By A. Denpok. Le Moyne College. 2018.
VLAs are the wide range of activities that individuals find mean- ingful or pleasurable generic 150mg diflucan visa, above and beyond activities that are necessary for survival or self-sufficiency purchase 200mg diflucan visa. Although the research discussed has been done primarily among individuals with rheumatoid arthritis (RA) purchase diflucan 50mg online, the concepts and relationships described are currently being studied among individuals with other chronic health conditions cheap diflucan 50 mg with amex, such as asthma, chronic obstructive pulmonary disease, and multiple sclerosis. Nonetheless, since the bulk of research has focused on individuals with RA, the examples within this manuscript will also focus on RA. This manuscript will (1) examine models of disability and where the concept of VLAs fits into existing models, (2) discuss findings on the impact of RA on the performance of VLAs, and (3) discuss the relationship between disability in VLAs and psychological status. The manuscript will close with a summary of clinical implications of this research and suggestions for future research. Background: Disability Theory Two models of disability have driven the bulk of disability research. The first is the International Classification of Impairments, Disabilities, and Handicaps (ICIDH; now known as International Classification of Functioning, Disability, and Health, or ICF) model, developed by the World Health Organization [2, 3]. It originally specified four components: disease, impairment, disability, and handicap. Impairments were defined as losses or abnormalities of structure or function at the level of the organ as the result of disease (e. Impairments may lead to disability, the restriction or inability to perform activities, measured at the level of the individual. Handicaps may result from disability or impairment, and reflect disadvantage and role limitation at the level of the individual in a social context [4–6]. Although useful in some situations, problems have been reported using the ICIDH model as a research model. The second model, developed by Nagi, and later adapted by the Institute of Medicine, also has four components: active pathology, impairment, functional limitation, and disability [6, 7]. Functional limitations and disability, covered in the ICIDH model under the concept of disability, are treated as separate entities in the Nagi model. Functional limitations are defined as limitation in performance at the level of the person, and disability refers to limitation in performance of socially defined roles and tasks at the level of the individual in a social context. The Nagi model does not include a concept parallel to handicap in the ICIDH model. Verbrugge and Jette expanded on the Nagi model to develop a model of the disablement process that included factors that may affect the pathway from pathology to functional outcomes (see fig. In their model, pathology refers to biochemical and physiological abnormalities, or disease, injury, or congenital/developmental conditions (e. Impairments are defined as dysfunctions or significant abnormalities in specific body systems that can have consequences for physical, mental, or social functioning Katz 42 Extraindividual factors Medical care, rehabilitation Medications, other therapeutic regimens External supports Built, physical, and social environment The main pathway Pathology Impairments Functional Disability (diagnoses of disease (dysfunctions and limitations (difficulty in injury, congenital/ structural abnormalities (restrictions in basic activities of developmental in specific body systems) physical and mental daily life) condition) actions) Intraindividual factors Risk factors Lifestyle, behavior changes (predisposing Psychosocial attributes, coping characteristics) Activity accommodations Fig. Functional limitations refer to restrictions in performing generic, fundamental physical and mental actions used in daily life in many circumstances (e. Finally, disability refers to difficulty performing activities of daily life (e. RA is a systemic condi- tion that is characterized by joint pain and swelling, among other symptoms. Joint pain and swelling may lead to joint stiffness, limited joint range of motion, and weakness, which may lead to limitations in mobility, gripping, reaching, and other physical actions. Limitations in these actions may, in turn, cause dif- ficulty in a wide range of activities from self-care to employment, to household maintenance, to hobbies. Verbrugge and Jette also recognized that certain predisposing factors could affect the presence or severity of impairments, functional limitations, or disability; these were termed ‘risk factors’. For example, women with RA seem to experience greater pain and more functional limitations than men; persons with low education also seem to experience greater functional limitations. In addition, certain factors can intervene in the process of disablement to reduce (or, in some cases, exacerbate) difficulties. These factors might include medical care, external supports such as assistance from others, psychosocial attributes such coping Disability and Psychological Well-Being 43 strategies, and activity accommodations such as modifying the way activities are performed. If disability is conceptualized as a gap between the capabilities of an individual and the demands of the environment, these interventions can lessen disability either by increasing capabilities or by reducing the demands of the environment.
