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By K. Fabio. Wayne State College. 2018.

The point at which this line crosses the force the posterior wall sign on both sides (the corresponding contours are resultant R (at an angle of approx 10mg toradol with mastercard. Labral lesions are clearly visible on both sides up to the determined anterior boundary discount 10mg toradol visa. This bounded area can be calculated very simply using the template (C Head center). The angle between the vertical and the line CE is termed the Center-Edge angle (CE angle) according to Wiberg sectors on the template is 18°. This load-relevant area can sively large and deep acetabulum can lead to impingement be calculated very simply by counting the rectangles and (known as a »pincer effect«). A projecting The freedom of movement between the femoral head and anterior inferior iliac spine that is positioned too low (e. Various anatomical and responsible for the femoral neck striking the acetabu- biomechanical studies have identified the factors which, lar rim, as typically occurs in slipped capital femoral instead of a smooth sliding movement between the femo- epiphysis (⊡ Fig. On the one hand, this damages ral head and acetabulum, cause the femoral neck to strike the acetabular labrum (known as a »cam effect«) and, on the acetabulum, in turn triggering a shear movement of the other, produces a shear movement of the head within the head in the joint [9, 19, 21, 24]. The shear movement mainly occurs during pingement« may lie in the acetabulum, the femur or both flexion, but can even be present during normal walking components together. The impingement As regards acetabular causes, reduced anteversion can be reduced by external rotation of the leg during (⊡ Fig. The excessively small loading area is a factor in the above-listed situations 1, 2, 4, 5 and 6. We encounter the adverse load transfer 3 orientation in situations 1, 3, 5 and 6. In many cases, the resulting shear forces cause arthroses that used to be described as »idiopathic«. In a triple osteotomy, all three bones (ilium, pubis and ischium) are divided, while the cut in a periacetabular osteotomy goes around the acetabulum (and thus through the triadiate cartilagetriradiate cartilage, as well). The acetabulum is not actually enlarged but is rather rotated laterally and – if necessary – anteriorly, thereby enlarging the relevant ⊡ Fig. CT with three-dimensional reconstruction in a 15-year loading area at the cost of the caudal sections. This op- old female athletic patient with apophyseal avulsion and excessively low growth of the anterior inferior iliac spine (arrow), resulting in eration is particularly suitable if the bony components are impingement with the femoral neck during flexion roughly spherical but inadequate lateral acetabular cover- age exists. In this case the anterior coverage is improved at the expense of the posterior coverage. Amtmann E, Kummer B (1968) Die Beanspruchung des menschli- Effects of incorrectly shaped bony chen Hüftgelenks. Braune W, Fischer O (1889) Über den Schwerpunkt des menschli- The crucial question in every case is whether an incor- chen Körpers. Brinkmann P, Frobin W, Hierholzer E (1980) Belastete Gelenkfläche rectly shaped component can lead to premature osteo- und Beanspruchung des Hüftgelenks. Elke R, Ebneter A, Dick W, Fliegel C, Morscher E (1991) Die sonog- following anatomical changes are present: raphische Messung der Schenkelhalsantetorsion. Hefti F (1995) Spherical assessment of the hip on standard AP ra- riorly, diographs: A simple method for the measurement of the contact 5. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Jt Surg A pre-arthritic condition probably also exists in cases of: Br 83: 171–6 10. Jani L, Schwarzenbach U, Afifi K, Scholder P, Gisler P (1979) Verlauf 11. Klaue K, Sherman M, Perren SM, Wallin A, Looser C, Ganz R (1993) We would expect a functional restriction without any Extra-articular augmentation for residual hip dysplasia. J Bone risk of premature osteoarthritis in the case of an: Joint Surg (Br) 75: 750–4 12. Kummer B (1968) Die Beanspruchung des menschlichen Hüftge- tions do not constitute pre-arthritis : lenkes. Legal H, Reinecke M, Ruder H (1980) Zur biostatischen Analyse des Historical background Hüftgelenks III. Morscher E (1992) Biomechanik als Grundlage der Orthopädie congenital form of hip dislocation. Orthopäde 21: 1–2 first to discover the importance of the role played by the inadequate 17. Murphy SB, Ganz R, Mueller ME (1995) The prognosis in untreated development of the acetabulum. J Bone Joint Surg (Am) 77: 985–9 Other important milestones in the development of its diagnosis 18. Murray DW (1993) The definition and measurement of acetabular 1846: Wilhelm Roser describes the »ilio-ischeal line«. J Bone Joint Surg (Br) 75: 228–32 passes through the iliac spine, the greater trochanter and the 19. Noetzli HP, Wyss TF, Stöcklin CH, Schmid MR, Treiber K, Hodler J ischial tuberosity, is straight under normal circumstances. In a (2002) The contour of the femoral head-neck junction as a pre- hip dislocation, however, the trochanter is well above the line, dictor for the risk of anterior impingement. Pauwels F (1935) Der Schenkelhalsbruch, ein mechanisches Prob- the examination technique discovered by C. Rab G (1999) The geometry of slipped capital femoral epiphysis: 1962: T. Roesler H, Hamacher P (1972) Die biostatische Analyse der Belas- Dates relating to treatment tung des Hueftgelenkes, II.

