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In reality cialis black 800 mg on line erectile dysfunction doctor in houston, some operant condi- tioning strategies are used with other psychological interventions and phy- sical/medical treatments within a multidisciplinary treatment program order cialis black 800 mg on line erectile dysfunction specialist doctor. What appears to be one of the most useful aspects of the operant approach is the identification of a broad range of behaviors that are associated with pain, rather than a focus on simply pain intensity (Keefe, Dunsmore, & Bur- nett, 1992). Furthermore, as a result of operant conditioning approaches, it appears that there has been much greater attention on reducing inactivity, and the negative side effects associated with it, and on goal setting in gen- eral (Fordyce, 1988). Finally, the operant approach also has served to em- phasize that chronic pain occurs in a social context (Fordyce, 1976). As such, therapists today are more likely to involve family members in treat- ment (Keefe et al. RESPONDENT THERAPY Background and Description Diverse pain management strategies deriving from the respondent formula- tion of pain are commonly used to treat chronic pain, such as progressive muscle relaxation and biofeedback. The rationale identifies the pain–ten- 276 HADJISTAVROPOULOS AND WILLIAMS sion cycle as contributing to the pain experience, and thus reduction of muscle tension is the characteristic goal of treatment (Linton, 1982). Central to this view is that pain elicits a response of increased muscle tension, which itself produces more pain, and contributes directly to secondary problems such as sleep disturbance, immobilization, and depression (Lin- ton, 1982). Therapy includes educating patients regarding the association between tension and pain, and learning to replace muscle tension with an incompatible response, namely, relaxation (Turk & Flor, 1984). Relaxation therapy involves teaching patients to achieve a physiological sense of relaxation. Beyond physically reducing muscle tension, and thus pain, relaxation can have other aims, including anxiety reduction, assisting with sleep disturbance and fatigue, increasing well-being, and perhaps most importantly improving a sense of control. Progressive muscle relaxation is undoubtedly the most common form of relaxation training, and involves systematically tensing and the relaxing major muscle groups throughout the body (Turner & Chapman, 1982b). Biofeedback also involves relaxation of muscles, but is achieved through monitoring bodily responses, typically through a computer or apparatus, and providing patients visual or auditory feedback about their physiologi- cal responding. With intense scrutiny and examination, it is hoped that the patient will be able to learn how to control certain physiological responses related to pain (Arena & Blanchard, 1996). Many forms of biofeedback exist, but electromyographic (EMG) feedback, aimed to reduce muscle tension, is by far the most common with chronic pain patients. The focus has also largely been on headaches, although other conditions such as low back pain (Arena & Blanchard, 1996; van Tulder et al. At times, relaxation and biofeedback strategies are used on their own, but most commonly they are used in combination with each other as well as with the other treatment approaches described in this chapter. The ex- ception to this is with headache sufferers where biofeedback and relaxation are not infrequently used as sole treatment strategies (Arena & Blanchard, 1996). Treatment is most often offered on an outpatient basis in a group or individual format (Blanchard, 1992). These techniques help the patient to recognize and alter pain behavior patterns. As such responsibility for treat- ment rests largely with the patient (Keefe & Bradley, 1984). Home practice is often encouraged with these techniques, as is application to stressful sit- uations and events. One interesting finding that has emerged with respect to headache is that home practice appears to be important with relaxation, but not necessarily with biofeedback (Blanchard, 1992). In addition to relaxation strategies and biofeedback, imagery and hypno- sis are also used to achieve similar effects with chronic pain patients 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 277 (Arena & Blanchard, 1996). To the extent that they rely on effective relax- ation, respondent theory is relevant to them. Imagery involves the purpose- ful use of visual images to strengthen distraction and/or to transform as- pects of the pain experience. Hypnosis involves suggestion for decreasing discomfort or transforming or altering pain into less noxious sensations (Syrjala & Abrams, 1996). Evidence A number of reviews of the effects of relaxation therapy and biofeedback have been carried out with headache (e.

