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Would a traditional family systems approach be as effective as an operant or CBT approach involving the spouse? With the described CBT approaches purchase protonix 20mg overnight delivery, would more attention to family issues that do not revolve around pain assist with outcomes? Would clinical work with in- dividual families be of greater benefit than family group treatment? Should issues or family interactions that are independent of illness-specific family issues also be addressed in therapy? What outcomes are of greatest inter- est in the treatment of families protonix 40mg discount, individual cognitive and behavioral out- comes, or transactions with family members? Much of this research has been undertaken with surprisingly little refer- ence to the psychological literature on couples and families, as if all usual interactions are rendered unimportant by the presence of pain. When ques- tioned or tested, the assumptions made about transactions are not well supported, such as the many interactions that don’t fit the widely used cat- egories of the Multidimensional Pain Inventory, which captures only re- sponses by spouses that are solicitous, punishing, or distracting (see New- ton-John & Williams, 2000). Further, as described earlier, in other fields of health and illness, social support is demonstrated to be a resource for health (e. In general, psychody- namic psychotherapy is not considered to be treatment of choice, but rather is regarded by some as a final treatment option for those who have not responded to other forms of psychological intervention or have not maintained treatment gains (Grzesiak, Ury, & Dworkin, 1996). It has been speculated that this form of treatment is appropriate for those individuals who have had early experiences (e. Others have elabo- rated that this form of therapy is appropriate for those who demonstrate certain psychological characteristics such as marked dependency, passiv- ity, masochism, denial, regression, repressed anger, overt hostility, or neu- roticism (Lakoff, 1983). Few extended discussions of psychodynamic therapy for chronic pain exist. Central to psychodynamic therapy, however, is the importance of influences on behavior of which the patient may not be aware (Perlman, 1996). Therapy involves gaining understanding of the patient’s world, es- pecially developmental history, on which a dynamic model of pain can be formulated (Lakoff, 1983). Pain appears by most therapists following this tradition to be understood as a “real” problem, not simply symbolic or metaphorical. Numerous themes may arise in psychodynamic therapy and have been discussed in a recent chapter by Grzesiak et al. Themes can range from discussion of early childhood experiences, such as relationships with family or the experience of physical or sexual abuse, to discussion of the expression, or lack thereof, of emotion. In part, the therapist and patient work together to release affect and may explore pain as in part a metaphor for underlying conflicts (Perlman, 1996). Psychodynamic therapists at times focus on the therapeutic relationship, which may be particularly appropri- ate for those patients who tend to be unrealistically dependent in their rela- tionship to caregiver. Therapy can utilize the patient–therapist relationship as a method of facilitating change; the therapist works to establish and sus- tain a relationship that enables patients to change. The themes that emerge in psychodynamic therapy are not necessarily unique to this approach and emerge in other types of therapy as well. It is incorrect to imply that only psychodynamic treatment addresses emotional problems. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 291 similar to CB therapy, namely, a cognitive emotional shift. The therapist aims to help the patient accept his or her pain as important but not a defin- ing aspect of the self, and as regrettable but nevertheless manageable. Through therapy the person becomes an individual with persistent pain, who is able to remove pain from the center of existence and find purpose instead of anguish (Grzesiak et al. Evidence and Commentary One of the main criticisms regarding the psychodynamic approach is that the ideas are not well formulated or comprehensive (Turk & Flor, 1984). There is very little data on the efficacy or effectiveness of psychodynamic therapy, and therefore one must question whether time and financial re- sources should be used for a therapy of no proven value. For psycho- dynamic therapy to warrant serious consideration, attention needs to be given to standardization of treatment protocols and randomized compari- son to alternate treatment strategies. Given the higher cost involved in this typically longer term approach, it needs to show itself to be considerably more effective than other approaches. PSYCHOLOGICAL INTERVENTION SECONDARY TO MEDICAL INTERVENTION Although psychological treatment for chronic pain is no longer conceptual- ized as a treatment of last resort, and some suggest it as first resort (Loe- ser, 2000), there are few published accounts of its integration with medical treatment and much less research. The primary area where reference is made to the integration of psychologists on medical teams is in multi- disciplinary pain clinics or programs (e.