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The ability to walk is lost around the age of 10 and life expectancy is between 25 and 30 years order toradol 10mg on line. These days discount 10mg toradol mastercard, heart failure rather than pulmonary insufficiency is the limiting factor. Historical background, etiology and pathogenesis This form of muscular dystrophy was first described by Duchenne in 1861 and occurs in 30/100,000 neonatal males. Duchenne dystrophy involves a gene defect that leads to an underproduction of a protein that is important for muscle function known as dystrophin. This protein is found in skeletal muscle, cardiac muscle, smooth muscle and the brain, and plays an important role in the excita- tion of the muscle cell [18, 23]. Clinical features and diagnosis Duchenne muscular dystrophy only affects boys. The disease with slight equinus feet, largely extended knees and hips and lumbar hyperlordosis. This is typical of a standing position that does not manifests itself as muscle weakness, usually during the require much muscle power first five years of life. A dystrophin deficiency for the prevailing muscle weakness) and frequent falls. As the condition progresses, patients are Female carriers can, in rare cases, also show muscle no longer able to rise from the floor without help and symptoms in the form of calf cramps, calf hypertrophy use their arms to climb up the legs and stand up (Gow- and muscle weakness in the legs, and sometimes even ers sign). Laboratory tests reveal a marked elevation in the cre- The ability to walk and stand is lost around the age atinine kinase level. The dystrophin deficiency can also be 4 of 10 or 11, and the children then become confined to confirmed in the laboratory [3, 10]. In this phase the leg muscles are no longer of myopathy while the sonogram of the muscles appears adequately stretched and contractures occur. The muscle biopsy is the decisive diagnostic muscles also become increasingly weaker, involving the factor. Histological examination reveals a picture with risk of rapidly progressing scolioses (⊡ Fig. The muscle Towards the end of the teens, the muscular dystrophy fibers show differing diameters, and the proportions of leads to progressive pulmonary insufficiency. The muscle volvement of the cardiac muscle is difficult to manage and fibers ultimately die. The (tonic) postural work is increas- constitutes a life-limiting factor. In addition to the striated ingly taken over by connective tissue, which becomes muscle, the smooth muscle also appears to be affected by correspondingly hypertrophic. Pa- In terms of the differential diagnosis, Duchenne mus- tients with muscular dystrophy are also associated with cular dystrophy must be differentiated from the Becker an increased bleeding tendency during surgeries, even type and from spinal muscular atrophy. One possible atrophy greatly resembles Duchenne muscular dystrophy, explanation is the involvement of vascular muscle and the but can affect both sexes and appears at an earlier age, with the result that patients are not even able to walk. The course of Becker muscular dystrophy is similar to that of Duchenne muscular dystrophy but the former progresses more slowly and has a better prognosis. Treatment and prognosis No causal treatment exists for Duchenne muscular dys- trophy. Transplantation of normal myoblasts has proved ineffective, and gene therapy is still in the experi- mental stage. The orthopaedic treatment is aimed at preserving the ability to walk and stand for as long as pos- sible and preventing contractures. Early surgical muscle and tendon lengthening procedures have been proposed as the statistics indicate that the loss of the ability to stand and walk can thereby be deferred [22, 30, 31]. The time gained is between 1 and 3 years, which is a significant period for these patients. Like several authors we also consider that these procedures, which combine lengthening of the hip abductors, knee flexors and triceps surae muscle, are indicated only when contractures start to interfere with everyday functions and the need for sur- gery becomes apparent even to critical parents. Braces and corsets are often required not only for postural correction, but also to replace the lost muscle function. The correction of abnormal spinal posture and spinal deformities is useful even for small angular deviations. Typical pseudohypertrophy of the calves in Duchenne cedure in a patient with a worse state of general health. The pronounced muscular atrophy, the lack of facial expression and the oversized tongue are additional visible a b signs of the muscular dystrophy of life and, in particular, the ability to sit and facilitates hood. Corset treatments are not very effective Muscle cramps are present during and after physical and useful only in exceptional cases when operations exertion. The muscle weakness tends to occur proximally are no longer possible or are declined. The pulmonary Since the Becker dystrophy progresses much more slowly, insufficiency manifests itself in the form of hypoxemic patients are still able to walk even after puberty. Life phases (particularly at night), which also affects mental expectancy is determined by the degree of respiratory performance during the day. A home ventilation program insufficiency and is between 40 and 60 years. The ortho- (assisted nocturnal ventilation) can significantly improve paedic and cardiac findings resemble those for Duchenne these symptoms. More difficult is the treatment of the muscular dystrophy, but are less pronounced. The inci- heart failure, which is likewise progressive and a life-limit- dence of scolioses is not known, but spinal deformities ing factor.