A better appreciation of all these factors can prove invaluable in the physician’s medical decision MEDICAL RESPONSIBILITIES OF THE making generic diflucan 150mg fast delivery. Additionally order diflucan 50 mg with mastercard, brief appearances at practice TEAM PHYSICIAN help the physician build collegial relationships with coaches and players order 150 mg diflucan fast delivery, establishing his or her role as a The first responsibility of a team physician is to deter- part of the team and distinguishing the physician from mining whether an athlete is fit to participate 50 mg diflucan mastercard. This other officials, support staff, and media representa- evaluation most commonly occurs during the prepar- tives who only participate in game-day activities. This examination may or may not Amount of time spent at the actual competition be preformed by the team physician, but the team depends on the team physician’s role and availability, physician should review the documentation of this as well as state laws and regulations of the governing examination so that he or she will know of any con- athletic association. Some laws mandate that a physi- dition that may limit competition or predispose the cian be in attendance for every game. This prepartici- allow nonphysician medical personnel, such as an ath- pation physical must be done prior to athletic training letic trainer, to cover an event with on-call physician or participation—preferably 6–8 weeks beforehand so backup (Herring et al, 2000a). A physician should cover part of one practice and at least one game for each all collision and high-risk sports. Providing good team medicine is can be covered by any allied health professional who is very difficult without observing the interactions and trained in recognition and initial treatment of athletic conditions of play and practice. A team physician must continually remind himself or herself that he or she is more than a spectator. The physician should be a CORE KNOWLEDGE OF THE “dispassionate observer,” meaning that the emotions of TEAM PHYSICIAN competition must not affect medical decision making. Attention should be directed to the safety of the partici- To perform his or her duties effectively, a team phy- pants, not the immediate passions of the game. This knowledge should encom- of play and individuals who are more prone to injury. Practical pharmacology for the team physician occur and attention should be focused on linemen, quar- includes not only knowing how to treat illnesses, but terbacks after releasing the ball, and wide-receivers after also an understanding of performance enhancing drugs catching the ball. Team physicians must be familiar be given to situations and players at high risk for injury. Mood distur- The team physician insures accurate diagnosis through bances and mental illnesses (like depression) affect use of additional studies and specialty consults, com- athletes and can be very common in injured athletes. Team physicians may refer athletes to tions when he or she is not immediately available. Assuming that the specialty before appropriate healing has occurred (Herring et al, provider will call with any important information, or 2000b). The ACSM consensus statement on return-to- that all pertinent information will flow back through play issues more fully details the responsibilities of the health care system, will result in confusion for the the team physician when returning athletes to compe- team physician and danger for the athletes. A safe playing environment also often dangerous situations that result from incomplete involves appropriate and properly fitting protective medical communication between subspecialists and equipment, available hydration, and an activity level the team physician. The team physician needs to keep formal and confidential medical records COMMUNICATION RESPONSIBILITIES OF THE that detail communication with consultants, give TEAM PHYSICIAN treatment and follow-up instructions, and provide details for insurance and reimbursement purposes For a team to receive optimal medical care, the team (Rice, 2002). Even before the season, they need to discuss athlete is initially cleared to begin competition and medical treatment protocols, which preferably are when a previously injured athlete may return to play documented in writing (Rice, 2002). TEAM PHYSICIAN Ateam physician needs to develop good rapport with the coach. Offering injury prevention suggestions and The team physician’s primary concern is the coordi- player health education may demonstrate to the coach nation of medical supervision. This organization a shared desire to assist the team attaining their goals. The confidentially, the team physician should provide the team physician encourages defined roles and respon- coach a timeframe for further evaluation or the sibilities for all involved in the medical care of the player’s return. In general, this should be communi- team, along with establishing a medical chain of com- cated in terms of a sport-specific timeline, such as: the mand. The team physician may not make all the daily player is out for a play, out for a series, reassessment decisions but should have full authority concerning will be done at half-time or game’s end, or the player medical policy-making. They seldom need to professional and personal satisfaction owing to their know medical or personal details of the athlete’s situ- interest in sports and athletes.
