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Brown 5 mg proscar otc, MD buy proscar 5 mg amex, Director, Sports Medicine, Madigan Army Medical Center, Fort Lewis, Washington Linda L. Brown, MD, Director, Allergy and Immunology Clinic, Madigan Army Medical Center, Fort Lewis, Washington Jennifer Burke, MD, Clinical Assistant Professor, Department of Community and Family Medicine, Team Physician, St. Louis University, Director of Sports Medicine, Forest Park Hospital, St. Busconi, MD, Associate Professor of Orthopedic Surgery, University of Massachusetts Medical School, Chief of Sports Medicine, UMass Memorial Medical Center, Worcester, Massachusetts Janus D. Butcher, MD, FACSM, Assistant Professor of Family Medicine, University of Minnesota, Duluth, Team Physician, US Cross Country Skiing, Staff Physician, Duluth Clinic, Duluth, Minnesota Robert C. Cantu, MA, MD, FACS, FACSM, Chief, Neurosurgery Service, Director, Services of Sports Medicine, Emerson Hospital, Concord, Massachusetts, Co-Director, Neurologic Sports Injury Center, Brigham and Women’s Hospital Boston, Massachusetts, Medical Director National Center for Catastrophic Sports Injury Research, Adjunct Professor Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, Neurosurgery Consultant, Boston College Football and Boston Cannons Dennis A. Cardone, DO, Associate Professor, Director, Sports Medicine Fellowship and Sports Medicine Center, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey Julie Casper, MD, Clinical Instructor and Sports Medicine Fellow, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California A. Bobby Chhabra, MD, Assistant Professor of Orthopedic Surgery, Division of Hand, Microvascular, and Upper Extremity Surgery, Virginia Hand Center, University of Virginia Health System, Charlottesville, Virginia Scott Chirichetti, DO, Chief Resident, Physical Medicine & Rehabilitation, University of Virginia, Charlottesville, Virginia CONTRIBUTORS xiii Steven B. Cohen, MD, Resident Physician, Department of Orthopedic Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia Brian J. Cole, MD, MBA, Associate Professor, Departments of Orthopedics & Anatomy and Cell Biology, Director, Rush Cartilage Restoration Center, Rush University Medical Center, Chicago, Illinois Ugo Della Croce, PhD, Associate Professor, Physical Medicine & Rehabilitation, Systems Engineer, Motion Analysis Lab, University of Virginia, Charlottesville, Virginia Loren A. Crown, MD, Emergency Medicine Fellowship Director, University of Tennessee College of Health Sciences, Covington, Tennessee Diane Dahm, MD, Assistant Professor, Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota Gregory G. Dammann, MD, Director, Sports Medicine, Department of Family Medicine, Tripler Army Medical Center, Honolulu, Hawaii Thomas M. DeBerardino, MD, Chief, Orthopedic Surgery Service, Keller Army Community Hospital; Team Physician, United States Military Academy, West Point, New York Patricia A. Deuster, PhD, MPH, Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland William W. Dexter, MD, FACSM, Director, Sports Medicine Program, Assistant Director, Family Practice Residency Program, Maine Medical Center, Portland, Maine Margarete DiBenedetto, MD, Professor and Former Chair (retired), Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia Jay Dicharry, MPT, CSCS, Staff Physical Therapist, University of Virginia/Healthsouth, Charlottesville, Virginia David R. Diduch, MD, Associate Professor of Orthopedic Surgery, Co- Director, Division of Sports Medicine, Director, Sports Medicine Fellowship, University of Virginia Health System, Charlottesville, Virginia John P. DiFiori, MD, Associate Professor and Chief, Division of Sports Medicine, Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California Nancy M. DiMarco, PhD, RD, LD, Professor, Department of Nutrition and Food Sciences, Nutrition Coordinator, The Institute for Women’s