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These differ- ences influenced the attitudes and practices of segments of the medical profession resulting in unjust treatment of persons with addiction with and without chronic pain purchase atarax 25mg line. The latest statistics indicate that even if patients with chronic pain and SUD desire addiction treatment that might enable them to receive therapy for chronic pain cheap 10mg atarax amex, it may not be available discount atarax 25 mg free shipping. The cohort of persons with substance abuse or dependence that needed treatment, but were not able to receive it rose from 3. The health care crises for the uninsured and working poor who are overrepresented in samples of both chronic pain and SUD patients compound the problem. The physician’s obligation to ‘support access to health care for all people’ is a principle of the AMA Code and is being given increasing attention in other statements of professional duties. From a pharmacological perspective, differential prescribing laws may not be justified. It may be unjust to prevent addicted patients from gaining access to a physician prescription for methadone maintenance for addiction when the same physician can use it for another patient with chronic pain, and may be able to use it to treat both simultaneously. These contradictions reach their nadir in regulations pertaining to methadone. Currently only federally licensed narcotic treatment programs (MMTPs) can legally dispense methadone for purposes of maintenance or detoxification for opioid addiction. However, any physician with a valid Drug Enforcement Administration (DEA) license can prescribe methadone for chronic pain and this is considered a legitimate medical purpose. These contradictory legal rulings and policy statements may leave clini- cians feeling as if they are caught between the Scylla of having state medical To Help and Not to Harm 161 boards investigate them for overprescribing and the Charybdis of being sued for undertreatment of pain. Understanding the realities both legal and clinical of pain management and addiction, the use of judicious consultation and care- ful documentation of the rationale behind drug choice, taking precautions to manage drug misuse, and assuring continued benefit from therapy can assist physicians to avoid both extremes of treatment. There is also ample evidence that addiction is a stigmatizing condition negatively influencing the delivery of health care to patients with addiction. Chronic pain and SUD are often coupled with other diseases like hepatitis C and HIV that are also stigmatizing. These multiple sources of stigma create overlapping vulnerabilities, which warrant additional ethical safeguards in the treatment of chronic pain in the context of addiction. Clinicians need to be sensitive to labeling patients as ‘addicts’ or ‘substance abusers’ and documenting such labels in the chart unless it will serve legitimate medical purposes such as facilitating proper treatment in the emergency room or arranging SUD therapy. The use of urine toxi- cology and other addiction tools for assessment and monitoring are important aspects of comprehensive care for chronic pain patients with a history of addic- tions, but careful attention must be paid to educating patients about the purpose of these tools, and protecting their privacy [66, 67]. When patients do engage in the misuse or abuse of prescription narcotics, limits must be set and patients held accountable but this must be done in a way that continues to respect their humanity and self-determination. This ethic of respect for persons has become one of the most challenging ethical issues in current medical practice. It directs us to respect patient auton- omy and facilitate shared decision making which incorporates patient values, preferences, and goals. 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.

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Moberg A order atarax 25mg with mastercard, Rehnberg L (1992) Incidence of Perthes’ disease in Up- (1999) Does thrombophilia play an aetiological role in Legg-Calve- psala order atarax 10 mg free shipping, Sweden cheap 25 mg atarax free shipping. Hefti F, Clarke NMP (2006) The »Epidemiology« of treatment of Legg-Calvé-Perthes disease: Statistical analysis of 116 hips. An investigation among the members of the Euro- Orthop 11: 153–8 pean Pediatric Orthopaedic Society. Herring JA, Neustadt JB, Williams JJ, Early JS, Browne RH (1992) The Perthes’ disease. Int Orthop 15: 13–6 lateral pillar classification of Legg-Calve-Perthes disease. Pettersson H, Wingstrand H, Thambert C, Nilsson IM, Jonsson K Part II: Prospective multicenter study of the effect of treatment on (1990) Legg-Calve-Perthes disease in hemophilia: incidence and outcome. Pillai A, Atiya S, Costigan PS (2005) The incidence of Perthes‘ disease Legg-Calve-Perthes’ disease. J Bone Joint Surg (Br) 68: versus surgery for Legg-Calve-Perthes disease. Purry NA (1982) The incidence of Perthes disease in three popula- unilateral Perthes’ disease. J Bone Joint Surg (Br) 69: 243–50 tion groups in the eastern cape region of South Africa. Joseph B, Srinivas G, Thomas R (1996) Management of Perthes Kindern und Jugendlichen nach Polychemotherapie. Kalenderer O, Agus H, Ozcalabi IT, Ozluk S (2005) The importance of Femoris und ihre Beziehung zur Hüftkopfnekrose (Morbus Perthes). Kealey W, Mayne E, McDonald W, Murray P, Cosgrove A (2000) The femoral valgus osteotomy in Legg-Calve-Perthes disease. Orthope- role of coagulation abnormalities in the development of Perthes’ dics 25: p513–7 disease. Kealey W, Lappin K, Leslie H, Sheridan B, Cosgrove A (2004) Endo- lateral pillar classification and Catterall classification of Legg-Calvé- crine Profile and Physical Stature of Children With Perthes Disease. J Pediatr Orthop 22: prognostic significance of the subchondral fracture and a two- 464–70 group classification of the femoral head involvement. Kumasaka Y, Harada K, Watanabe H, Higashihara T, Kishimoto H, Surg (Am) 66: 479–89 Sakurai K, Kozuka T (1991) Modified epiphyseal index for MRI in 65. Shang-li L, Ho TC (1991) The role of venous hypertension in the Legg-Calve-Perthes disease (LCPD). Lappin K, Kealey D, Cosgrove A (2002) Herring classification: how 194–200 useful is the initial radiograph? Boston Med ease in Greater Glasgow: is there an association with deprivation? Sponseller PD, Desai SS, Millis MB (1988) Comparison of femoral and Legg-Calve-Perthes disease and the consequences of surgical treat- innominate osteotomies for the treatment of Legg-Calvé-Perthes ment. Livesey J, Hay S, Bell M (1998) Perthes disease affecting three female 68. Stevens D, Tao S, Glueck C (2001) Recurrent Legg-Calve-Perthes dis- first-degree relatives. Stulberg SD, Cooperman DR, Wallenstein R (1981) The natural his- diolucent changes following ischemic necrosis of the capital femoral tory of Legg-Calve-Perthes disease. Margetts B, Perry C, Taylor J, Dangerfield P (2001) The incidence and 70. Van Campenhout A, Moens P, Fabry G (2006) Serial bone scintig- distribution of Legg-Calve-Perthes’ disease in Liverpool, 1982–95. Vasseur PB, Foley P, Stevenson S, Heitter D (1989) Mode of inheri- abduction brace for the treatment of Legg-Perthes diasease. Fractional necrosis of the femoral head Arthrodiastasis in Perthes’ disease. Vila-Verde V, da Silva K (2001) Bone age delay in Perthes disease and Calve-Perthes diasease. Yrjonen T (1992) Prognosis in Perthes’ disease after noncontain- orthosis for the treatment of Legg-Perthes disease. Müller was the first to describe this condition, in 1888, in his pa- per entitled »On abnormal curvatures of the femoral neck during growth«. Fat children and sporting children are particularly at risk of suffering a Occurrence slipped capital femoral epiphysis...