This ethic of respect for persons has become one of the most challenging ethical issues in current medical practice generic 150mg diflucan overnight delivery. It directs us to respect patient auton- omy and facilitate shared decision making which incorporates patient values purchase 150mg diflucan free shipping, preferences discount 150mg diflucan with mastercard, and goals 50 mg diflucan fast delivery. An aspect of respect for persons often neglected in the ethics of pain management is belief and trust in the credibility and integrity of the patient. Too often clinicians start an assessment of pain from a position of bias both personal and scientific. It is well documented that medical train- ing tends to see the objective and organic as ‘real, true and significant’ and the subjective and psychological as somehow ‘unreal, false, and less important’ [19, 69]. These terms have deep philosophical roots traced to the mind–body dualism of Greek philosophy and Descartes with their modern counterparts in clinician suspicion, disparagement, labeling, and rejection of patients with irri- table bowel syndrome, fibromyalgia and other functional somatic syndromes [69–71]. Edwards has said that when clinicians fail to respect the person of the pain patient, ‘Medical professionalism then become inflictors of pain rather than pain relievers’. Contemporary research in psychosomatic medicine, much of it conducted in consultation-liaison psychiatry, has questioned these Geppert 162 distinctions and supported an integrative approach to pain assessment and man- agement that utilizes the best of modern diagnostic technology while honoring the validity and truthfulness of the patient’s experience [72, 73]. A corollary of respect for persons is honoring and protecting the privacy and confidentiality of patient’s medical information. Physicians need to be aware of the special regulations and protections for substance abuse informa- tion, particularly in the light of the new Health Insurance Portability and Accountability Act (HIPAA) mandates. They need also to realize the enor- mous potential negative consequences of documenting addiction or even a pos- itive toxicology for employment, education, security clearance, health and life insurance, as well as family relationships. An essential but often overlooked part of chronic pain treatment for persons with addiction is being clear at the onset of care about the limitations and protections for confidentiality. Patients who are receiving treatment under the auspices of third-party payers, the crim- inal justice system, or as part of occupational health must be educated about the dual roles of the providers involved and the restrictions on confidentiality [67, 75]. Clinicians may be faced with difficult decisions such as whether to report drug diversion or prescription forgery to the authorities. Family members may be allies in the patient’s treatment and yet physicians cannot speak to them without the patient’s explicit permission except in emergency situations. They must be careful to protect both the family member and the patient if they choose to act on the information. Suicidal and homicidal impulses, child abuse, domes- tic violence, and driving under the influence are not uncommon in chronic pain and SUD and physicians must inform themselves and patients of the legal and ethical mandates allowing breaches of confidentiality and privacy in such cases [76, 77]. The ethic of autonomy and respect for persons are operationalized in the doctrine of informed consent. Informed consent encompasses the capacity to understand the risks, benefits, and alternatives of a treatment, to communicate a choice regarding therapy, to deliberate and reason about the consequences of the proposed medication, and to appreciate how the treatment will affect life and values. Finally decisions must be made in the absence of strong internal or external coercion. Informed consent is the premise behind the widely used opioid contract which is a valuable aid in maintaining patients with a history or current problem with chemical dependency in chronic pain treatment. The degree to which addiction is voluntary is a very old debate recently revived. Evidence from basic science studies of the pathophysiology and pharmacology of both chronic pain and addiction, and from neuroimaging and molecular genetics suggests that both the cognitive and volitional capacities required for informed consent are diminished in patients with addiction and chronic pain to varying degrees. The behavioral phenomena that characterize SUD, To Help and Not to Harm 163 compulsion, obsession, loss of control, craving, and the continuation of sub- stance use despite negative, medical, psychological, and social consequences are understood from this perspective as symptoms of a brain disease [57, 80]. The neuropsychiatric correlates of these behaviors, neuroadaptation and sensi- tization, appear to diminish the authentic freedom and decisional capacity of the addicted individual as they pertain to informed consent. It is widely recognized that stress, sleep deprivation, anxiety, trauma, and depression or other psychological factors that often accompany pain and SUD may both lower the pain threshold and diminish decisional capacity and autonomy [1, 82]. The practical implication of these theoretical findings is that patients with a history of substance abuse or an active problem may enter into opioid con- tracts with good intentions but diminished capacity for informed consent.
