By H. Ateras. University of Houston, Victoria.

    Because of the likely pr esence of a progres- BREAKFAST LUNCH DINNER sive course order finast 5 mg fast delivery, medication overuse order finast 5 mg amex, and neuropsychiatric DAY (mg) (mg) (mg) comorbidity in this population buy 5 mg finast with mastercard, a more comprehensive 1 20 (4 pills) 20 20 approach beyond medications alone21,22 is required. Organic illness must be ruled out with appropriate testing in 6 10 5 (1 pill) 5 patients with frequent or daily headache and in those with neurologic findings (see Table 25–4 later). DIAGNOSTIC TESTING AND Hospitalization is required for many complex patients SECONDARY HEADACHE DISORDERS whose medication misuse or the presence of intractable pain and behavioral/neuropsychiatric More than 300 entities may produce symptoms of symptomatology has reached an intensity and com- headache, many of which mimic the primary plexity that makes outpatient therapy no longer headache disorders. Aggressive and thorough ruling in and ruling out potentially relevant conditions diagnostic assessment is mandatory to either rule out in patients with recurring or persistent headache. Disturbances of CSF pressure, ischemic disease, and allergic conditions must be considered. Table 25–4 HOSPITALIZATION lists diagnostic tests that should be considered in intractable or variant cases. Symptoms are severe and refractory to outpatient Because of the relevance of the cervical spine to the treatment. Premature or excessive use of interventional proce- Confounding medical illness is present. Even more advanced treatments, such as Interrupt daily headache pain with parenteral proto- implantable stimulators, are on the horizon. Physical examination Treat behavioral and neuropsychiatric comorbid Metabolic evaluation conditions. Toxicology (drug screens, etc) A variety of parenteral agents can be used during hos- Standard x-rays pitalization to control attacks, particularly during Neuroimaging CT rebound withdrawal: MRI/MRA/MRV Dihydroergotamine (0. Ketorolac (10 mg IV or 30 mg IM, three times daily) 140 VI REGIONAL PAIN Valproic acid (250–750 mg IV, three times daily) 8. Periaqueductal gray matter dysfunction in Magnesium sulfate (1 g IV, twice daily) migraine: Cause or the burden of illness. PET and MRA findings WHEN TO USE OPIOIDS in cluster headache and MRA in experimental pain. Use in acute situations when other treatments are blind pilot study with parallel groups. Short-lasting primary headaches: Focus on When all else fails following a full range of trigeminal autonomic cephalgias and indomethacin-sensitive headaches. When contraindications to other agents exist 2a Plasticity of 5-HT serotonin receptor in patients with anal- In the elderly or during pregnancy gesic-induced transformed migraine. Nearly 75% of refrac- (serotonin 5-HT1b/1d agonist) in acute migraine treatment: A tory patients placed on daily opioids fail to gain meta-analysis of 53 trials. What matters is not the differences between trip- maintained on opioids demonstrated noncompliant tans, but the differences between patients. Olanzapine 1,27,28 in the treatment of refractory migraine and chronic daily in a significant percentage of patients. Chronic daily headache prophylaxis with tizanidine: A double-blind, placebo-controlled, multicenter outcome study. Baltimore: Lippincott Williams & of botulism toxin A for chronic myogenous orofacial pain. New York: Oxford the chronic headache patient: Review and management rec- Univ. Migraine: Current chronic paroxysmal hemicrania: A review of 74 patients. Comprehensive inpatient treatment for intractable migraine: Cephalalgia. Long-term scheduled opioid treatment for 26 LOW BACK PAIN 141 intractable headache: 3-year outcome report. Poor physical fitness and comorbidity Social class, occupation, and employment status Increasing age up to 55 years5 Obesity5 Further Reading Dimensions of spinal canal Smoking Goadsby PJ, Lipton RB, Ferrari MD. Philadelphia: Lippincott 5 A positive straight leg test Williams & Wilkins; 2000.

