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Kassete felt weaker and weaker, and when the pain increased, he increased his dose of codeine. Since he was worried, he used his next trip to his family in Addis Ababa for another visit to the doctor his brother knew. When this doctor was not available, he was seen by another colleague from the internal medicine department, who admitted him immediately when seeing him: he had a maximally extended abdomen, with no bowel movements on auscultation. Rectal examination revealed 137 Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. After that enemas, bisacodyl, and senna were able to regulate the consistency of Mr. He was advised to take senna daily and add a tablespoon of vegetable oil or liquid margarine to his daily diet. Since it was assumed that the constipation was at least in part codeine-induced, the doctor advised him to take senna on a regular base with lots of fluids. According to the opioid equivalence dose list, he calculated the daily morphine demand to be 10 mg q. But his family was shocked to learn that the oldest son was now "on drugs" and joined him on his next visit to the doctor to complain. It took the doctor a lot of courage to explain why opioids were now inevitable and would have to be used by the patient for a long time to come. He also revealed to the patient and the family for the first time that the diagnosis was pancreatic cancer without surgical options. A Cuban doctor currently present at the department suggested a celiac plexus block, but Mr. Kassete travel back to Nazret, and he moved in with his family, which allowed him to use a small room for himself. The hospital dispensary had no slow-release morphine available but handed him morphine syrup in a 0. He was in bed most of the time now, and washing and sitting up for a little snack increased his pain unbearably. But he found that a regular smoke of some "bhanghi" helped reduce the nausea, allowing him, at least, a little food intake. In the next few weeks, his general condition deteriorated, but with 15 mg morphine 4 times daily, and sometimes 6 times daily, Mr. Kassete was fine until he again developed a massive abdominal swelling, with nausea and abdominal pain. Since he was now too weak to go to the hospital, a neighbor working as a nurse was called to see him. When she noticed the foul smell of the vomit, it was clear to her that intestinal obstruction was present, and no further efforts could be indicated to restore his bowel function. Kassete found some rest, was relieved from the pain and from vomiting twice daily, and was almost free of nausea. After becoming sleepy on the fourth day, he died in the night of the sixth day after the beginning of his deterioration.


  • Bleeding time
  • Chlorprothixene (Taractan)
  • The spray is approved for healthy people aged 2 through 49 years.
  • Corticosteroid injections into joints, tendons and ligaments, and around the spine
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A study of male physical education students reported that decreased strength of the muscles that dorsiflex the ankle was associated with an increased risk of suffering an ankle ligament injury (Willems et al. In contrast, a study of male military recruits found no relationship between muscle strength and the likelihood of suffering an ankle ligament injury. Playing position Volleyball athletes are at increased risk when they play the front row positions, by landing under the net after a jump for a spike or block. However, in sports such as basketball and soccer which also involve jumping, planting, and cutting, the risk of ankle ligament injury appears to be similar between positions. Therefore, while in certain sports ankle sprain risk may not be directly associated with playing position, an athlete at a specific playing position Shoe type An extrinsic risk factor, which has been well investigated, is the shoe type. Although most would agree that current athletic shoes offer limited support to an ankle in response to inversion trauma, it is important to recognize that little is known about the effect 36 Chapter 4 may be so well adjusted to his or her tasks that changing roles on the team increases risk. Take-home message In recent years considerable research has focused on risk factors related to ankle sprains. This has resulted in a number of potential risk factors, of which most are surrounded by conflicting findings from scientific studies. The only well documented, and probably by far strongest risk factor for an ankle sprain, is a history of a previous similar injury, especially an injury during the past year. Therefore, it is important to map previous injury and test proprioceptive ankle function by means of a postural sway test. Although preventive measures should be advocated to all athletes, especially this subgroup of previously injured athletes should be targeted with preventive measures, such as proprioceptive training, taping, or bracing. Anterior talofibular ligament Posterior talofibular ligament Calcaneofibular ligament Figure 4. The lateral ankle ligaments Injury mechanisms for ankle sprains Anatomical and biomechanical aspects Before describing the injury mechanisms leading to an ankle sprain, a short description of the ankle complex is required. The ankle is a so-called hinge joint, bringing the lower leg (tibia and fibula) and the foot (talus) together. The hinge allows dorsiflexion (pulling the ankle up to make the toes face up) and plantar flexion (stretching the ankle and make the toes face down). Due to its shape the talus provides maximum stability in dorsiflexion but minimal stability in plantar flexion. Although there is room for some inversion and eversion movement (turning the foot inward or outward respectively), the range of motion of these movements is limited. This limitation in movement is primarily restricted by the capsule surrounding the ankle, which is reinforced by both medial and lateral ligaments. The lateral ligaments, the area of interest here, are the anterior talofibular ligament, the calcaneofibular ligament, and the posterior talofibular ligament (Figure 4. When sitting with a relaxed ankle, the ankle tends to hang in a slight plantar flexed inversed position, that is, the toes are slightly facing the floor and pointing slightly inward.