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Such patients less clear that psychological factors play an important can experience symptoms at an early stage buy generic toradol 10mg on-line, i order toradol 10mg without prescription. When adolescents present with severe lumbar back severe cases does actual lumbar kyphosis occur. Pigmentation over the spinous processes is often an outwardly visible sign Differential diagnosis of local kyphosis in the lumbar area. Are irregular endplates sufficient for di- 3 During the examination it is important to note the fixa- agnosing a case of Scheuermann’s disease? A flexible kyphosis is not indicative Schmorl node count as Scheuermann’s disease? Only if the kyphosis cannot be many wedge vertebrae with a particular angle are needed corrected during the examination should the possibility of for confirming the diagnosis? One striking feature is the increased finger-floor dis- tance that is almost invariably measured in Scheuermann patients as a result of contraction of the hamstrings. While the cause of this muscle contracture remains unclear, it may be an expression of a generally contracted posture in Scheuermann patients. Contraction of the pectoral muscles is always present in the thoracic form. Radiographic findings The typical radiographic changes are shown in ⊡ Fig. On the lateral x-ray of the thoracic or lumbar spine we observe: ▬ Schmorl nodes ▬ Apophyseal ring herniation ▬ Wedge vertebrae ⊡ Fig. Radiographic changesin the thoracic spine of a 13-year old boy with Scheuermann disease, including apophyseal ring herniation, ▬ Intervertebral disk narrowing intervertebral disk narrowing and wedge vertebrae (arrows) These findings may be located purely at the thoracic (⊡ Fig. At the thoracic level they are associated with hyperky- phosis, whereas a lumbar finding may initially only be accompanied by slight flattening of the lordosis. Schematic presentation of radiographic changes in Scheuer- the apophyseal ring herniation (arrows) on vertebral bodies L1 and L2 mann’s disease and the kyphosing in this area 97 3 3. The patient’s history obviously plays an important role, although it should be borne in mind that trauma details reported by adolescents can be misleading in both posi- tive and negative senses. On the other hand, pa- tients may be keen to associate back pain with a particular event that was certainly not capable of causing injury. Associated diseases ▬ Scoliosis Over 50% of patients with Scheuermann disease also suffer from scoliosis to a greater or lesser extent. This is directly connected to the Scheuermann’s dis- ease and has nothing to do with idiopathic scoliosis. This mechanism contrasts angle in Scheuermann disease: Straight lines are drawn through the strongly with the process involved in the development endplates: through the inferior and superior endplates of the same of idiopathic scoliosis, where the vertebral bodies grow vertebra for measuring the wedge shape, and through the endplates of the two vertebrae that are most severely tilted towards each other faster anteriorly than posteriorly and create extra space for the overall kyphotic angle. Since diminished growth the overall kyphotic angle occurs on the anterior side in Scheuermann disease, the associated scoliosis involves less rotation compared to the idiopathic form, and it is obviously not lordotic The statements in the literature are very contradictory. The We apply the following rules: prognosis for Scheuermann scoliosis is relatively good ▬ In the thoracic area the overall kyphotic angle and and severe lateral curvatures rarely develop. Thorac- Spondylolysis ic Scheuermann’s disease is diagnosed, regardless Adolescents with Scheuermann’s disease are also as- of the radiographic changes, if the overall kyphotic sociated with an increased incidence of spondylolysis angle exceeds 50° and the kyphosis is clinically. If the x-ray shows two or more wedge ver- which is compensated for by hyperlordosis, thereby tebrae of >5° or Schmorl nodes / apophyseal ring increasing the pressure on the interarticular portion herniations, the condition can be diagnosed even if of L5. The spondylolysis is known to be caused pre- the overall kyphotic angle is less than 50°. Since Course, prognosis the height of the disk on the x-ray depends greatly Fixed, thoracic kyphoses of less than 50° do not rep- on the projection this is difficult to assess. However, the outwardly visible deformity can be a or one Schmorl node / apophyseal ring herniation. While the measured kyphotic angle is not relevant In cases of fixed, thoracic kyphoses of more than 50°, for diagnostic purposes, it is useful for assessing back pain is no more frequent, but is likely to be more the severity and prognosis of the condition. Such patients tend to choose physically less demanding occupa- It can sometimes prove difficult to distinguish between tions, while lung function is only impaired in very wedge vertebrae caused by Scheuermann disease and those severe kyphoses. The following find- Kyphosis of more than 