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    Despite the encouraging reviews just cited discount finast 5mg amex, there are some nega- tive studies that led Compas et al effective 5 mg finast. Turner and Chapman (1982b) suggested that much of the interest in biofeedback has resulted from the efforts of commercial equipment suppliers purchase finast 5 mg with mastercard. From an efficiency perspective alone, relaxation ther- apy is often preferred. With respect to imagery, although there is significant research support for usage of this technique with acute pain patients (e. Nevertheless, these techniques are commonly part of treatment of chronic pain patients. Similarly, much of the evidence that is used to support the us- age of hypnosis (e. Perhaps some preliminary support for use of hypnosis with chronic pain patients comes from a study by Haanen et al. This group of researchers compared hypnosis with physical therapy (but primarily massage and relaxation therapy) for pa- 278 HADJISTAVROPOULOS AND WILLIAMS tients suffering from fibromyalgia, and reported that the former treatment resulted in greater reductions in pain, sleep difficulties, and fatigue than the latter. Commentary In general, although there is evidence in support of respondent tech- niques with patients, the evidence in support of the respondent theory it- self is much lower. There is very little evidence for muscle tension under voluntary control causing pain (e. On the other hand, there is evidence for greater muscle activity in the sites distal to the primary pain location among patients compared to healthy controls (Flor, Birbaumer, Schugens, & Lutzenberger, 1992). For instance, Flor and colleagues (1992) used anxiety or personally relevant stress induction techniques with healthy controls and individuals with chronic pain conditions (including low back pain, temporomandibular pain, and tension-type headache), and found significantly increased activ- ity in the musculature specific to the person’s pain complaints among pain patients as compared to healthy controls. This research shows very slow return to baseline of muscles after they have tensed, making for a painful and effortful movement (Watson, Booker, Main, & Chen, 1997). Finally, centrally mediated deep muscle tension around the spine has been found to occur in response to pain and instability; this then puts un- manageable demands on superficial muscle, and these mechanisms are hard to bring under voluntary control (Simmonds, 1999). The respondent theory has been criticized most strongly for being an oversimplification of the nature of chronic pain problems and especially the involvement of psychological factors in pain (Turner & Chapman, 1982b). Self-efficacy appears crucial to understanding the effects of respondent techniques, especially relaxation and biofeedback. This research group demonstrated that it makes little difference whether subjects learn to increase or decrease their muscle tension in terms of experiencing improvements in chronic head pain. On the other hand, participants who were told that they were successful in their at- tempts to alter their muscle tension, whether they were increasing or de- creasing it, reported greater improvement in headache compared to those who were told they were only moderately successful with the technique. Blanchard and his group (Blanchard, Kim, Hermann, & Steffek, 1993) found similar results with relaxation procedures among chronic headache suffer- ers. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 279 relaxation report greater improvement in their headaches, whether they are in actual fact successful or not. COGNITIVE-BEHAVIORAL THERAPY Background and Description Cognitive-behavioral therapy (CBT) for chronic pain evolved from the be- havioral interventions described above, but with the addition of cognitive methods. Both the focus and some of the behavioral techniques have changed since the early 1980s when CBT was first described (Turk, Meichen- baum, & Genest, 1983). The early formulations drew substantially on stress management methods from mainstream psychological treatment, and this was compatible more with respondent and relaxation methods than with operant programs. The model emphasized the reciprocal influence of cog- nitive content (schemata and beliefs), cognitive processes (automatic thoughts, appraisals of control), behavior, and its interpersonal conse- quences; all were the proper target of intervention. Some cognitive strategies such as distraction and relabeling were imported from successful use in acute (particularly proce- dural) pain, although never satisfactorily demonstrated to be effective for moderate to severe chronic pain. They also pointed out the confusion developing in the cognitive arena due to multiple overlapping instruments measuring overlapping con- structs that are studied using correlation and thus cast little light on causal processes. A contemporaneous review, Turk and Rudy (1992), used an in- formation-processing model to describe patients with low expectations of control over pain or their situations, and as thereby inactive and demoral- ized. Since these reviews in 1992, there have been exciting developments in cognitive therapy, with some concepts, predominantly catastrophizing, emerging as key variables from diverse studies in several countries (e.

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    In Aging and society: Taking charge of the future order finast 5 mg amex, Official program book of the 31st Annual Scientific and Educational Meeting of the Canadian Association on Gerontology (p buy 5 mg finast overnight delivery. Psychometric development of a pain as- sessment scale for older adults with severe dementia: A report on the first two studies generic finast 5mg with amex. An examination of pain perception and cerebral event-related potentials following carbon dioxide laser stimulation in patients with Alzheimer’s disease and age-matched control volunteers. Pain-relevant support as a buffer from de- pression among chronic pain patients low in instrumental activity. Subjective judg- ments of deception in pain expression: Accuracy and errors. Are physicians’ ratings of pain af- fected by patients’ physical attractiveness? A theoretical framework for understanding self- report and observational measures of pain: A communications model. Using facial expressions to assess musculoskeletal pain in older persons. Age- and appearance- related stereotypes about patients undergoing a painful medical procedure. Measuring movement exacerbated pain in cognitively impaired frail elders. Beautiful faces in pain: Biases and ac- curacy in the perception of pain. Detecting deception in pain expressions: The structure of genuine and deceptive facial displays. Effectiveness of oral sucrose and simulated rocking on pain response in preterm neonates. Pain and cognitive status in the institutionalized elderly: Perceptions and interventions. Development of an observation method for assessing pain be- havior in chronic low back pain patients. The relation- ship of gender to pain, pain behavior and disability in osteoarthritis patients: The role of catastrophizing. The Pain Behavior Check List (PBCL): Factor structure and psychometric properties. The role of marital inter- action in chronic pain and depressive symptom severity. The effects of experimenter gender on pain report in male and female subjects. The effect of disabil- ity claimants’ coping styles on judgements of pain, disability and compensation: A vignette study. The tragedy of dementia: Clinically assessing pain in the confused, non- verbal elderly. Infant crying as an elictor of parental behavior: An examination of two mod- els. Individualized patient education and coaching to improve pain control among cancer outpatients. Pain complaints and cognitive status among elderly institution residents. The effects of perceived versus enacted social support on the discriminative cue function of spouses for pain behaviors. The consistency of facial expressions of pain: A comparison across mo- dalities. Expressing pain: The communication and interpretation of facial pain signals.