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Training in standing is important for all patients who control buy discount atarax 25mg on line, standing frames that allow active standing with are unable to stand upright actively buy discount atarax 25mg on-line. Various braces are osteoporosis order 10 mg atarax visa, extends the hips and knees, ventilates the available on the market for this purpose. The upright with just two vertical supports that are securely linked to position also has a positive psychological effect. Straps, or more rigid fixation elements, are patients no longer have any postural function at all, they attached to these supports to keep the patient upright. In can still be positioned in tiltable standing frames, with this way, the various joints of the spine and lower extremi- the hip slightly overextended and the knee fully stretched. This allows the whole skeleton to be fitted with wheelchair wheels, although the adaptability of loaded. Achieving this position is particularly difficult if these mobile devices is limited. When the patient lies face down on the tiltable standing frame, the hips are Walking aids generally flexed by approx. For patients with better body with hoist attachments and are particularly suitable for 733 4 4. Crutches with three legs are available for children obliged to learn to walk on crutches. The stability is greater and the crutches remain upright even when released. Bicycles > Definition Bicycles for disabled patients possess maximum inherent stability either thanks to two large back wheels or stabi- lizers. Bicycles enlarge the radius of activity, which is important for the psychological development of patients. However, since pedaling does not require full extension at the knees and hips, in contrast with walking, bicycles are not suit- able for use as training devices for building up strength in order to improve walking. Barnett SL, Bagley AM, Skinner HB (1993) Ankle weight effect on gait: orthotic implications. Helen R, Moran SA, Ashley RK (1989) Effects of ankle-foot orthoses on the gait of children. Burdett RG, Borello-France D, Blatchly C, Potter C (1988) Gait comparison of subjects with hemiplegia walking unbraced, with ankle-foot orthosis, and with Air-Stirrup brace. Carlson JM (1987) Biomechanik und orthetische Versorgung der unteren Extremitäten bei Kindern mit zerebraler Lähmung. Good posture in the standing frame with extended hips thop Tech 9: 497–507 thanks to the wedge placed under the thighs before the frame is 6. Cerny D, Waters R, Hislop H, Perry J (1980) Walking and wheelchair righted energetics in persons with paraplegia. Diamond MF, Ottenbacher KJ (1990) Effect of a tone-inhibiting dynamic ankle-foot orthosis on stride characteristics of an adult with hemiparesis. Guidera KJ, Smith S, Raney E, Frost J, Pugh L, Griner D Ogden JA older and heavier patients. Walkers help train the patient (1993) Use of reciprocating gait orthosis in myelodysplasia. J Pedi- in walking without the need for additional postural sup- atr Orthop 13: 341–8 port from nursing personnel. Hullin MG, Robb JE, Loudon IR (1992) Ankle-foot orthosis function standing frames and walkers include frames on wheels in low-level myelomeningocele. J Pediatr Orthop 12: 518–21 that allow the patient to take controlled steps. Lehmann JF, Ko MJ, de Lateur BJ (1980) Double-stopped ankle- foot orthosis in flaccid peroneal and tibial paralysis: evaluation of vices compensate for the patient’s poor balance by hold- function. Arch Phys Med Rehabil 61: 536–41 ing the body in a secure grip, although the arms remain 11. Patients can therefore choose their own direction of hinged polypropylene ankle-foot-orthoses in the management of walking, while the hands are free for grasping. Prosthet Orthot Int 12: 129–35 ables them to move independently on their own initiative 12. Myhr U, Wendt L von(1993) Influence of different sitting positions and abduction orthosis on leg muscle activity in children with within their immediate environment, grasp and transport cerebral palsy.

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