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Interestingly, a high proportion of identified muscular trigger points coincide with Chinese acupoints. Various tests and questionnaires for the definition of the pain may be used if appropriate, as discussed in the respective chapters. Acupuncture needles are extremely thin and can often penetrate the skin with no pain at all. Some areas may be more sensitive and feel like a small pinch as the needle in inserted, but that lasts for less than a second. Once the needles are in place, there should be no pain, but only a sensation of dull pressure (known as a "De Qi feeling") reflecting activation of A-beta fibers. Application of the needle may be done with the patient in any position, as long as the patient feels comfortable and is relaxed, but it would be clearly advisable to use the supine position during treatment because a minority of patients might get a feeling of dizziness. The acupuncture needles are held between thumb, index finger, and middle finger, with the needle parallel to the index finger. During this time the needles may be manipulated to achieve the effect of toning or sedating the Qi, according to the situation. Needle manipulations generally involve lifting, thrusting, twisting, and rotating, according to treatment specifications for the health problem. Acupuncture in pain management What is more effective in the management of chronic pain? As always, specialists are convinced that their own method is superior, and therefore acupuncturists tend to see acupuncture as a panacea (cure-all). Nevertheless, experienced pain therapists who use acupuncture and go through a thorough training would use a more sophisticated view: creating an antagonism between these two approaches of acupuncture and conventional pain management would be counterproductive for acupuncture in the long run, since its effects are considerable but not overwhelming. Therefore, pain specialists are trying to incorporate acupuncture as a complementary technique into regular pain management as one module together with manual therapy, therapeutic exercises, and psycho- and pharmacotherapy within a therapeutic, rehabilitative, and preventive management complex. Using acupuncture does not eliminate the need for thorough history taking, a physical examination of the patient, as well as laboratory and functional diagnostics. Before applying acupuncture, a proper diagnosis should be established, and it should be decided if acupuncture or another mode of therapy is more promising. Pain is assessed, as always, by using the visual analogue scale What are the complications and side effects of acupuncture? If the practitioner is adequately qualified, side effects and complications are rarely observed. Care must be taken in certain regions in the body where vulnerable structures are close to the skin, such as the lung in the thoracic area or superficial blood vessels and nerves, none of which should be needled. However, this concept is not widely recognized, and existing scientific literature has not evaluated this pragmatic approach. Since the technique of needle placement is simple and acupuncture needles are widely available and relatively inexpensive, it would be a pity if acupuncture would not be used because of the lack of adequate training facilities. Nevertheless, at least some practical and theoretical training as well as anatomical knowledge are indispensable to make acupuncture an effective and safe pain management technique. In situations where even the minimum training is not available, it is advisable to replace the needling technique by acupressure with superficial point stimulation, such as by using small wooden sticks.

