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By F. Altus. Jarvis Christian College.

During these visits purchase avana 50mg with mastercard erectile dysfunction 9 code, providers include a written ity prescription) should include clear written instruc- physical activity plan (exercise prescription) only tions about the frequency avana 50mg discount impotence 20 years old, intensity, type, and duration 25% of the time. FREQUENCY All patients should be encouraged to engage in at least THE EXERCISE PRESCRIPTIONS: 30 min of moderate to vigorous physical activities on OVERCOMING BARRIERS most and preferably all days of the week (Stephens, TO ACTIVITY O’Connor, and Deuster, 2002). Small bouts of physi- INTENSITY cal activity scattered through the day help overcome this barrier. An alternative is to remind patients that to There are many ways to prescribe exercise intensity. Patients should be encouraged Individuals wishing to improve health and lower dis- to seek alternative forms of physical activity, such as ease-specific risk should be advised that sufficient parking farther away from the store, or using the stairs levels of physical activity can be accumulated through instead of the elevator. A dedi- Fatigue: Patients should be reminded that physical cated activity or training session is not necessary. Patients are instructed to exercise at a range of THE EXERCISE PRESCRIPTION: 40–80% of HRmax based on their specific goals. ASSESSING READINESS TO CHANGE Amodification of the target heart rate includes calcu- lation of the heart rate reserve. This method takes into Not all patients are immediately ready to embark on a account the patient’s resting heart rate. The likelihood the target heart rate based on this method: of sustaining an active lifestyle can be quickly assessed a. HRreserve = {(220 – patient age) – HRresting} using the stages-of-change model (Zimmerman, Olsen, b. HRresting} The talk test provides another safe and easy way to Precontemplation counsel individuals about exercise intensity. Patients Individuals who are in the precontemplative stage should exercise at an intensity where they are able to have not seriously considered participating in regular carry out a conversation without undue shortness of physical activity. Informing patients about risks associated with physical inactivity and encouraging them to be more active are useful TYPE counseling points for patients who are in the precon- templative stage. Contemplation Activities involving repetitive movement of large Patients who are contemplating change are ready for muscle groups are recommended. Walking is the eas- an exercise prescription, but often will present barri- iest activity on which to base an exercise prescription. Non-weightbearing activities, such as swimming, Steady encouragement with suggestions for overcom- rowing, and cycling should be considered for individ- ing predictable barriers is helpful for patients in the uals with orthopedic concerns. CHAPTER 15 EXERCISE PRESCRIPTION 93 Preparation/Action lift one time using proper technique). To develop mus- Patients in this stage should have an individualized cular endurance, an individual should perform several exercise prescription. Encouragement and support sets using lower resistance-—typically 8–20 RM. Household items such as rubber tubing can Maintenance also serve as creative forms of resistantce. The exercise pre- tioning, time refers to the number of sets of a particu- scription should be revised and updated periodically lar exercise that an individual performs. Most individuals incorporating an exercise prescrip- tion into their routine lifestyle will progress through predictable phases of acclimation, improvement, and maintenance. EXERCISE PRESCRIPTIONS FOR Acclimation: Acclimation typically lasts several SPECIAL POPULATIONS weeks and is often the most psychologically challeng- ing phase. Patients should be encouraged to commit to the frequency of activity first, then to dura- Regular physical activity helps prevent many common tion, and finally to intensity. Patients experi- sis, stroke, depression, colorectal cancer, and prema- ence predictable improvements in self-efficacy, phys- ture death (Stephens, O’Connor, and Deuster, 2002). The exercise prescription can Regular physical activity improves an elderly individ- be modified during the improvement phase as well to ual’s ability to carry out functional activities of daily target patient goals. Strength training, Maintenance: In addition to the psychologic charac- balance training, and flexibility training are particu- teristics described with the stages-of-change model, larly important for elderly patients. Elderly patients should also perform account for changes in cardiovascular condition and strength training activities with single sets of 10–15 enhanced muscular performance. While many elderly patients are fearful that increased levels of physical activity increases their risk of falling and bone fracture, evi- THE EXERCISE PRESCRIPTION: dence indicates that patients who are physically active BEYOND CARDIOVASCULAR have a reduced risk of falling and lower rates of frac- ENDURANCE ture (Mazzeo and Tanaka, 2001). The same FITT principle can be DIABETES applied to muscular conditioning as well.