Health, Coordinator, Masters Program in Exercise and Sports Nutrition, Texas Women’s University, Denton, Texas Robert J. Dimeff, MD, Assistant Clinical Professor of Family Medicine, Case Western Reserve University; Associate Professor of Family Medicine, The Ohio State University; Medical Director, Section of Sports Medicine, Vice- Chairman, Department of Family Practice, Cleveland Clinic Foundation, Cleveland, Ohio Kevin J. Elder, MD, Bayfront Medical Center Sports Medicine Program, FP Residency, St. Ellini, MD, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico Jay Erickson, MD, Assistant Professor of Family Medicine, Uniformed Services University School of Medicine, Director, Primary Care Clinics, Robert E. Essery, Doctoral Candidate, Department of Nutrition and Food Sciences, Texas Women’s University, Denton, Texas Karl B. Fields, MD, Director, Family Medicine, Residency and Sports Medicine Fellowship, Moses Cone Health System, Greensboro, North Carolina xiv CONTRIBUTORS Catherine M. Fieseler, MD, Head Team Physician, Cleveland Rockers, Division of Sports Medicine, Cleveland Clinic Foundation, Cleveland, Ohio Scott B. Flinn, MD, Consultant to the Surgeon General, Navy Sports Medicine, Naval Special Warfare Group ONE Logistics Support, Medical Department, San Diego, California Nicole L. Frazer, PhD, Director of Clinical Psychology, Assistant Professor of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland Michael Fredericson, MD, Associate Professor, Physical Medicine & Rehabilitation, Team Physician, Stanford University, Palo Alto, California Michael C. Gaertner, DO, Instructor, Emergency Medicine Fellow, University of Tennessee, Tipton Family Practice, Covington, Tennessee Robert Giering, MD, Fellow, Pain Management, Department of Anesthesiology, University of Virginia, Charlottesville, Virginia John E. Glorioso, MD, Brigade Surgeon, SBCT Brigade, Second Infantry Division, Fort Lewis, Washington John P. Goldblatt, MD, Assistant Professor, University of Rochester, Division of Sports Medicine, Rochester, New York Tom Grossman, ATC, Department of Athletics, University of Virginia, Charlottesville, Virginia Carlos A. Guanche, MD, Clinical Associate Professor, University of Minnesota, The Orthopedic Center, Eden Prairie, Minnesota David D. Haight, MD, Department of Family Medicine, Madigan Army Medical Center, Tacoma, Washington Kimberly Harmon, MD, FACSM, Clinical Assistant Professor, Department of Family Medicine, Clinical Assistant Professor Department of Orthopaedics and Sports Medicine, Team Physician, University of Washington, Seattle, Washington Joseph M. Hart, MS, ATC, Athletic Trainer, University of Virginia, Sports Medicine/Athletic Training, Charlottesville, Virginia R. Todd Hockenbury, MD, Assistant Clinical Professor of Orthopedic Surgery, University of Louisville, Blugrass Orthopedic Surgeons, PSC, Louisville, Kentucky Halli Hose, Internist, San Diego VA Healthcare System, Assistant Clinical Professor, University of California, San Diego Thomas M. Howard, MD, Chief, Department of Family Medicine, Associate Director, Sports Medicine Fellowship, Dewitt Army Community Hospital, Fort Belvoir, Virginia Garrett S. Hyman, MD, MPH, Sports, Spine, and Musculoskeletal Fellow, Kessler Institute for Rehabilitation, Department of Physical Medicine & Rehabilitation, UMDNJ-New Jersey Medical School, West Orange, New Jersey Christopher D. Ingersoll, PhD, ATC, FACSM, Director, Graduate Programs in Sports Medicine/Athletic Training, University of Virginia, Charlottesville, Virginia Carrie A. Jaworski, MD, Family Practice and Sports Medicine, Associate Director, Resurrection Family Practice Residency, Team Physician and Medical Director, Athletic Training Program, North Park University, Chicago, Illinois Jeffrey G. Jenkins, MD, Assistant Professor of Clinical Physical Medicine and Rehabilitation, University of Virginia School of Medicine, Charlottesville, Virginia Michael W.