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Static Opener Position - painful side uppermost with a bolster under the lower side. If this increases symptoms return foot to couch and place a bolster under waist instead. Degree of opening - depends on response to positioning Duration - 30-60 seconds at first. Monitor symptoms at rest and, if they improve, offer this position as a pain relief strategy. Either leg can be lowered, depending which is more effective in achieving lateral flexion and what is more comfortable for the patient. Progression 1c - Static Opener Position - as above, two feet placed over the side of the couch. Dynamic Opener/mobilisation (Level 1 continued) Passive opener - contralateral lateral flexion Can be done as small or large amplitude, in the inner or outer range. Can be performed as a home also Level 2 - Standard Indications/clinical features At this point, there is little to be found on neurological examination. Now the treatment changes from treating pathophysiology in the nerve root to treating the mechanical dysfunction in the interface. Dynamic Closer Closer mobilisation ?inner, middle and outer range Position - start mobilisation in open position and gently move toward closed position Mobilisation - in the direction of closing but only to the neutral position. If the same after mobilisations, repeat sets of mobilisations, stop and reassess at next session. This can be progressed by positioning the patient into ipsilateral rotation, less hip/ lumbopelvic flexion and even into some extension but care must be exercised. Neural Dysfunctions Clinical Features Symptoms reproduced by movements that produce sliding in one particular direction. You now have a wide variety of techniques below level two that are not likely to provoke symptoms. If they take more than a few seconds, it may be better to do something more gentle. Make sure the amplitude is large so you retreat from the symptomatic position each time. Advanced - reduced closing with neural tension dysfunction Patient position - painful side up Mobilisation - closing (ipsilateral lateral flexion) + neck flexion and knee extension (ie. British Journal of Plastic Surgery 58: 533-540 Beith I, Robins E, Richards P 1995 An assessment of the adaptive mechanisms within and surrounding the peripheral nervous system, during changes in nerve bed length resulting from underlying joint movement. In: Shacklock M (ed), Moving in on Pain, Butterworth-Heinemann: 194-203 Bove, G, Ransil B, Lin H-C, Leem J-G 2003 Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues.

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The N30 potential recorded over the cervical spine (C5S?z montage) represents activity in the fasciculus gracilis, the spinocerebellar pathways, and possibly the gracile nucleus. Stimulation of the posterior tibial nerve bilaterally is frequently helpful in eliciting the tibial lumbar and cervical responses (Fig. It may reflect postsynaptic activity from many generator sources in the brain stem and, perhaps, thalamus. The activity of the foot area in primary somatosensory cortex is ascribed to P38 (also known as P37). To be certain that P38 is absent, record from the ipsilateral scalp as well as from the usual midline location. Key Points ?The major clinically important potentials with tibial nerve stimulation are the N8, N22, N30, and P38 potentials. However, the amplitude of the potentials is much smaller than those obtained with mixed nerve stimulation, and responses are not obtained over the spine. Cutaneous nerve stimulation is used (1) to assess the integrity of specific cutaneous nerves that are not readily studied with conventional nerve conduction study techniques, (2) to evaluate isolated root function, and (3) to assess patchy numbness for medical?egal reasons. Stimulation sites are the thumb (C6), adjacent sides of the index and middle fingers (C7), little finger (C8), the dorsal surface of the foot between the first and second toes (L5), and the lateral side of the foot (S1). Stimulation sites and normal values are available for the cervical, thoracic, and lumbosacral levels. Similarly, the absence of a waveform that is easily recorded on the contralateral side also indicates an abnormality. Occasionally, the lumbar and cervical responses following tibial nerve stimulation are absent in normal subjects and frequently absent in older and obese subjects, particularly if they have difficulty relaxing. Stimulation of the nerve is performed twice to assess for reproducibility of the recorded responses, which helps to assess technical reliability. The lack of superimposable tracings at the lumbar and cervical levels often represents a technical limitation rather than an abnormality. Subcortical or peripheral Somatosensory Evoked Potentials 267 potentials may be low in amplitude or absent, but because of central amplification and several parallel central pathways, a relatively normal scalp response may still be obtained. Factors That Affect the Amplitude and Latencies of the Evoked Response A number of physiologic and technical factors can affect the amplitude and latencies of the evoked responses, and are important to consider in the interpretation of the study. In older age groups, there is a small decrease of peripheral sensory nerve conduction and amplitude, which is most marked distally. According to one study, median nerve central conduction time (N13?20) was constant between the ages of 10 and 49 years, increased by 0.