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    CHAPTER 20 EXERCISE TESTING 123 SIGNS AND SYMPTOMS ELECTROCARDIOGRAPHIC RESPONSES TO EXERCISE TESTING The presence or absence of symptoms such as chest pain generic finast 5 mg amex, claudication discount 5mg finast amex, or exercise-induced wheezing ST segment changes are the most common signs of needs to be mentioned in the report order finast 5 mg with mastercard. ST segment depression is subendocardial, exercise-induced angina have been shown to have a and one cannot localize ischemia based on EKG worse prognosis than patients with only ST depres- location of the ST depression. Therefore, these patients, even is transmural, and the location of the anatomic in the absence of EKG ischemic changes, should be obstruction correlates with the associated EKG regarded as having a test “suggestive of myocardial changes. It is valuable to NORMAL RESPONSES WITH EXERCISE measure during exercise testing as it correlates well The PR segment shortens and slopes downward in the with HR and VO2. The QRS complex may show 0–10 to the RPE with a higher number indicative of increased Q wave negativity and a decrease in R wave more difficult exertion (Borg, Holmgren, and amplitude with an increased S wave depth. The T wave decreases in amplitude and the ST segment DYSRHYTHMIAS/CONDUCTION develops a positive upslope that returns to baseline DISTURBANCES within 60–80 m. Unifocal pre- YANOWITZ, AND WILSON, 1988) mature ventricular contractions (PVCs) are seen fre- ST segment depression: This is the hallmark of quently during testing and are not specific for ischemia and a positive treadmill (see next section). High-grade ectopy (couplets, ST segment elevation: In patients without a prior his- mutiforme/ multifocal PVCs, ventricular tachycardia) tory of MI, consider acute MI (if accompanied by is more suggestive of severe ischemic heart disease chest pain), or serious transmural ischemia. ST eleva- and higher mortality than those without ectopy (Califf tion over Q waves in patients with a previous history et al, 1983). Supraventricular dysrhythmias (atrial-fib- of an MI suggests areas of dyskinesis or ventricular rillation/flutter) require termination of the test and aneurysm (Evans and Karunarante, 1992b). Intracardiac blocks can occur Uwave inversion: U wave inversion during exercise is before, during, or after testing and advanced forms of suggestive of ischemia. Bundle branch blocks occur very infrequently with exercise and require further evaluation, especially FINAL DETERMINATION FOR LBBB which may portend an increased mortality if MYOCARDIAL ISCHEMIA there is structural heart disease (Evans and Froelicher, 2001). Horizontal or downsloping ST segment depres- estimate from workload performed in a maximal test. The results can then be compared with that is ≥1mm at 60 ms past the J point standard tables of fitness levels for age and sex 3. A 40-year old male with atypical angina has a past the J point pretest probability of about 35%. Upsloping ST segment depression that is probability of CAD becomes nearly 70%, a much greater than 0. Chest pain occurring with exercise typical of between 1 and 2 mm of ST depression, her posttest angina probability of CAD still is less than 20%, and little 6. Abnormal 1-min HRR or 3-min systolic BP PREDICTION OF SEVERITY OF CAD response 9. ST-segment depression in recovery only A suggestive or positive written report may be used to 10. Normalization of abnormal ST-segments/ further manage patients by predicting the severity of T-wave inversion CAD. The following are important exercise to at least 85% of predicted HRmax test predictors of severe CAD (Goldschlager, Selzer, d. ST depression beginning at low workload, <5 METS ischemia based on the above criteria. Downsloping configuration (99% predictive of the patient is not on B-Blockers or has CAD) or ST elevation chronotropic incompetence. Low workload ability, <5 METs Physicians can use the results of the exercise test to i. Exercise induced hypotension guide them in the management of their patients. Chronotropic incompetence approach should include a probability statement of k. Anginal symptoms CAD and a prediction of severity of CAD, prognosis ST depression only at high workloads (HR >160 bpm of the likelihood of future adverse events in a patient or changes only after Stage IV—Bruce protocol at based on the exercise treadmill score (ETS), and exer- 12 min) correlates with a low mortality and good prog- cise prescription. In fact, the ability to exercise >13 METs has a good prognosis regardless of the EKG changes. Many cardiologists recommend repeating the PROBABILITY OF CAD exercise test in 6 months without further workup in these patients (Goldschlager, Selzer, and Cohn, 1976).

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