70° can also be progressive in ings on the lateral x-ray suggest a compression fracture: adulthood. In contrast with scoliosis, a kyphosis can not disease are often painful in adolescence, and the prog- only be stabilized by brace treatment but also corrected nosis in terms of pain during adulthood is poor be- in a patient with sufficient growth potential [4, 8, 14]. Lumbar The wedge vertebrae are straightened by the compensa- kyphoses shift the center of gravity anteriorly, which tory growth of the anterior sections (⊡ Fig. Of has to be compensated for by increased postural work course, a precondition for a successful outcome is good by the paravertebral muscles. Possible braces for thoracic Scheuermann disease are Treatment straightening braces with a three-point action (e. However, we generally use ▬ Brace treatment the smaller Becker brace (⊡ Fig. While the kyphosis remains flexible and no radiographic changes are ap- parent, the patient is merely suffering from a postural abnormality rather than Scheuermann’s disease. It is more effective to manage postural abnormalities by encouraging the patient to practice some sporting activity than by expen- a b sive physiotherapy. If growth potential is still present, wedge-shaped verte- and are almost never able to perform regular exercises on bral bodies can still be straightened out with brace treatment. It is more useful to persuade adolescents to vertebrae in Scheuermann disease in a 14-year old girls. The specific sport ened vertebral bodies two years later, after 18 months of brace treat- involved is of secondary importance. Active, corrective ment (figures refer to wedge angle in degrees) physiotherapy is indicated, however, in a case of fixed ky- phosis. The only inappropriate sports are rowing, cycling with drop handlebars (⊡ Fig. Brace treatment Brace treatment should be considered for a thoracic kyphosis of more than 50° in a patient who is still ⊡ Fig.

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Oral intake is allowed order 10 mg toradol free shipping, but wounds should be kept clean to avoid any graft shearing and infection cheap 10 mg toradol mastercard. Stage Two: Second Look and Autografting Approximately 1 weeklater (between 4 and 7 days after excision and homograft- ing), the patient returns to the operating room for definitive wound closure. If homo- grafts are well adherent to the wound bed and there are signs of revasularization, the wound is ready for skin autografting. When the homografts are found to be loose and nonadherent, facial wounds need to be excised and homografted again. In this case, patients return 4 days following the second stage for a further inspec- tion. If the wound bed is vital, epinephrine-soaked (1:10,000) Telfa dressings are applied. When grafts need to match nonburned or healed face areas, the scalp should be used. When the entire face must be grafted, the scalp does not provide enough quantity of skin graft. The skin grafts must be obtained from the same donor site to graft the entire face with the same quality of skin to render a good color match all over the face. It is not acceptable to obtain skin from the scalp and elsewhere at the same time. This will inevitably leave an area of color mis- match that will be not accepted by the patient. When the scalp is used, the size and form of the skin grafts should be drawn on the surface before any subcutane- ous infusion is applied. Four good-sized pieces of skin autografts can usually be obtained from the scalp: One anterior piece from ear to ear posterior to the hair line One posterior piece from vertex to the occipital region Two lateral pieces from the retroauricular region to the neck The scalp is infiltrated with epinephrine-containing normal saline (1:200,000) until large flat areas are obtained. The larger guards should be used to obtain good-quality grafts with appropri- ate width. The assistants should hold the head and the anesthetist control the ET tube while the harvesting is in process. Pressure must be exercised on the opposite part of the head to maintain the countertraction. Two assistants are necessary, main- taining pressure on the periphery of the skull to leave the entire area around the top of the scalp ready for harvest. After harvesting, epinephrine-soaked (1:10,000) Telfa dressings are immediately applied and left in place for 10 min. The scalp is then dressed in the standard fashion (either Biobrane or Acticoat dressings). When the entire face must be grafted, the scalp will not provide enough skin grafts. An alternative donor site is chosen (the backprovide large amounts of good quality skin), and all skin grafts necessary to graft the entire face are taken from the same area to provide excellent color match. It is important to preserve the donor site that might be used for face grafting in order to provide the best quality of skin. A master plan is developed shortly after admission, and, if at all possible, the donor area to be used for face burns is spared. Donor sites are also infiltrated with large amounts of normal