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After major surgery, the first 48 hours will be the critical period, but some patients will need analgesia for weeks. Analgesia can be started with intravenous strong opiates, with or without regional and local anesthetic techniques, and gradually tapered to weaker drugs by the oral or rectal routes over several days. The intramuscular use of drugs immediately after operations is not advisable because the results are not very predictable and they are difficult to control. When using systemic analgesia, we are particularly concerned about the use of opioids. Respiratory depression can be difficult and unreliable to detect at the initial stages. Since excessive sedation usually comes before respiratory depression, if we monitor sedation carefully and regularly, we should be able to prevent respiratory depression. A simple sedation score like the one below should be used for all patients on opioids: Grade 0 patient wide awake Grade 1 mild drowsiness, easy to rouse Grade 2 moderate drowsiness, easy to rouse Grade 3 severe drowsiness, difficult to rouse Grade S asleep, but easy to rouse the key to safe use of opioids in poorly resourced countries is therefore to monitor the sedation score very closely and avoid Grade 3 sedation. Although we still do not fully understand the development of chronic pain after surgery, we now know a lot about the incidence of chronic pain after surgery and about ways to prevent its occurrence. Although the numbers tend to vary after most types of surgery, about one out of every 10?0 patients will have long-term pain after surgery, and for half of them, the pain will be severe enough to need treatment. We now know that good pain control, no matter how it is achieved, will reduce the number of patients experiencing long-term pain after major surgery. We also know that only a negligible number of patients who receive opioids for acute pain after surgery will become addicted or dependent on opioids if the drugs are used in a controlled manner. There is, therefore, no justification for withholding strong opioids from patients because of the fear of addiction, as is done in many developing countries. Ironically, many patients in these countries can barely tolerate the euphoria, drowsiness, and other effects caused by the opioids. Some patients in poorly resourced countries will not accept opioids postoperatively when given the choice. All patients should have the following monitored after all major surgery: ?Level of consciousness ?Position and posture of the patient ?Rate and depth of respiration ?Blood pressure, pulse, and central venous pressure, when indicated ?Hydration state and urine output ?All medications being administered along with analgesics ?Patient activity and satisfaction. Complications such as nausea and vomiting can be troublesome and should be controlled with antiemetics. Constipation may be a problem after prolonged use of opioids, and mild laxatives like lactulose can be used. Renal, bleeding, and other problems can be worsened by the use of nonsteroidal anti-inflammatory drugs and other analgesics, and patients should be Pain Management after Major Surgery monitored more closely if there is any cause of suspicion from the history and examination. Peripheral analgesics Peripheral analgesics are sometimes described as weak to moderate analgesics, and they can be used intravenously, intramuscularly, rectally or orally. Although they may not be able to control pain alone after major surgery, they are very useful in combinations with one another or with opioids and other analgesic techniques. One of the new major developments in postoperative pain management is the regular use of peripheral analgesics after all grades of surgery.

