Manual Clinical Behavioral Medicine: Some Concepts and Procedures

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Clinical Behavioral Medicine

These patients are usually relieved just as rapidly by a few days of rest as by much longer periods of inactivity Deyo et al. Clinical efforts should be directed at relieving pain with mild, nonaddicting analgesics while the patient continues to be as active as possible. Inappropriate extended periods of inactivity reduce the effective muscle mass and may make the patient more vulnerable to subsequent strains. Furthermore, prescriptions for re- stricted activity may heighten patients' attention to and awareness of their symptoms and convince them that they are sicker than they really are.

At a certain point, such a view can undermine effort and motivation and alter social interactions. Thus, there can be physical, psychological, and social iatrogenic consequences of Tong periods of inactivity. Most patients with chronic back pain may need to be.

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Drug Therapy Analgesics narcotic and non-narcotic and muscle relaxants benzodiazepines and non-benzodiazepines are very commonly pre- scribed for back pain. In addition, hypnotics may be used to help pain patients sleep, and antidepressants have recently begun to be pre- scribed for pain see Chapter Used in relatively small doses for a short period of time, these medications can often be effective, either alone or in conjunction with other therapies.

Often, when pain com- plaints continue, increasingly powerful drugs are prescribed over long periods of time in increasingly large doses. This is particularly likely when patients have consulted multiple providers. There is considerable controversy in the medical community about the appropriateness of Tong-term drug therapy with opioid analgesics for nonmalignant chronic pain. Until very recently it was generally thought that the risks of physical and psychological drug dependence, drug abuse, increased psychological distress, and impaired cognition were too great to warrant the extended use of narcotic analgesics for severe chronic pain see, for example, Maruta et al.

In the last several years, however, there have been reports indicating that long-term therapy with these drugs can be successful. For example, Portenoy and Foley found that 24 out of 38 patients maintained on opioid analgesics for at least 4 years for nonmalignant chronic pain achieved "acceptable or fully adequate relief of pain. Clearly, drug therapy is an unportant element in the treatment of chronic pain, either alone on in conjunction with other modalities.

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Regardless of the type of drug prescribed or the duration of drug treatment, physicians need to be alert to the possible unintended, often adverse, side effects of drugs, including physical and psychological depen- dence, impaired motor coordination, altered daytime functioning, and symptoms of withdrawal when medication is discontinued. More careful monitoring of the effects of medications may prevent unnecessary iatrogenic complications. Even when an extruded lumbar disc is suspected, analgesics and a period of rest are indicated unless a major, progressive neuro- logical deficit develops.

Surgical treatment for chronic Tow back pain is less often effective than in acute sciatica, and rarely produces dramatic relief of back or leg symptoms except in problems of spinal stenosis, or in unusual abnormalities due to tumor or infection. Problems of spinal stenosis are becoming increasingly recognized and are amenable to surgical treatment in the majority of patients whose condition is confirmed by myelography, computerized body tomography, and magnetic reso- nance imaging.

Infection, tumor, and spinal instability problems may all result in chronic back pain; and although these conditions are relatively uncommon, surgical treatment remains a definitive man- agement. Of concern are those conditions in which the pathology demonstrated is not a clear cause for chronic low back pain, in which case surgical treatment should not be considered. Numerous research studies and clinical observations reported in the literature indicate that surgery for chronic back pain is overused and often misused, that it is seldom any more effective than nonsurgical treatment in either the short or long term and often is less effective, and that back surgery especially repeated surgery frequently results in serious iatrogenesis.

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Generally, after one unsuccessful back opera- tion the chances of rehabilitation are significantly reduced, and after two or more failed operations it is very unlikely that operative treatment will be of value. An important exception to this general statement is when evidence is uncovered suggesting that the initial operation was not effectively designed or executed to address the known pathology.

In such cases, additional surgery may be warranted and effective. In cases of chronic intractable disabling pain in which the specific etiology cannot be determined or treated, neurosurgical procedures for. For patients with disabling pain after failed lumbar surgery, dorsal column stimulation or focal installation of spinal morphine may, in a very few cases, offer a temporary period of pain control during which some of these patients can become functional.