More recently 100mg avana for sale erectile dysfunction causes emotional, Fuchs generic avana 200 mg jacksonville impotence treatment center, Hadjistavropoulos, and McGrath (2002) and Fuchs and Hadjistav- ropoulos (2002) have developed a similar instrument for seniors with de- mentia and reported good initial psychometric properties. These studies taken together have begun to address serious decoding challenges and pave the way for more effective and thus more systematic treatment of pain among such persons. CONCLUSIONS This chapter provided an overview of important functions of pain commu- nication within the context of a communications model of pain. Given that pain is a subjective and private experience, its communication is of vital importance both where systematic study and clinical care are involved. This places psychology, with its focus on behavioral expression and sub- jective states, in a very important position within the multidisciplinary study of pain. Like any form of interpersonal communication, the communication of pain—and especially the self-report of pain—is subject to conscious distor- tion. Moreover, it is subject to contextual and social influences that affect both those producing the pain message and those trying to decode it. Find- ings that suggest pain messages are not perfectly consistent across commu- 4. SOCIAL INFLUENCES AND COMMUNICATION OF PAIN 107 nication modalities complicate this issue further, and indicate that clini- cians and caretakers should give careful consideration to all modes of pain expression. ACKNOWLEDGMENTS The preparation of this chapter was supported in part by a Canadian Insti- tutes of Health Research Investigator Award to Thomas Hadjistavropoulos and by a Canadian Institutes of Health Research Senior Investigator Award to Kenneth D. Wound sensitivity as a measure of analgesic effects follow- ing surgery in human neonates and infants. Incidence of significantly altered pain experience among individuals with developmental disabilities. Crying in the child with a disability: The special challenge of crying as a signal. Behavioral treatment of chronic pain: Variable af- fecting treatment efficacy. Behavioral treatment of chronic pain: The spouse as a discriminative cue for pain behavior. Measuring pain accu- rately in children with cognitive impairments: Refinement of a caregiver scale. Preliminary validation of an observational pain checklist for cognitively impaired, non-verbal persons. Anger management style, hostility and spouse responses: Gender difference in predictors of adjustment among chron- ic pain patients. A compari- son of faces scales for the measurement of pediatric pain: Children’s and parents’ ratings. A comparison of faces scales for the measurement of pediatric pain: Children’s and parents’ ratings. Spatial summations of pain processing in the human brain as assessed by cerebral event related po- tentials. Social and medical influences on attributions and evaluations of chronic pain. The contributions of interpersonal conflict to chronic pain in the presence or absence of organic pathology. Environmental stressors and chronic low back pain: Life events, family and work environment. The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patient. Relationship of pain impact and significant other rein- forcement of pain behaviors: The mediating role of gender, marital status and marital satis- faction. In Aging and society: Taking charge of the future, Official program book of the 31st Annual Scientific and Educational Meeting of the Canadian Association on Gerontology (p. Psychometric development of a pain as- sessment scale for older adults with severe dementia: A report on the first two studies. An examination of pain perception and cerebral event-related potentials following carbon dioxide laser stimulation in patients with Alzheimer’s disease and age-matched control volunteers. Pain-relevant support as a buffer from de- pression among chronic pain patients low in instrumental activity.