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Reproduced with permission from Myklebust and Bahr (2005) skiers and snowboarders indicating a significant reduction in the risk of head injury with helmet use (Hagel et al. Many major public health and specialty journals are currently publishing new studies in this field. The publication of these studies in highly respected medical, physical therapy and nursing journal illustrates that sports injury prevention is an important public health issue. There is no longer any doubt that regular physical activity reduces the risk of premature mortality in general, and of coronary heart disease, hypertension, colon cancer, obesity, and diabetes mellitus in particular. The question is whether the health benefits of sports participation outweigh the risk of injury and long-term disability, especially in high-level athletes? A study from Finland has investigated the incidence of chronic disease and life expectancy of former male worldclass athletes from Finland in endurance sports, power sports, and team sports (Sarna et al. The overall life expectancy was higher in the high-level athlete compared to a matched reference group (75. They also showed that the rate of hospitalization was lower for endurance sports and power sports compared to the reference group (Kujala et al. This resulted from a lower rate of hospital care for heart disease, respiratory disease, and cancer. However, the athletes were more likely to have been hospitalized for musculoskeletal disorders. Thus, the evidence suggests that although sports participation is beneficial, injuries are a significant side effect. To promote physical activity effectively, we have to deal professionally with the health problems of the active patient. This does not only involve providing effective care for the injured patient, but also developing and promoting injury prevention measures actively. To prevent injury, scientists must first correctly identify one or several risk factors, the mechanisms of injury, devise an effective intervention to modify it, implement the intervention with sufficient compliance, and study the outcome of the intervention with a method that is sensitive enough to detect reductions in the injury rate which are clinically meaningful. When prevention is successful or fails, it may not always be clear which step in this chain of events was deficient. The list is increasing year by year for the benefit of the athlete and the sports. In addition, this book initiative has been supported by all of the major sports and sports medicine organizations, which bodes well for the future. The future of injury prevention Do we need to further develop prevention programs in the future?

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They also may need help talking with the school about accommodations, developing study skills and dealing with symptoms that may interfere with success. High School If the young person is in high school, the school will need to be involved to give them educational services if they are hospitalized, in day treatment or unable to attend during the traditional school day. Loved ones should work with school officials to develop a plan for completing any work that was missed during the crisis. Time out of school for mental health reasons should be treated the same as for any other condition, such as cancer. When the student returns to school, they will likely be taking antipsychotic medication. Side effects of antipsychotics that can affect a student at school include drowsiness or lack of energy, dizziness, dry mouth, blurred vision and constipation. An accommodation for someone with a side effect of drowsiness or lack of energy, for example, might be to have a study hall in the first period, when the fatigue is greatest, or arrange to start the school day later. Before the student returns to school, meet with school officials to create a plan to ensure success. People with disabilities have the same access to public education as any other student. Under the law, schools must provide reasonable accommodations to anyone with a disability, including mental illness. Small accommodations such as scheduling a study hall first thing in the morning can be arranged by using a document called a 504 Plan, named after a section of the law. If the student needs more help than a 504 Plan can give, an evaluation for special education services may be needed. You should feel free to offer suggestions, ask questions and approve or disapprove of any action of the special education team. If special education is agreed to, a meeting will be held to decide what extra help and support the student will get. Young people who want to go on to college or job training should talk with their high school guidance counselor about accommodations in college or trade school. This is the time the young person should be learning about their educational rights. College College or job training is an achievable goal for young adults with mental illnesses. If there is no formal office, they can ask the admissions counselor whom to contact. But it is important for them to know whom to contact if help is wanted or needed later. The student should meet with school disability services staff every time they register for classes to see if more accommodations are needed. Bouts of depression, anxiety, difficulty with concentrating and other symptoms, as well as medication changes and side effects, can make college success a challenge.