In 1952 cheap proscar 5 mg on-line, Risser presented nitely play a crucial role buy cheap proscar 5 mg, more so than for other (passive) the »localizer cast«, a more sophisticated form of the treatments. Given that neither the brace treatment nor »turnbuckle cast« that applied additional lateral correc- surgery are attractive options for young people, this en- tive pressure. Stagnara introdu- Based on our current knowledge of the pathogenesis ced a brace with a compressive action while, in 1975, of scoliosis and also given the substantially increased Hall developed the Boston brace as a purely corrective incidence of scoliosis among female gymnasts and bal- orthosis. Perhaps kyphosing ex- Modern braces for the treatment of scolioses work ac- ercises and the practice of corresponding sports (e. Both brace treatment and surgery must always be supple- mented by exercises. The Milwaukee brace was primarily designed as a pas- sively extending brace. A chin and neck ring was Clinical and radiographic follow-up connected to a pelvic girdle by rods, and the rods were Provided a scoliosis has not exceeded 20°, annual checks elongated to produce passive extension. In a diographic follow-up is only necessary if the scoliosis is later development, the chin and neck ring only produced thought to be increasing on the basis of rib prominence an admonitory effect and sought to compel the patient measurement with the inclinometer or raster stereogra- actively to straighten up. The clinical checks should be increased to half-yearly ing principle for the treatment of idiopathic adolescent during the pubertal growth spurt, or even every 3 months scoliosis is basically incorrect. We do not have any experience with compressing braces (Stagnara or Wilmington brace) because of con- cerns about the possible impairment of lung function. We use braces that produce a corrective action by pads and also have a derotational effect, for example the Cheneau brace [104] (⊡ Fig. Such braces have a derotational effect, although this tends to affect the rib hump rather than the actual scoliosis [106]. Fabric bands tensioned to a computer-calculated force produce a mainly corrective action during move- ments of the patient (⊡ Fig. However, the efficacy of such braces has yet to be adequately proven in scientific studies. The SpineCor brace is a dynamic brace consisting of fabric bands with a computer-controlled tensile force ⊡ Fig. The Cheneau brace is a modern derotation brace whose primary objective is not extension but lateral correction according to the 3-point principle and derotation 84 3. If the brace is consistently worn, however, the patient can be We consider that brace treatment is indicated if the reassured that the scoliosis will continue to remain exactly following apply as it is. On the other hand, braces are only this effective up ▬ idiopathic scolioses with a Cobb angle of >20°, to a curve angle of approx. At this age there is a great In a recent study compliance was measured electroni- need not to appear different from their peers if possible. A female scoliosis pliance rate for the patients whose curve progressed (>5°) patient will often be the only person in her class, or even was 62%; the compliance rate for the patients who did not in the whole school, wearing a brace. In the group that had high compliance much more isolated than, say, a wearer of dental braces. Charleston brace appears to be effective when worn ex- The psychological effects of brace treatment have been clusively at night. Although there were hardly The following factors should also be taken into ac- any serious long-term adverse effects, for most adolescents count during brace treatment: the brace treatment was a psychological burden [2, 50]. The brace impairs lung function while it is worn, This also explains why compliance with the treatment is though this recovers very quickly when the brace is not very good. In an interesting study involving the new dynamic braces (SpineCor), although cor- 50 patients with a Boston brace, silver platelets were incor- responding study results are still awaited. The brace cannot correct the rotation of the vertebral These platelets oxidized on contact and were thus able to bodies [106] or the lordosis. Brace-wearing period: While this investigation calls into question the efficacy of The brace must be worn consistently day and night brace treatment, a more recent study showed that a brace until growth is complete (Risser IV). Since the psy- worn for only part of the time is almost just as efficient as chological strain associated with brace treatment is when worn for the whole day. A significant advantage of considerable, the patient needs good support. Only if the dynamic SpineCor brace is the much better acceptance everyone involved (doctor, parents, physical therapist, by the patients and thus better compliance. The brace must scolioses, however, than for thoracic scolioses, since sur- be worn for 22–23 hours a day, and may be removed gery does not represent a satisfactory alternative for the only for sports activities or during physical therapy. Brace treatment must always be backed up by physical ther- Results of brace treatment apy and exercise since wearing of the brace results in Although brace treatment can halt the progression of the atrophy of the paravertebral muscles, which have less scoliosis it cannot correct the condition in the long term. This atrophy must be countered The initial reduction in curvature is lost again when treat- by swimming, sport and postural exercises. With the Zielke instrumentation, produced by digital methods are also suitable. When the a derotation can be performed while at the same time brace is ready, its effect must be checked radiographically preserving the lordosis. Clinical checks are then arranged every 3 threaded rod that can be rotated by a special derotation months. Kyphosing is avoided by the insertion of al- should be recorded every 6 months (AP only, without the logenic bone grafts in the spaces between the disks. In the 1970’s Luque introduced the rods named for Regular check-ups should continue at this rate until the him (which are anchored without hooks) and the tech- patient is weaned off the brace. The principal advantages of segmental wiring: the correction is produced not just Electrical stimulation via longitudinal but also via transverse forces; a certain In the 1970’s and 1980’s, electrical stimulation raised amount of derotation also occurs, thereby increasing sta- hopes of an alternative to the brace. This technique still has an important role to play in been shown to be ineffective [3, 90]. At the start of the 1980’s an instrumentation system that introduced new elements in the surgical treatment of Surgery can not only halt the progression of scoliosis, scoliosis was developed by Cotrel and Dubousset in France but can (to a certain extent) straighten the curvature. This system allows the curvature to be corrected and essentially maintain the correction after the spinal in three dimensions and provides stable fixation with a fusion has stabilized.