In most medical centers, other neurosurgical operations, such as cordotomy, extensive rhizotomies, or midline myelotomy are no longer used in rehabilitative efforts for the patient disabled by chronic pain of nonmalignant origin. In a study of work disability in newly diagnosed cases of arthritis, people who underwent surgery were less likely than others to continue working Yelin et al.

In fact, cessation of employment was predicted twice as well by having had surgery as by physicians' judgments of the initial severity of the illness. Moreover, for each therapy and drug regimen commonly prescribed by physicians for patients with arthritis, stopping work became more likely but to a lesser degree than for surgery. Although it is possible that the need for therapy indicated severity of disease more sensitively than the physicians' reported judgment, it is also possible that in addition to providing some relief from pain, medical therapies may also have served to reinforce a lifestyle of invalidism.

Thus, an important preventive measure to avoid iatrogenesis and mitigate long-term disability is to refrain from back surgery unless there is a clearly identified, surgically correctable problem and reasonable conservative treatment has failed. Pain, like insomnia and functional bowel distress, is a symptom complaint that has been relatively neglected in medical education and clinical research despite the fact that it is a common problem.

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In recent years there has been an increased interest in the multifaceted clinical aspects of chronic pain, but much research remains to be done. There are three broad questions for which clinical research would be particularly useful: 1. For what types of patients and in what circumstances does acute pain progress to chronic disabling pain, and can these patients at risk be identified early?


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What specific treatment modalities are effective for which pa- tients, and how do particular aspects of the doctor-patient relationship influence the effectiveness of treatment? What are the optimal times in the pain-disability course for particular kinds of interventions? As discussed in Chapter 6, less than 10 percent of people with acute back pain develop chronic disabling pain.

If those people who are at risk for long-term illness and impairment could be identified early, it might be possible to design more effective treatment plans that could prevent long-term chronicity for at least some patients. At this time certain factors are known to be correlated with Tong-term problems, but they are not useful as predictive factors. More detailed patient topologies and classifications based on the development of chronic pain and disability are needed.

There is a paucity of data in the literature about the effectiveness of diagnostic tools including the history-taking interview and physical examinations and treatment modalities for pain. The Quebec Task Force on Spinal Disorders Spitzer and Task Force, concluded that methods of treating chronic pain are, by and large, untested in well-controlled clinical trials. Few treatments have been shown to improve the natural history of nonspecific spinal disorders. Clearly, there is a need to assess interventions in order to see what works alone or in combination and for which kinds of patients.

Among the treatments that should be evaluated are some of the alternative care therapies offered by chiropractors, holistic health care practitioners, and others that were discussed in Chapter 8. A number of questions could usefully be addressed: Do these therapies actually alleviate pain or do they alter pain perceptions or attributions so that disability is avoided despite persistent pain?

Do particular forms of heating techniques preclude or interfere with medical treatment, or do they complement medical care by taking account of important psycho- social factors sometimes neglected in current medical practice? Are particular therapies elective only with individuals with certain group affiliations or personal characteristics?

Do certain alternative thera- pies have potentially harmful erects that may exacerbate pain and disability? If, as a few studies suggest, outcomes depend on the characteristics of the provider more than on the actual techniques used, such findings may point the way to specific alterations in physician behavior or in the doctor-patient relationship that will promote rehabilitation and recovery. Finally, there is a very critical question about the optimal timing of. However, this has not been adequately tested.

Generally, clinicians agree that the longer people have been impaired, the harder it is to treat or rehabilitate them see Chapter What is not known is whether early interventions and rehabilitation efforts prevent later problems. Physical illness and psychiatric disorders.

Comprehensive Psychiatry , Barr, J. Ruptured intervertebral disc and sciatic pain. Bennett, R. Fibrositis: misnomer for a common rheumatic disorder. Bourdillon, J. Spinal Manipulation, 3rd Ed. Heinemann, W.


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London: Appleton, Century, Crofts, Cabot, R. Differential Diagnosis.

Introduction

Philadelphia: Saunders, Cailliet, R. Low Back Pain Syndrome. Philadelphia: F. Davis, Campbell, S. Clinical characteristics of fibrositis. A "blinded," controlled study of symptoms and tender points.