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This response has a positive peak maximal at the vertex and a latency of about 1400 ms. It is unreliable in recordings unless preferential A-fiber block suppresses the late component. A deep dipole in the midline corresponding to the location of the anterior cingulate gyrus is primarily responsible for the P2 component. Contralateral primary and secondary somatosensory cortex activity appears to be the generator of the middle latency (N1) component. In a case of polyneuropathy in which the nerve conduction distance between the hand and the foot was 0. This study confirmed that A peripheral afferents are responsible for transmission of the late component Electrophysiology of Pain 687 Hand Conventional average Latency corrected average Conventional average Foot ?10 V + 0 t (ms) Subject H. Top traces: Following stimulation of the right hand, a normal A-fiber-related late potential was recorded. Bottom traces: Following stimulation of the left foot, the late potential was markedly decreased in amplitude and a C-fiber-related ultralate potential was documented. The heat-pain threshold for laser stimuli was unremarkable in both areas, but a pronounced temporal summation occurred with stimulation of the foot. This unmasking appears to provide a cortical correlate for disinhibition of C-fiber responses to noxious heat that occurs in persons who display wind-up when A fibers are impaired. Contact heat is a natural stimulus, but previously could not be used as a suitable stimulus for evoked potentials due to its slow rise time. Forty trials are averaged and recordings are performed as per routine somatosensory evoked potential. Four peaks become visible then: N450 (at T3), N550 (at Cz), P750 (at Cz), and P1000 (at Pz). This stimulus appears to activate both A and C fibers; it sometimes can induce two types of sensations: a first sharp pain followed by a second, duller type pain. The calculated conduction velocities for the first peak (N550) would fit A fibers (10 m/second) and can be generated at temperatures of 45 C. The later components (around 1000 ms) would be the result of C-fiber activation (velocities estimated at 2? m/second) and are visible only with higher peak temperatures around 52 C. The reduction in flare response and fiber count correlated with the potential amplitude. Contact heat stimuli at 53 C evoked a blink-like response in the relaxed orbicularis oculi muscle and a silent Electrophysiology of Pain ?0 Amplitude (V) ? 0 5 0 ?0 Amplitude (V) ? 0 5 0 ?5 Amplitude (V) ?0 ? 0 5 10 0 Cz/P750 Cz/P1000 Moderate pain (l-6) Cz/N550 Slight pain (l-4) Warm, nonpainful (l-2) 689 Figure 40?1. Vertex waveforms in relation to stimulus heat energy levels (I-2, I-4, I-6), resulting in increasing pain sensation on verbal rating score.


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We are now able to offer additional treatment modalities that make the original Prolotherapy even better, including Cellular Prolotherapy and guidance options. We have spread the word about the life-changing effects of Prolotherapy through books, blogs, the Journal of Prolotherapy, and social media. We will continue to press on in our quest to provide awesome service to our patients as well as provide you with the best quality and cost-effective services that we can. They have been told to "live with the pain" or "wait until you are old enough for joint replacement surgery. I also saw the lack of significant pain relief by modern treatments such as surgery, physical therapy, and anti-inflammatory drugs. The psychological aspect of the pain is addressed, but in many cases the cause is not determined. The only other time I had come across the term was when a fellow resident showed me a book on the treatment. I learned that if someone suffers from pain and someone else has a technique that will help alleviate the pain, time and expense are minor considerations. One can go through each body part, as this book will cover many of them, and the scenario is the same. As this book explains, the concept applies to the spine, hip, shoulder, ankle and every other joint in the body. I am an avid athlete myself, having completed five ironman triathlons, a number of ultramarathons and marathons, as well as many other shorter running, cycling, and swimming events. I am passionate about helping people get back to doing the things they love to do. I cannot even tell you how many times I have benefited from receiving Prolotherapy for the many injuries I have sustained over the years of hard training. As Prolotherapy continues to be established in areas around the world, it is exciting to see how other doctors and their patients are finding out what we have known for a very long time-No matter how bad your pain, how long you have had it, or how many surgeries you have gone through, you can always "Prolo Your Pain Away! Prolotherapy solutions are injected into the painful areas, which produces local inflammation in the injected area(s). The shrinking collagen tightens the ligaments that were injected and makes them stronger and more secure, thus stabilizing the unstable joint(s). One of the most important aspects of healing is injecting enough of the right type of solution into the entire injured and weakened area(s). Hackett, who believed chronic pain was simply due to ligament weakness in and around the joint. Prolotherapy stimulates structures to repair and strengthen, thus it can eliminate most structural musculoskeletal pain located anywhere in the body. The force is typically felt in the ligaments, especially if there is a rotatory component to the stress. The term enthesopathy typically refers to a degenerated enthesis; though when modern medicine uses this term, they typically mean enthesitis. This book will discuss in more detail later how the body actually heals by the process of inflammation; thus anti-inflammatory medications not only do not treat the underlying cause of the condition, but make it worse by halting the healing process.


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