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Overview of a stepped approach to population-based healthcare for postwar idiopathic pain and fatigue Step Emphasis Setting Goal General Information approach systems 1 Postwar symptom Preclinical Incidence and General prevention Identify prevention prevalence efforts based on precipitating reduction exposures and events proximity 2 Routine primary Primary care Identification Primary care provider Identify care symptom and prevalence delivers diagnostic symptoms and mitigation reduction services purchase cialis black 800mg mastercard erectile dysfunction caused by anabolic steroids, low intensity concerns treatments buy 800 mg cialis black visa erectile dysfunction drugs generic names, and psychosocial support 3 Collaborative Primary care Prevalence Interdisciplinary Identify persistent primary care reduction practice team symptoms or symptom reduction intensifies care in concerns and disability coordination with prevention primary care provider 4 Intensive Specialty care Morbidity Specialized Identify persistent rehabilitative reduction multidisciplinary symptoms or reduction of symptom and multifaceted concerns duration and disability rehabilitative combined severity programs with disability Table 3. Preclinical modalities used to prevent chronic idiopathic postwar pain and Workplace screening fatigue Workplace education and support networks Informal (‘lay’) debriefings Family education and support networks and chronic pain, fatigue and other idiopathic symptoms are common after catastrophic events including war. Workplace educational approaches teach workers about health risks and psychosocial responses to war. Community and workplace leaders often facilitate an early return to usual work routines and other roles in an effort to maximize postattack productivity. Town hall-style meetings in which leaders address community concerns provide forums for information dissemination and feedback to leaders from members of the community. Telephone ‘hot lines’ also afford personalized contact to people with health-related questions or concerns or who desire clinical care. However, randomized controlled trials of psychological debriefings have shown no efficacy and even potential for harm. Perhaps this is not surprising given that the majority of individuals do well after a traumatic experience and can therefore only experience potential adverse effects (e. In addition wide-scale preclinical debriefings are seldom feasible to perform with appro- priate quality control procedures. Workplace liability concerns and over- whelming community desires to help victims often fuel preclinical debriefings, but scarce community resources may be better directed toward targeted clinical efforts to recognize and intervene early for adverse trauma-related outcomes including chronic pain, fatigue and other idiopathic symptoms. Population-based preclinical screening is another commonly considered postwar strategy. Screening involves identification of individuals in need of clinical management (individual-level intervention delivered in a healthcare setting). Surveillance, by comparison, is the use of active and passive health measurement strategies to characterize the health of a community and its subgroups. It is often assumed that screening is harmless, but population- based preclinical screening has the potential to unnecessarily medicalize psychosocial concerns, and there are often significant problems with false- negative and false-positive findings. Particularly in military and other occupa- tional settings, forced screening has the paradoxical potential to stigmatize the exact problems one is seeking to identify for the purpose of providing care. Instead, screening for postwar symptoms and disability in the privacy of the primary care setting, clinical tracking of associated outcomes, and intensifica- tion of treatment for those with identified needs is the approach we currently recommend. Routine Primary Care Mitigation of Postwar Symptoms Chronic postwar pain and fatigue, among other idiopathic symptoms, should be expected even after relatively successful implementation of preclinical prevention programs, because clearly effective preclinical strategies are lacking. Data from the general population suggest that virtually all individuals with chronic postwar pain and fatigue will see a primary care provider over the course of a year. Therefore, a key population-based healthcare response following war is early primary care recognition of these and other idiopathic postwar symptoms (see table 4). Once identified, providers can administer modest individual-level interventions to mitigate the impact of the precipitating event and reduce the potential for perpetuating factors to prolong the symptoms and their related disability. The focus on intensifying treatment for those Engel/Jaffer/Adkins/Riddle/Gibson 110 Table 4. Modalities for routine primary care mitigation of chronic idiopathic postwar pain and fatigue Patient screening for symptoms and distress Patient education regarding chronic pain and fatigue, depression, and distress Management of depression Clinician reminders Clinician feedback regarding patient outcomes Systematic consultation based on complications, nonresponse/persistence seeking care helps avoid stigma that may be introduced by preclinical screening and referral. Because the symptoms linked to disability in the primary care setting are often idiopathic, a patient-centered approach is most comprehensive. An appropriate approach involves initial diagnostics directed toward clinical suspicions with watchful waiting to ensue if the evaluation is negative. In parallel, provider and patient collaboratively negotiate the nature, probable cause, and treatment focus. Assessment of depressive and anxiety disorders and, when necessary, introduction of related treatment options should occur early and openly. Providers often fail to communicate the degree of diagnostic uncertainty inherent in clinical practice, and they often equate ‘absence of an explanation’ to ‘psychological explanation’, alienating many patients in the process. Instead, given the expected relationship between war, distress, mental illness, idiopathic symptoms, and disability, the possibility of future mental health consultation should be destigmatized by describing it early to patients as ‘a routine part of caring for patients distressed by disabling postwar pain and fatigue’.