Hummer HP purchase 20mg protonix free shipping, Rupprecht H (1985) Die Asymmetrie der Trichter- possible 40 mg protonix sale, which can result in a compensatory countercurve brust: Beurteilung, Haufigkeit, Konsequenzen. Z Orthop 123: 218–22 in the proximal part of the spine (compensatory bending 5. Iseman MD, Buschman DL, Ackerson LM (1991) Pectus excava- towards the opposite side in scoliosis or cervical lordosis in tum and scoliosis. Any combination of these deformi- nary disease caused by Mycobacterium avium complex. Am Rev ties is possible depending on the posture of the patients Respir Dis 144: 914–6 and the externally acting forces. Miller K, Woods R, Sharp R, Gittes G, Wade K, Ashcraft K, Snyder C, Andrews W, Murphy J, Holcomb G (2001) Minimally invasive While the deformity in younger children can appear repair of pectus excavatum: a single institution‘s experience. Nuss D, Kelly R, Croitoru D, Katz M (1998) A 10-year review of a the mobility of the spine is largely preserved as a rule. Waters P, Welch K, Micheli LJ, Shamberger R, Hall JE (1989) Sco- come increasingly structurally fixed and can cause severe liosis in children with pectus excavatum and pectus carinatum. The pain is predominantly triggered by the Pediatr Orthop 9: 551–6 ribs coming into contact with the iliac crest. While children with very severe spastic cerebral palsies are unable to complain about the pain verbally, this does not imply its absence. However, those who look after such patients generally notice when the children do experience pain. Radiographic findings Compared to an idiopathic scoliosis, a neurogenic sco- liosis associated with cerebral palsy shows the following features: ▬ The scoliosis is in the form of a broad C-shaped arch: In patients with severely impaired balance and body control, the characteristic countercurves observed in a idiopathic scolioses are absent (⊡ Fig. This cor- relates directly with the patient’s mental and neurolog- ical status. This lack of countercurves is most marked in patients who are unable to either sit or stand independently, whereas cerebral palsy patients who are capable of walking always have a countercurve of varying degree on both sides of the main curve, al- though they are often unable to straighten themselves out as well as patients with idiopathic scolioses. Pelvic obliquity and hip dis- a location can mutually influence each other. The hip on the higher side of the pelvis is particularly at risk since it is adducted. There is no statistical correlation, however, between the side of the hip dislocation and the direction of the pelvic obliquity. Treatment ▬ In contrast with idiopathic scolioses, neurogenic sco- Therapeutic objectives lioses are frequently associated with a kyphosis. The Most patients are so severely disabled that they are con- kyphoses are usually thoracic and severe hyperlor- fined to a wheelchair. The seat of the wheelchair must dosis is often present at the lumbar level. In certain take into account the problems associated with the sitting patients the kyphosis is the dominating factor, over- position and the spinal deformity and be adapted accord- riding the lateral curvature in terms of severity. Stabilization of the trunk usually also improves the head control, in some cases giving the patient some head control for the first time. When the patient is upright, the unstable trunk tilts to one side as a result of weak muscle tone. Gravity pulls on the trunk, exacerbating 3 the deformity, which becomes increasingly fixed, par- ticularly during growth. Conservative treatment Brace treatment is possible provided the spine can be straightened sufficiently to allow the axial pressure to be deflected so that it is over the spine in the upright posi- tion. This goal can best be achieved if the plaster cast is prepared in a position of hypercorrection, because the patient will tend to spring back to his abnormal shape while wearing the brace. Brace treatment is indicated if the Cobb angle is between around 30° and 70°. No precise limit can be stated, since other factors unrelated to the severity of the scoliosis are also important, for example obesity, tolerability of the brace and the mate- rial, respiratory impediments, disorders of the airways and acceptance by the parents and caregivers. This allows flexion should not be fitted too tightly at the thorax because of movements yet still provides adequate lateral support the need to allow chest movements for breathing.

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