saline with epinephrine and powered dermatomes are used. The manual Padgett dermatome is the best instrument to obtain skin for cheeks and forehead, but it is cumbersome and difficult to use. Common thicknesses for face burns skin grafting are as follows: Eyelids: 16/1000 inch Children (all other areas): 14–18/1000 inch Adults (all other areas): 18–21/1000 inch The grafts are then carefully stitched into place with 4/0 and 5/0 plain catgut or Vycril rapide. Bolsters are used on the eyelids, but the rest of the face is left exposed. Grafts should be stitched with slight tension to return grafts to their normal physi- cal properties and avoid wrinkles. Darts are commonly used on the lateral aspect of the neckwhen the graft joins normal skin. An alternative to skin autografts is the use of synthetic skin substitutes or dermal templates. Many groups have started to use Integra to close deep dermal and full-thickness face burns. Results differ among them, but common problems are still color match and graft texture. Even though their use is becoming more common practice in other anatomical locations, the routine use of synthetic skin substitutes in the management of face burns is still evolving and subject to intense research. At present, their use should be reserved for cases in which the entire face is to be grafted. POSTOPERATIVE CARE Grafts are normally exposed unless an elastomer mold can be applied with interim pressure garments. If the use of elastomers is feasible (depending on the capabili- The Face 289 ties of the rehabilitation services), a negative impression is made at the end of the excision and application of homografts (stage one). It allows the occupational and physical therapists to fabricate an elastomer that is applied under interim and permanent pressure garments. In general, graft care includes the application of antimicrobial ointments on graft seams and petrolatum or antimicrobial creams on the graft surface to prevent desiccation. If these develop, they are drained through small incisions placed in the relaxed skin tension line. When hematomas are large, the patient is returned to the operat- ing room so that surgeons can lift the graft, remove the hematoma, and stitch the graft backwith the patient under general anesthesia. Patients are kept from any oral intake for 4 days, and are fed via a nasogas- tric or nasojejunal tube.

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For example buy toradol 10mg mastercard, specific behavioral measures exist for assessment of premature infants (e cheap toradol 10mg online. Behavioral measures are especially valuable in the case where self-reports of pain are not possible (e. Research has generally indicated that observer ratings underestimate children’s pain in- tensity (Chambers, Reid, Craig, McGrath, & Finley, 1998), although no re- search has documented age-dependent differences in agreement between observer and child reports of pain. Physiological measures are also employed in the assessment of pain in children (Sweet & McGrath, 1998). These include heart rate, respiratory rate, and skin blood flow, among others. Research has generally shown that such physiological responses tend to habituate over time and are not spe- cific to pain, although they can be useful in providing complementary infor- mation regarding a child’s pain experience (Sweet & McGrath, 1998). As indicated earlier, age-related differences in children’s physiological respon- siveness to pain have been reported (Bournaki, 1997). Regardless of the specific type of pain measure of interest, it is of impor- tance to give consideration to the unique developmental features of the measure and its appropriateness for use with children of particular ages. Al- though it is helpful that available measures have been tailored to children of specific ages, this approach may, in part, hinder our ability to conduct com- parisons of children’s pain responses across developmental periods. Treatment Considerations During Various Stages of Childhood Developmental factors must also be taken into account when considering pain management in children. Pain management techniques can be broadly classified into either pharmacological or cognitive/behavioral approaches. Specific guidelines for the management of children’s acute pain have been established by the American Academy of Pediatrics and the American Pain Society and are beyond the scope of this chapter (AAP, 2001). Research has shown that the efficacy of certain pharmacological interventions may vary 5. Using chil- dren’s self-reports of pain, the results showed a superiority of the local an- esthetic cream in the youngest age group (4 to 6 years) when compared to the older children and adolescents in their sample. Characteristics of new- born physiology and the pharmacology of opioids and local anesthetics within the infancy period may also contribute to age-related differences in responsiveness to pharmacological interventions for pain (Houck, 1998). Similarly, the appropriateness of certain psychological interventions, such