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Strength training buy 800mg cialis black with mastercard impotence following prostate surgery, Maintenance: In addition to the psychologic charac- balance training cialis black 800 mg line erectile dysfunction alcohol, and flexibility training are particu- teristics described with the stages-of-change model, larly important for elderly patients. Elderly patients should also perform account for changes in cardiovascular condition and strength training activities with single sets of 10–15 enhanced muscular performance. While many elderly patients are fearful that increased levels of physical activity increases their risk of falling and bone fracture, evi- THE EXERCISE PRESCRIPTION: dence indicates that patients who are physically active BEYOND CARDIOVASCULAR have a reduced risk of falling and lower rates of frac- ENDURANCE ture (Mazzeo and Tanaka, 2001). The same FITT principle can be DIABETES applied to muscular conditioning as well. Exercise and Intensity: To develop muscular strength, individuals proper nutrition are essential components of diabetic should perform several sets of exercises using three to disease management. The Pregnancy-induced hypertension, preterm, or prema- content of the meal should be tailored in accordance ture rupture of membranes, preterm labor, persistent, with estimated intensity, duration, and energy expen- or unexplained vaginal bleeding or intrauterine diture of the exercise session. If the pre- activity serum glucose is less than 100 mg/dL, a sup- plemental snack should be consumed before exercise. If the serum glucose is greater than 250 mg/dL or the urine is positive for ketones, the exercise session REFERENCES should be postponed. Balady GJ, Ades PA, Comoss P, et al: Core components of car- After exercise, patients should monitor serum glucose diac rehabilitation/secondary prevention programs: A state- levels and be alert for signs and symptoms of either ment for healthcare professionals from the American Heart hypoglycemia or hyperglycemia. Association and the American Association of Cardiovascular and Pulmonary Rehabilitation Writing Group. Evidence-based nutrition principles and recommendations for the CORONARY ARTERY DISEASE treatment and prevention of diabetes and related complica- tions. Philadelphia, reduced in patients suffering a myocardial infarction Lippincott, Williams & Wilkins, 2000, pp 165–199. Promoting and prescribing exercise for the guidelines regarding staffing, supervision, and progres- elderly. Physical activity PREGNANCY and health: A report of the surgeon general. Atlanta, GA, US Department of Health and Human Services, Centers for Physical activity is safe for pregnant patients and should Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Healthy People mulate 30–60 min of moderate physical activity at least 2010: Understanding and Improving Health. Washington, DC, three times per week (American College of Obstetricians US Department of Health and Human Services, Government and Gynecologists, 1994). Behavioral counseling in pri- As pregnancy progresses, a pregnant woman’s center mary care to promote physical activity: Recommendations and of gravity changes, and she should be counseled to rationale. The Surgeon General’s Call to Action Centripetal obesity in which the waist-to-hip ratio is to Prevent and Decrease Overweight and Obesity. Rockville, high indicates a subset of individuals at much higher MD, US Department of Health and Human Services, Public risk of cardiovascular diseases (Perry et al, 1998). Health Service; Washington, DC, Office of the Surgeon In spite of the health risks of obesity, a number of over- General, 2001. In some sports, including football, weight primary care physicians in the era of managed care. A ‘‘stages of change’’ power lifting, excessive weight has generally been approach to helping patients change behavior. These may include diets with excessive high fat and high glycemic foods. Michael Shea, MD Highly competitive athletes may need to consume Rebecca Spaulding, MD 1500 to 2000 access calories per day to account for David Stewart, MD the calorie expenditure of intense training. Dietary calorie consumption appears to be a learned behavior and appetite often does not decline with a reduction in activity levels (King, Tremblay, and Blundell, 1997). INTRODUCTION Injured athletes and athletes who retire from a sport have a tendency to continue to ingest excessive calo- Medical problems are common in athletes and lead to ries. This may lead to weight gain during injury approximately 70% of the visits that athletes make to recovery, the off-season, or after retirement in those doctors.