The injury pattern is typi- cally a greenstick fracture of the middle third of the clavicle with no associated ligamentous damage (Fig diflucan 50 mg on line. Occasionally order 150 mg diflucan, in 5% of injuries discount 200 mg diflucan visa, a fracture of the outer third of the clavicle may be seen and any displacement at this site is sug- gestive of coracoclavicular ligamentous damage diflucan 200mg lowest price. The coracoclavicular and acromioclavicular ligaments hold the clavicle in position and damage to these ligaments can result in clavicular subluxation or dislocation2 (Box 7. Salter-Harris type Features Diagram I Separation of the metaphysis and epiphysis which is seen radiographically as misalignment or widening of the physis Accounts for 6–8% of injuries and is most commonly seen in children under 5 years of age II Separation of physis (with or without misalignment) plus a metaphyseal fracture Commonest fracture pattern and accounts for 70% of injuries Most frequently seen in distal radius injuries and in children over 8 years of age III An intra-articular fracture through the epiphysis which results in a separated epiphyseal fragment Accounts for 7% of injuries and is commonly seen in the distal femoral and tibial epiphyses IV An intra-articular fracture through the epiphysis, physeal plate and metaphysis Accounts for approximately 12% of injuries and is most frequently seen in the lateral condyle of the humerus V Compression of the physis which has serious prognostic consequences This is the most serious physeal injury and accounts for 0. It is most commonly seen in the distal tibia and femur but can be difficult to identify, particularly after fusion across the physis has begun in adolescence 134 Paediatric Radiography Fig. Type 1: Spraining of the acromioclavicular ligaments with no movement of the clavicle. Type 2:T earing of the acromioclavicular ligaments with coracoclavicular ligaments remaining intact. Minimal malalignment may be seen with displacement of the acromioclavicular joint of up to half the thickness of the clavicle. Type 3:T earing of both the acromioclavicular and the coracoclavicular ligaments with possible associated avulsion of the coracoid process. The acromioclavicular joint is widened and the clav- icle is seen above the level of the acromion process. The scapula The scapula is rarely fractured owing to its thick covering of muscles and there- fore significant force is necessary to cause injury (e. The secondary ossification centres on the lateral aspect of the acromion can cause confusion and it is important to remember that they do not appear until between the ages of 15 and 18 years and can be fragmented in appearance. The glenohumeral joint Dislocation at the glenohumeral joint is rare in children as the proximal humeral growth plate forms a natural line of weakness and will transmit any force to gen- erate a Salter-Harris type injury. However, if a true dislocation does occur, it is likely to be in an anterior direction (97% of cases) following a fall on an out- stretched hand. Humeral shaft fractures will commonly occur following direct trauma and may have an asso- ciated open wound whereas transverse, oblique and spiral fractures are gener- ated by indirect forces. Up to 25% of humeral shaft fractures will have an associated elbow, shoulder or clavicular injury and, therefore, it is essential that the whole of the humerus is imaged including the elbow and shoulder joints. The elbow The elbow is a complicated joint both to adequately image and to interpret and, as a result, several lines and systems of review have evolved to assist in the accu- rate diagnosis of elbow trauma. The elbow has six secondary ossification centres that ossify in sequence and these can be remembered as the mnemonic CRITOL (Fig. The order of ossi- fication can assist the radiographer in identifying true trauma from normal ossi- fication appearances. For example, if trochlear ossification is apparent but the radial head has not yet ossified then it is likely that the appearances are related to trauma rather than normal elbow ossification. In addition, the age at which the secondary centres of the elbow ossify can also help in the diagnosis of subtle elbow trauma3 (Box 7. Other useful review tools are the anterior humeral line and the radiocapitel- lar line (Fig. The anterior humeral line should be drawn along the anterior humeral cortex on the lateral elbow projection and should pass through the ante- rior to the middle third of the capitellum in a normal elbow (Fig. However, care must be taken as this line is only useful if the elbow is imaged in a truly lateral position. In contrast, the radiocapitellar line can be successfully applied to all elbow projections and it should be drawn through the middle of the proximal radial shaft to intersect with the centre of the capitellum in the normal elbow (Fig. Failure of the radiocapitellar line to intersect with the capi- tellum on any one projection suggests dislocation or subluxation at the radio- capitellar joint. Elevated fat pads, seen on the lateral elbow projection, are a good indication that an intercapsular fracture is present, even if the fracture cannot be identified Box 7. Capitellum 2 months–2 years Radial head 3–6 years Internal (medial) epicondyle 4–7 years Trochlea 8–10 years Olecranon 8–10 years Lateral epicondyle 10–13 years 138 Paediatric Radiography Fig. The anterior fat pad, which sits in the shallow coro- noid fossa of the humerus, can be seen on most lateral elbow projections but its position is more markedly raised following trauma (the sail sign). The posterior fat pad sits in the deeper olecranon fossa and is rarely seen unless elevated as a consequence of trauma and is therefore a more significant finding (Fig.
