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Multicomponent programs necessitate a range of professionals with ap- propriate training; key members are physicians generic 100 mg extra super lovevitra mastercard, clinical psychologists buy extra super lovevitra 100mg with mastercard, and physiotherapists or physical therapists; occupational therapists, and thera- pists with particular focus on vocational concerns may also be involved. A little-addressed aspect of multidisciplinary treatment is the extent to which the team members of different disciplines really work in an integrated way, or alternatively operate independently, and potentially with incompatibili- ties between them. Treatment on an outpatient basis provides the greatest opportunities for the patient to apply and generalize pain management techniques learned on the program to his or her own environments, but in- tensive (usually inpatient) programs may be required to enable change in more severely disabled and distressed patients (Williams et al. Evidence The Division of Clinical Psychology of the American Psychological Associa- tion (APA) published a list of 25 empirically validated psychological treat- ments for various disorders (APA, Division of Clinical Psychology, 1995). CBT for chronic pain was included in this list, based mainly on evidence ex- amined by Keefe et al. A recent systematic review and meta-analysis of 25 randomized control trials (RCTs) of CBT for chronic pain except head- ache by Morley et al. This summary represents an optimistic picture, qualified somewhat by concerns that these RCTs probably represented the better end of the spectrum of treatment, and by the recognition of enormous di- versity among them, to the extent that subgroup analyses or dose-response effects could not be addressed despite the large n. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 283 Two other systematic reviews have appeared since, both concerned only with chronic low back pain. For the comparison of CBT with alternative treatment (such as physical therapy), six studies showed no significant improvement in any of the three outcome areas. Guzmán, Esmail, Karjalainene, Irvin, and Bombardier (2001) con- cluded from 10 studies that only intensive (longer, rather than brief) multi- disciplinary treatment with a CBT approach reduced pain and improved function when all were compared with treatment as usual (a conclusion also borne out by Williams et al. They thus recommended careful at- tention to treatment content by referrers. Among patients with rheumatoid arthritis, CBT was the only form of psychological intervention that was found to be efficacious; among patients with headache, CBT was actually no more effective than simpler re- spondent techniques (Compas et al. Only one study appears to have addressed the question of inpatient ver- sus outpatient treatment.

A more comprehensive discussion of these matters can be found in the clinical practice guidelines on the management of chronic pain from the American Geriatrics Society expert panel (AGS extra super lovevitra 100 mg low price, 2002) cheap extra super lovevitra 100mg with mastercard. Pharmacological therapy is always more effective when combined with nonpharmacological approaches designed to optimize pain management. Regular physical activity can increase fitness and reverse the physical deconditioning that is often seen in patients with chronic pain problems. PAIN OVER THE LIFE SPAN 139 recent randomized control trial demonstrated a significant overall improve- ment in pain, functional status, and performance measures in elderly veter- ans with chronic musculoskeletal pain (Ferrell, Josephson, Pollan, Loy, & Ferrell, 1997). Unfortunately, this study did not include a young adult com- parison group and there is no other evidence to show whether older per- sons respond as well, less well, or to the same extent as younger cohorts. Psychological approaches for the management of pain have been well es- tablished in young adult populations (for review see Gatchel & Turk, 1998). Uncontrolled, essentially descriptive studies have also shown that older adults can benefit from relaxation training (Arena, Hannah, Bruno, & Mea- dor, 1991; Arena, Hightower, & Chong, 1988), biofeedback (Nicholson & Blanchard, 1993), behavior therapy (Miller & Le Lieuvre, 1982), and cogni- tive-behavioral treatment programs (Puder, 1988). Recently there has been one randomized control trial of cognitive-behavioral therapy in nursing home residents (Cook, 1998). Cognitive-behavioral therapy involving 10 weekly sessions of education, reconceptualization of pain and belief struc- tures, and training in coping skills, relaxation, and goal setting was shown to greatly improve self-rated pain and functional disability, but not de- pressed mood. In com- bination, these findings may help refute the notion that older persons are less accepting of psychological approaches to pain management (Kee, Mid- daugh, & Pawlick, 1996), but without formal age comparative data, it is im- possible to evaluate the relative treatment efficacy within different age seg- ments of the adult population. Multidisciplinary pain management facilities are thought to offer state-of- the-art treatment for more complex chronic pain problems, particularly when conventional management strategies have failed (Flor, Fydrich, & Turk, 1992; Guzman et al. Several authors have noted the importance of modifying standard treatment protocols in order to accommodate the special needs of older patients (Arena et al.

The cellular mechanism a nondisruptive strain injury demonstrates responsible for attracting the neutrophils is not decreased load to failure when subjected to stress completely known but probably involves a com- (Obremsky et al buy extra super lovevitra 100mg otc, 1994; Taylor et al generic extra super lovevitra 100 mg with visa, 1993). Mediators such as basic tion, these partially injured muscles generate signif- fibroblast growth factor (bFGF), platelet-derived icantly less contractile force. This may explain the growth factor (PDGF), and interleukin-1 (IL-1) clinical observation that significant muscle strain stimulate macrophages and fibroblasts within the injuries are frequently preceded by a minor injury. Distinct subclasses of macrophages have been identified and play spe- REPARATIVE RESPONSE cific roles in the healing process. One subclass of Similar to the general reparative response of muscle macrophages is involved in the phagocytosis of described above. A second subclass of make the muscle more susceptible to additional macrophages helps modulate the reparative process injury. Muscle As mentioned above, reduced activity is key in the injury stimulates these cells to differentiate into treatment of muscle strain injuries. This helps control myoblasts, which fuse together and develop into mult- inflammation and prevents further tissue damage. This connective tissue scar for- days) results in muscle that demonstrates lower loads mation may inhibit the complete repair of injured to failure and should be avoided (Noonan and Garrett, muscle (Lehto and Jarvinen, 1991). MUSCLE STRAIN INJURY NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Animal studies demonstrate that nonsteroidal anti- Muscle strain is the most common injury sustained in inflammatory drugs (NSAIDs) reduce the inflamma- sports. This type of muscle injury can range from tory response associated with muscle strain injury but CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 57 may delay complete healing of the muscle tissue PATHOPHYSIOLOGY (Nikolaou et al, 1987; Obremsky et al, 1994). The High tension over a small cross-sectional area (seen in indication for the use of these drugs in muscle strain eccentric muscular contraction) results in cytoskeletal injury is unclear. This stimulates nociceptors within the Muscle strengthening is an important factor in the muscle resulting in the production of pain recovery of injured muscle and the prevention of rein- (Armstrong, 1984).