as hypnosis, muscle relaxation, and control of negative thoughts, may also vary depending on the age of the child. A recent systematic review of randomized controlled trials of psychological therapy for pediatric chronic pain has revealed strong evidence in support of relaxation and cognitive behavioral therapy as effective treatments for reducing the severity and fre- quency of chronic pain in children (Eccleston, Morley, Williams, Yorke, & Mastroyannopoulou, 2002). The authors indicate that there is insufficient evidence to permit conclusions regarding the effectiveness of these treat- ments in reducing pain-related mood disturbance and disability. Of note, the age of the youngest children included in these trials was 9 years (Sanders & Morrison, 1990; Sanders et al. As a result, data regarding the effectiveness of these approaches for treating chronic pain in younger children are not available. Indeed, children less than 8 or 9 years of age may have difficulties engaging in these interventions and require the in vivo as- sistance of a parent or other coach (McGrath, 1995). In contrast, a recent re- view of psychological treatments for procedure-related pain (e. Ad- ditional research is needed to provide data regarding the relative efficacy of different psychological approaches to pain management among children of varying ages. This information, in turn, could be used to inform psycho- logical treatment of chronic pain among young children. PAIN DURING THE ADULT YEARS As previously noted, the developmental pain literature has emphasized no- tions of order change, growth, and maturation when dealing with neonatal and pediatric samples. In marked contrast, the adult phase of the life span has been characterized by concepts of stability, invariance and eventual se- nescence or decline. An important implication of this general view has been the decided lack of interest in developmental processes over the adult years. In fact, the conceptualization of a life-span approach has been a very 126 GIBSON AND CHAMBERS recent innovation in the adult pain literature (Gagliese & Melzack, 2000; Riley, Wade, Robinson, & Price, 2000; Walco & Harkins, 1999) and develop- mental concepts have been largely ignored. This situation must change if we are to develop a more comprehensive understanding of the pain experi- ence in all persons, both young and old, who suffer severe or unremitting pain and seek our clinical care. From a developmental perspective it is clear that biological, psychologi- cal, and social factors all alter over the life cycle, and these influences have been used to help define stage of life during the adult years. However, so- cial transitions, biological processes, and even chronological life stage can vary as a function of gender, culture, and individual experience. As a result, chronological age has become the de facto gold standard in most research settings, and it is argued to provide the best overall surrogate of life stage (Birren & Schaie, 1996). Demographic and epidemiological convention has often divided the adult population into two broad age cohorts: 18–65 and 65 plus, which presumably reflects the official retirement age in most Western societies. Others have added further age subdivisions in describing the population as being young adult, mid-aged, the “young” old (65–74), the “old” old (75–85), and more recently the “oldest” old (85+; Suzman & Riley, 1985) and the “very oldest” old (95+). Although these age categories can help account for specific differences in physical, social, mental, and func- tional abilities particularly during the later years of life, they have rarely been used in the study of pain. In fact, the working adult population (18–65) has attracted the overwhelming majority of interest in pain research stud- ies and has formed the customary comparison group for studies on chil- dren or the aged. For this reason, discussions are focused around the broad categories of adulthood and the aged with appropriate demarcations into finer age cohorts where possible. Age Differences in Pain Experience and Report During the Adulthood Recent reviews of the epidemiologic literature reveal a marked age-related increase in the prevalence of persistent pain up until the seventh decade of life and then a plateau or decline (Helme & Gibson, 2001; Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998). In contrast, the point prevalence of acute pain appears to remain relatively constant at approximately 5% regardless of age (Crook, Rideout, & Browne, 1984; Kendig, Helme, & Teshuva, 1996). The absolute prevalence figures of persistent pain vary widely between cross-sectional studies and probably reflect differences in the time sample under consideration (e. PAIN OVER THE LIFE SPAN 127 Nonetheless, with one exception (Crook et al. These findings of reduced pain in very advanced age are perhaps surpris- ing given that disease prevalence and pain associated pathology continues to rise throughout the entire life span.

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