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If 178 Barret and Dziewulski A B FIGURE 10 Biobrane is the treatment of choice for small and medium-sized burn injuries purchase proscar 5mg. Biobrane is then applied (it must be stapled to itself) and (D) dressed with petrolatum-soaked fine-mesh gauze or standard burn dressing proscar 5mg. As re-epithelialization occurs in 10–14 days, Biobrane spontaneously separates from the healed wound. Patients are allowed to bathe, although the dressing must be kept dry, which is usually accomplished by exposing it to room air. If wound infection supervenes, the Biobrane rapidly becomes nonadherent and can trap any exudate by the wound. For this reason it is not used in patients presenting more than 24–36 h following their injury. In larger wounds ( 30% TBSA) it must be used with caution, since collections under the Biobrane may extend and the patient become septic. If the Biobrane appears nonadherent in some areas, it should be trimmed and a topical antimicrobial or Mepitel applied. This is particularly true in children, who must be managed quickly to prevent any septic episode. After the first Biobrane check, patients are discharged home and monitored in the burn outpatients department. Patients with small superficial burns can be discharged soon after the injury (usually between 24 and 48 h). A more cautious approach is advised for patients with larger superficial burns, which are usually discharged between the third and fourth day, after a second Biobrane check to rule out any deeper area or infection. Experienced nurses well-versed in the care of open wounds must staff it and burn specialists and surgeons should be available 24 h a day. The burn outpatient department should function as an extension of the burn unit, with availability to manage patients 7 days a week. Alternative temporary skin substitutes Xenograft skin (porcine skin or pigskin) can be used in similar fashion to Bio- brane. After proper cleansing, it is applied to the raw surface and affixed in place with a light dressing. Patients are allowed to wash the areas and it separates when complete re-epithelialization has occurred. It forms a dry surface that can be uncomfortable for some patients (Fig. Another good alternative for small- and medium-size superficial burns is Mepitel. It is a silicone sheet that sticks to normal skin but not to the wounds. Its application and removal are painless with excellent patient satisfaction. After gentle debride- ment, wounds are covered with the silicone sheet and protected with a light dressing. The dressing is left in place for 5 days, and it is replaced until complete re-epithelization has occurred. Other synthetic dressings such as Duoderm and hydrocolloids have all been used with some success to dress such wounds. Another semisynthetic biological dressing that is very effective in this type of wound is TransCyte. Their inner A B C FIGURE 11 Superficial burns (A) can be treated with pig skin application (B). It is less expensive than Biobrane, but patients may experience more discomfort when it desiccates (C). It is much more expensive than Biobrane, so we reserve its use for neonatal and infant burns. Topical Antimicrobial Creams The usual alternative for superficial burns that has been the standard and tradi- tional method for the last 30 years is the application of topical antimicrobial creams. The treatment of choice in many burn centers around the world is 1% silver sulfadiazine (Silvadene, Flammazine). After the wound is cleaned and the blisters, debrided, silver sulfadiazine is applied topically to the wound. Dressings are changed once or twice daily until re-epithelialization occurs and the wound has healed. This method requires frequent dressing changes, which can be painful and produce severe discomfort and anxiety. We reserve this method for the following situa- tions: Plantar burns Perineal burns Patients presenting late after injury with a colonized or infected wound Plantar burns are frequently colonized soon after the injury. Our experience is that management of this type of burns with synthetic dressings results in a high rate of infection. Therefore, we believe that daily wash with application of silver sulfadiazine is the treatment of choice. Patients are best managed with daily wash of the area and application of silver sulfadiazine until complete re-epithelialization has occurred. Pain is very low, and patients feel very comfortable with this dressing. Another type of burns that can benefit of silver sulfadiazine application are some hand burns not suitable for Biobrane or Mepitel application (geographical burns with large nonburned areas, hand–palm burns, finger burns). The application of hand bags with silver sulfadiazine is painless and allows easy and early mobilization of the involved anatomical areas. Treatment ofLarge Superficial Partial-Thickness Burns ( 30% TBSA) Homograft These are uncommon injuries that can lead to a high morbidity and mortality rate.