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Indeed buy cialis black 800mg visa erectile dysfunction in young adults, according to Mechanic buy 800mg cialis black erectile dysfunction usmle, cultural differ- ences cannot be explained by learning and personality alone, but also re- quire an appreciation of the sector of society to which people belong. Me- chanic’s observation raises interesting questions about how those working in pain might better explore social identity with their patients, and at the same time provides a link to a higher level of analysis in this model. Pain severity also affects decisions about whether, when, and from whom to seek health care, and consequently has economic as well as social implica- tions for mechanisms of health care delivery (Foster & Mallik, 1998). How- ever, contrary to popular belief, people do not always seek help for their health when they are “sickest,” but are more likely to do this when the symp- toms interfere with their lives (Zola, 1973). Indeed, the point at which some- body obtains professional help may in some cases be a factor contributing to the transition from mild to severe pain, if the delay is considerable. Concep- tually, it is worth considering the relationship between acute anxiety and de- pression, and the perceived severity of symptoms, as this combination is known to be a springboard to seeking help from others, whether this is self- referral to health professionals (Ingham & Miller, 1979), the utilization of lay networks, or help from alternative, spiritual, and other sources. The way that individual pain patients behave is guided by how they see themselves, the way they organize knowledge about their bodies, the na- ture of the pain, the availability and accessibility of care, and information that determines whether treatments prescribed are acceptable. Abstract concepts, or schemata, are theories that pain patients hold about pain and treatment that influence the ways in which they selectively absorb new knowledge, remember it, and make use of it, to make sense of their painful experience and to inform decision making. Reality is structured and simpli- fied, and these schemata mix and interpret past and present experience. In- vestigating and systematically recording the nature of these key concepts, and how those about the painful experience are stored and organized in the memory, allows us to better understand how patients think and therefore more readily anticipate what they may or may not do as a consequence. This is particularly important when trying to maximize concordance with medical advice or in outlining pain management strategies. By doing this, the twin goals of increasing self-efficacy and improving outcomes may be better achieved (Jensen, Turner, & Romano, 1991). Emotions and mood states like depression are influenced by our social surroundings. Moods are worth studying not only be- cause they relate to the affective qualities of pain that are more commonly expressed by those in chronic pain (Skevington, 1995) but also because 186 SKEVINGTON AND MASON they are firmly grounded in coping behaviors, or shortage of them. In a study of humor related to pain and disability, Skevington and White (1998) found that patients with chronic arthritis (n = 100) reported they could readily change their own mood and that of others by using humor and jokes to deflect the social unease caused by visible evidence of their pain and disability. Linking into levels 2 and 3, the use of humor sets others more at their ease in this socially uncomfortable situation. Such studies re- veal the potential for people to affect their social environment by adopting particular strategies. These studies could have important implications for managing social relationships while simultaneously managing pain. Given the large body of literature illustrating the clear link between pain and depression (e. In a recent systematic review and meta-analysis, Dickens and colleagues looked at the strength of the relationship between rheumatoid arthritis (RA) and depression (Dickens et al. Examining 12 independent studies comparing depression in RA patients and healthy controls, they found that depression was more common in RA patients and could be at- tributed to the level of pain. Other important psychological concepts include anxiety and fear avoid- ance (e. The fear–avoidance model has received considerable empirical attention recently, particularly in the development and maintenance of chronic mus- culoskeletal pain. Vlaeyen and Linton (2000) extensively reviewed the litera- ture on fear–avoidance, the concept of fear of pain and methods of assess- ing pain-related fear. They concluded that the bulk of evidence pointed toward the importance of pain-related fear in explaining the differences ob- served in physical performance and self-reports of disability. Related to this concept is catastrophizing, where pain is interpreted as threatening. The perception of threat may be a precursor to fearing pain, and the conse- quent hypervigilance to bodily sensations (Vlaeyen & Linton, 2000). In a re- cent study, Sinclair (2001) examined the predictors of catastrophizing in a study of 90 female RA patients. Dispositional pessimism, passive pain cop- ing, venting, and arthritis helplessness were found to predict catastro- phizing (Sinclair, 2001).

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