Pain requires central integration and modula- tion of a number of afferent and central processes (i cheap avana 200 mg amex erectile dysfunction venous leak. This formulation acknowledges the importance of various levels of anal- ysis of pain purchase avana 200 mg fast delivery erectile dysfunction zinc. The biological sciences (molecular biology, genetics, neuro- physiology, pharmacological sciences, etc. Ultimately, however, a unified theory of pain must integrate this understanding with the product of work in the behavioral and social sciences, as well as the hu- manities, because pain cannot be understood solely at the level of gene ex- pression, neuronal firing, and brain circuitry. Many of the serious problems in understanding and controlling pain must be understood at the psycho- logical and social level of analysis. What accounts for some people reacting dispassionately and others with great distress to what appears to be the same degree of tis- sue damage? The discipline of psychology must play a central role in the study, as- sessment, and management of pain. It is not surprising that Ronald Melzack, one of the developers of the most influential theory in the field of pain, is a psychologist. Nor is it unexpected that at least 2 of the 10 most influential clinicians and researchers in the field of pain (as assessed by survey of a random sample of members of the International Association for the Study of Pain [IASP]) are psychologists (Asmundson, Hadjistavropoulos, & Anto- nishyn, 2001). These two individuals (Ronald Melzack and Dennis Turk) are contributors to this volume. In this book we have tried to capture major features of the psychology of pain and the most influential contributions of psychologists to pain re- search and management. We are primarily interested in the ultimate impact of advances in understanding and controlling pain. Hence, although much of the volume covers applied issues, basic processes are also given careful consideration. FROM DESCARTES TO THE NEUROMATRIX Historical trends demonstrate the importance of psychological mechanisms. Descartes’s (1644/1985) early mechanistic conceptions of pain resulted in the biomedical specificity theory that proposed that a specific pain system transmits messages from receptors to the brain. This theory is sometimes referred to as “the alarm bell” or “push button” theory (Melzack, 1973), INTRODUCTION 3 because of its apparent simplicity. Descartes’s early views were refined substantially over the years, and more complex mechanistic views gradu- ally emerged as investigators struggled to incorporate in their models of pain the complexities and puzzles of pain that dismayed patients and clini- cians struggling with pain control. Nevertheless, biomedical specificity theory continued to exert an enormous influence through the first half of the 20th century. There was little room for recognition of the importance of psychological processes such as emotion, attention, past experience, and cognitive processes in the study of pain. Patients suffering from pain without a pathophysiological basis or signs often were considered “crocks” (Melzack, 1993). Despite dominance of sensory specificity and biomedical models of pain, clinicians were increasingly finding emotional and motivational processes to be important in understanding pain. Merskey (1998) observed that psy- chological explanations about motives for complaints about pain and psy- chodynamic theories gradually became popular during the early and mid- dle parts of the 20th century (e. Early investigation of psychiatric patients with pain had led to the erroneous conclusion that physical and psychological factors in pain were mutually exclusive and that pain is either physical or psychologi- cal (IASP Ad Hoc Subcommittee for Psychology Curriculum, 1997). Persis- tent pain with no identifiable causes was frequently labeled as psychogenic, a regrettable construct because it perpetuates mind/body dualistic thinking (Liebeskind & Paul, 1977) and fails to recognize that biological mechanisms are integral to all psychological phenomena, including pain. Freud (1893–1895) viewed pain as a common conversion symptom and favored the position that pains encountered in hysteria were originally of somatic origin. In other words, he argued that the pain was not created by the neurosis, but rather the neurosis served to maintain it. Dynamic con- ceptions of pain emphasize the role of psychic energies derived from innate drives linked to aggression, dependency, and sexuality and postulate that the pain experience is associated with the gratification or frustration of these drives (Pilowsky, 1986). For example, pain can be construed as the product of aggression that is inflicted either on oneself or on others and can be related to the formation of a cruel superego with an associated chronic sense of guilt and low self-esteem (Pilowsky, 1986). Although psychodynamic approaches were frequently used to charac- terize patients whose pain unfortunately had been labeled as “psycho- genic,” they have not led to any major empirically supported advances in pain management, and this perspective has been losing favor over the years (e. Efforts to bolster the psychodynamic perspec- tive come from case studies, although some work has linked suppressed an- ger to the experience of persistent pain.

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