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From “Psychological Evaluation of Patients with Fibromyalgia Syndrome: A Comprehensive Approach cheap proscar 5 mg with mastercard,” by D cheap proscar 5mg free shipping. Williams, 2002, Rheumatic Disease Clinics of North Amer- ica, 28, 219–233. ASSESSMENT OF CHRONIC PAIN SUFFERERS 227 SIGNIFICANT OTHER INTERVIEW Because significant others may unwittingly contribute to pain expression and disability, whenever possible a chronic pain evaluation should include an interview with a significant other. The rationale offered to the patient is that by interviewing a significant other, the treatment team can learn more about the patient and ultimately can provide better treatment. It is also helpful to mention that significant others are frequently affected by the patient’s persistent pain and appreciate the opportunity to express their feelings and concerns. When possible, it is also helpful to interview the patient and significant other together. As mentioned previously, it is useful to observe patient and significant other interactions, noting any behaviors that might be related to the patient’s disability. For example, are there indications that the signifi- cant other inadvertently reinforces pain behaviors? How does the signifi- cant other respond to the patient as he or she describes the pain and dis- tress (e. He experienced immediate lower back pain that he rated as a 9 on an 11-point scale (0–10, with 10 representing the worst pain possible). At present he reports that his pain is at level 7 most of the day and is worst in the morning. C reports he has difficulty falling asleep due to discomfort and re- curring worry about his future. C indicates that he wakes up three to four times per night every night due to pain. When he wakes up, he notes that he watches television or “surfs” the Internet. He acknowledges that he smokes one pack of cigarettes per day, the last one being immedi- ately before going to bed. C reports that he consumes five cups of cof- fee per day, the last being about 2 hours before going to bed. He describes poor sleep hygiene and would benefit from interventions to help him fall asleep and maintain his sleep. Chronic sleep deprivation and a disrupted sleep cycle can lead to increased pain, increased stress, depressed or anxious mood, de- creased concentration, and irritability. C notes that he drinks four beers per day and this has been his pat- tern since he was 21. He acknowledges that he had one arrest for driving while intoxicated when he was 20. C displayed the following pain behaviors during the interview: hold- ing his lower back, wincing periodically, moaning when sitting down and getting up out of the chair, and changing position frequently. His wife ex- presses sympathy verbally and helps him to get out of the chair. She re- ports that she feels sorry for him and gives him massages several times a week. C and his wife admit that he is irritable and that his wife has had to take over many of the household chores he used to do prior to his injury. C acknowledges that she is getting frustrated with her husband as he “orders me around and does little to help me or himself. C indicates that he has difficulty with most physical activities of daily living, such as lifting, bending, pushing, pulling, and carrying. He appears to have difficulty pacing his activities, tending to do more when he feels better. This leads to increased pain, which in turn leads to decreased activity. The DSM–IV Axis I diagnoses would be: Pain disorder associated with both psychological factors (and a general medical condition [code 307. STANDARDIZED SELF-REPORT INSTRUMENTS A large number of psychological instruments have been used to assess do- mains relevant to patients with chronic pain. Many of these instruments were not devel- oped on patients with medical problems. For example, Piotrowski (1998) conducted a survey of psychologists who were engaged in the assessment of chronic pain patients and reported that the most frequently used meas- ures in order of frequency of use included the Minnesota Multiphasic Per- sonality Inventory (MMPI; Hathway & McKinley, 1967; Hathway, McKinley, & Butcher, 1989), Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), McGill Pain Questionnaire (MPQ, Melzack, 1975), and SCL–90R (Derogatis, 1983), and the Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985). Only the MPQ and MPI were specifically developed for use with chronic pain sufferers. Data gathered from measures not specifically developed or normed on a chronic pain sample should be interpreted with caution as the patient’s medical condition may influence some of the responses. ASSESSMENT OF CHRONIC PAIN SUFFERERS 229 have few or no pains,” “I am in just as good physical health as my friends,” and “I am about as able to work as I ever was” (from the original MMPI) il- lustrate the concern (Pincus, Callahan, Bradley, Vaughn, & Wolfe, 1986). It is reasonable to assume that the sensitivity of these measures may be rela- tively low and there may be a tendency of “overpathologize” patients. Cutoffs for depression on standard measures, such as the Beck Depres- sion Inventory, do not apply to chronic pain patients (Novy, Nelson, Berry, & Averill, 1995). In addition, it is unclear how pain medications might affect the way patients respond to psychological instruments. As mentioned ear- lier, it is best to corroborate findings from psychological measures with other sources of information, such as the patient or significant other inter- view or medical records. In some cases, it will not be possible to corrobo- rate information and interpretations should be made cautiously. Decisions regarding which measures to select will depend, at least to some extent, on the information obtained during the interview and data de- rived from the initial psychological screening instruments.

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