If the centers of rotation of the head and acetabulum of sensing tension situations in the capsule and thus acti- do not match buy cheap diflucan 150 mg line, the gap between the points of muscle inser- vating the muscles dynamically to stabilize the joint cheap diflucan 50mg line. In this position the length of the adductors is too short relatively buy diflucan 50mg overnight delivery, thereby preventing Course and development of hip dislocation the abduction required for centering of the joint buy 150mg diflucan fast delivery. However, The consistent application of the same type of pressure no direct evidence can be inferred from this for a causal and in the same direction by the femoral head on the lat- component for the hip dislocation. Nor should the fact be eral acetabular epiphysis causes the latter to roll out and overlooked that the hip adductors also stabilize the hip and be pushed away, producing a groove-shaped deformity in the absence of this muscle group increases joint instabil- the acetabulum (⊡ Fig. While the prophylactic effect of an adductor tenotomy has been demonstrated in large patient populations, a closer analysis reveals that the indications in these studies varied considerably. They are often based on measure- ments of the lateralization of the femoral head, in some cases on incorrectly recorded x-rays. It is not certain whether these hips would also dislocate without treat- ment. On the other hand, our experience has shown that a dislocation can be prevented in at-risk hips only in isolated cases. However, the harm resulting after adductor division or destruction, with external rotation contrac- tures and hip instability, is far greater than that resulting from the actual dislocation of the hip, since the dislocated hip can be reconstructed, whereas the destruction of the adductors is irreversible. Furthermore the abduction deformity of the operated hip forces the contralateral ⊡ Fig. Three-dimensional reconstruction of a dislocated hip in infantile spastic cerebral palsy: The anterior and posterior rims of the hip into an adduction position, potentially resulting in a acetabulum are clearly visible. A constant abduction limits the a single direction along a groove-shaped spur. The indentation can be patient’s ability to make motor progress as standing and seen on the lateral side of the head and is caused by the reflected part walking is difficult in this position. The instability of the hip leads to a restriction, or even a loss, of the ability to stand and walk, and prevents any further motor progres- sion [3, 6]. The dislocated hip becomes stiff and the long lever arm, together with the reduced weight-bearing as a result of the dislocation, leads to a much greater risk of fractures. The general activity level of these children, which is already restricted, thus declines still further, whether in school, family situations, or ultimately even while eating. It is always amazing to see, again and again, how such general and non-specific skills of the pa- tients can be improved by the treatment of the dislocated hip. In a unilateral dislocation, the pelvic obliquity can also result in scoliosis. Clinical appearance of a bilateral anterior hip dislocation in a female patient with infantile spastic cerebral palsy. Note the skin The conservative treatment of a dislocated hip simply protrusions over both hips caused by the anteriorly dislocated femoral involves acceptance of the dislocation and management heads of the pain with analgesics. It is important that any seat- ing aids are adapted to the specific movement restric- tion. This conservative approach may be indicated for severely disable patients who are in a very poor general The femoral head initially moves up and down in this condition. Abduction should be avoided as it may cause groove until it becomes fixed at its upper end, eventually pain by pressing the dislocated femoral head against the forming a secondary acetabulum. Thus either the This groove most commonly points laterally in a sector decentering of the hip can be corrected (see below) or the between 25° ventrally and 30° dorsally. One possible first-line treatment Genuine ventral or dorsal dislocations do occur but is Lioresal (baclofen), administered orally or intrathecally are rare. We therefore merely recommend that painful situations should be avoided and the patient should be left Pathological anatomy to continue his rehabilitation program unchanged regard- The head is pushed out of the cup as it forms a groove in less of the hip. Any hip problems that arise will, of course, the acetabulum, resulting in a unidirectional instability have to be resolved accordingly. In younger children the head epiphy- Anterior dislocations are particularly awkward. In sis grows increasingly in the lateral direction (»head in such cases the femoral head can press directly on the neck«), while an indentation forms in older children un- femoral nerve, leading to severe pain.