viewed as significant but, rather, as secondary reactions to (or symptoms of) the muscle strain. In Jamie’s case, intervention was targeted at healing the muscle strain and all symptoms subsided within 5 weeks. But, for every Jamie there is an- other person for whom application of an identical intervention does not re- solve pain and other symptoms, including disability, despite eventual heal- ing of physical pathology. As becomes evident in this chapter, the reductionistic and exclusionary assumptions of the biomedical models have not been upheld. We now know that pain involves more than sensa- tion arising from physical pathology. Indeed, many people with persistent pain, including perhaps the majority with low back pain, will never have had an identifiable medical diagnosis of tissue damage. Most 20th-century models of pain, including amendments to the tradi- tional biomedical model (e. For example, they posited a primary role for sensation and did not recognize the possibility that sensation and affect might be proc- essed in parallel (Craig, 1984). Still, they demarcated a beginning to the rec- ognition of the interplay between biological, psychological, and sociocul- tural factors in the pain experience. Before turning attention to integrated multidimensional models of pain, we lay more of the groundwork by taking a look at models of the psychodynamic tradition. PSYCHODYNAMIC MODELS The psychodynamic model can be considered to be among the first to posit a central role for psychological factors in pain (see Merskey & Spear, 1967), albeit with an emphasis on persistent (or chronic) rather than acute pres- entations. These models are similar in that, unlike the traditional biomed- 38 ASMUNDSON AND WRIGHT ical model, they shift focus from physical pathology by conceptualizing per- sistent pain as an expression of emotional conflict. Rather than review all of the psychodynamic models, we provide an overview of the influential mod- els of Freud (Breuer & Freud, 1893–1895/1957) and Engel (1959). Freud (Breuer & Freud, 1893–1895/1957) held that persistent pain was maintained by an emotional loss or conflict, most often at the unconscious level. Central to Freud’s model was the process of conversion, or express- ing emotional pain (i. Freud be- lieved that the somatic expression of pain would subside with resolution of the emotional issues.

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Evaluation of the maturation status in boys and girls Stage Characteristics Duration Development stages of the genitalia in boys Stage 1 Prepuberty: Scrotum and penis remain the same size as during childhood Stage 2 Enlargement of scrotum and testes 1 year Stage 3 Lengthening of penis 1 year Stage 4 Penis becomes larger and thicker trusted 4mg reminyl, the glans develops generic 4mg reminyl free shipping, the scrotal skin turns a darker color 2 years Stage 5 Genitalia assume their adult form Maturation stages of pubic hair in boys and girls Stage 1 Prepuberty: Still without pubic hair Stage 2 Sparse growth of fine, light-colored, downy hair, which is straight or only slightly curly, primarily on the 1 year root of the penis and the labia Stage 3 Hair becomes darker, coarser and more curly. Downy facial hair in boys 1 year Stage 4 Hair growth resembles the adult pattern, but the area covered by the hair is smaller, hair growth also in 2 years the armpits. Facial growth more pronounced in boys Stage 5 Pubic hair assumes its adult form Development stages of the breast in girls Stage 1 Prepuberty: Still without breasts, but nipples project Stage 2 Budding breast: Projection of the breast and nipple as a small protuberance 1 year Stage 3 Further enlargement and swelling of the breast without demarcation of contours, the areola also grows 1 year Stage 4 Separate swelling of the areola and nipple across the actual surface of the breast 2 years Stage 5 Breast assumes its adult form. The areola recedes into the general contour of the breast, and only the nipple projects 48 2. The rate of regeneration of the and always in adolescents, between athletic, leptosomic chondrocytes on the one hand and their hypertrophy and pyknic physiques. The intercellular substance with its collagen References fibers maintains the internal cohesion of the growth 1. Thieme, cartilage and is almost exclusively responsible for its me- Stuttgart New York, S 54–55 chanical strength. J Pediatr Orthop 21: 549–55 Within the epiphyseal plate we can distinguish be- 3. Prader A, Largo RH, Molinarik L, Issler C (1989) Physical growth of tween various zones that differ in terms of their organi- Swiss children from birth to 20 years of age. Helv Paediatr Acta zation, the shape and size of the chondrocytes and the Suppl 52 quantitative relationship between cells and intercellular 4. Since the intercellular sub- Stuttgart stance is primarily responsible for the mechanical loading capacity, the weakest zone is in the area of the hypertro- phic cells close to the metaphysis, where the volumetric 2. The growth rate in all mammals is at its greatest im- W e have become accustomed to seeing teenagers win- mediately after birth, and an acceleration of growth also ning Olympic medals in certain sports, for example in occurs during puberty. But perfor- properties of the growth plates occur during this phase, as mance training frequently begins before the completion has been shown by animal experiments employing tensile of growth in other disciplines as well. Sporting activity almost invariably involves peri- in a reactive enlargement of the chondrocytes in the zone ods of acceleration and thus forces and torques. Potential energy is constantly being converted into A reduction in the ability of the epiphyseal plate to kinetic energy and vice versa. If the forces exceed a withstand tensile forces is observed at the start of puberty, certain level, the structure subjected to the greatest particularly in male rats (⊡ Fig. Various hormones stress will fail at the point of weakest mechanical specifically affect the growth plate. If this hormone is lacking, growth tures undergo major changes in terms of their mechani- stops, the epiphyseal plate narrows and its mechanical cal strength between birth and adulthood. By contrast, the administration of important difference between children and adults is the growth hormone above a certain optimal level prolongs presence of growth cartilage. During sexual maturation, the anabolic effect The growth plate normally adopts a position at right an- of the androgens predominates, while estrogens acceler- gles to the force resultants. The anabolic effect of jected to compressive and shear forces and, more rarely, the testosterones is responsible both for the faster growth to tensile forces. Typical growth cartilage plates subjected of male animals (and boys) and for the decline in the to tension are those of the lesser trochanter and humeral mechanical strength of the epiphyseal plate at the onset epicondyle. Unlike androgens, estrogens do not have any plays an important role in the strength of the connec- obvious effect on protein synthesis. At low doses, they tend tion between the epiphyseal plate and the metaphysis. During puberty estrogens slow down the activity of the epiphyseal plate possesses indentations and notches the epiphyseal plate, resulting in an acceleration of the mat- of varying depth. This probably explains why shear forces, but do not play a major role in resisting the phase of epiphyseal plate weakening lasts longer, and is tensile forces. Ultimate tensile strength of the anterior cruciate liga- plate in rats according to age and sex. This is markedly reduced during ment after partial division compared to the sham-operated opposite the pubertal growth spurt (between the 30th and 50th days of life), side in young and full-grown rabbits. Experiments have demonstrated that just 15 minutes of loading is required to stimulate osteoblast growth by extracellular signal-regulated kinase (ERK). Ligaments Stiffness, tensile strength and the collagen concentration of ligaments increase with age, whereas their water con- tent decreases. Effect of sex hormones on the tensile strength of the anterior cruciate ligament of juvenile rabbits has a lower proximal tibial epiphyseal plate in rats: a untreated normal male rats, b castrated male rats, c castrated male rats treated with testosterone, tensile strength but a higher elasticity compared to that of a’ untreated female rats, b’ castrated female rats, c’ castrated female full-grown animals (⊡ Fig. The bone in small ligaments increases steadily from birth until the end of children under 6 years of age also has a lower bending puberty, but that the anchorage between ligament and strength than that of adults (150 Pa vs.

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