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By F. Gunnar. University of Hawai`i, Hilo. 2018.

So we can see how terms connected with the back and spine can also be used to describe emotion-provoking ac- tivities and properties that are closely related to a person’s state of mind purchase kamagra super 160mg without a prescription. Linguists are unable to explain whether the language actually creates this link between physical posture and mental outlook purchase kamagra super 160 mg visa. Victor Hugo generic 160mg kamagra super with mastercard, in particular kamagra super 160mg amex, made » The body is the visible manifestation of the soul kamagra super 160mg sale. The latter play was used as the basis for The back – a mirror of the soul? And the French Parents’ concerns about the posture or the shape of the poet Paul Féval has a hunchback as the main character in back of their offspring are one of the commonest reasons Le Bossu. But in these literary examples the hunched back for a visit to the pediatrician or the orthopaedist. On the other hand, it is a generally known fact that But while the body is indisputably an expression of back pain is one of the commonest conditions suffered the soul, the connections are much more multilayered in adulthood and one that might possibly be prevented and complex than suggested by the vernacular language. Thus, parents always want their But why are parents so worried about their child’s ap- child to adopt as straight a posture as possible. But the pearance, particularly in relation to back problems, even drooping and loutish posture of the adolescent is precisely though the back is usually covered by clothing and thus an expression of the desire not to »bend« to the will of his less exposed than, say, the face or the hands? A »good« Lumbar back pain is one of the commonest conditions posture for the spine is »upright«, just as a person’s char- suffered by adults and the number one reason for lost pro- acter can be described as »upright«. Thus, according to one epidemiological study, relationship between truth and dishonesty. And even a group of individuals in their twenties (Swiss recruits and soldiers) showed a prevalence of 69% for lumbar back pain. In Switzerland, too, back though this lumbar lordosis is not absolutely essential pain is the second commonest cause of disability, after for an upright posture, it came about primarily for func- accidents. The cervi- sia, indicating that back pain is not a specialty of the cal and lumbar lordosis, and also the thoracic kyphosis, West, although it is clearly a much more serious problem act like linked elastic springs. Any major deviations in industrial nations than in the developing world. The from these functionally-adapted curves in the spine are significance of back pain evidently tends to parallel the mechanically inappropriate and result in adverse loading degree of industrialization. In Oman, the demand for back treatment has risen The upright posture also has implications for other dramatically since the oil boom, a finding that is also organs as well as the spine. According to a Canadian mans is much wider than in quadrupeds, since it has statistical survey, approximately 30% of the total amount to help carry the internal organs. The detorsion of the paid in 1981 as compensation for loss of earnings in the femoral neck during growth is another phenomenon form of disability pensions was paid to back patients. In fact, humans have paid very The pain frequently starts at a young age, and around dearly for this unique advantage of an upright posture half of adolescents complain of occasional back pain and have evidently not yet completely come to terms ( Chapter 3. Man’s unique erect posture For all of the reasons outlined above, it is perfectly not only contributes to his special dominant role in na- understandable that parents are worried about what could ture, at the same time it has become a direct potential happen to their children’s backs in future. Evolution of upright walking and posture Humans are unique among all living creatures in exhibit- Postural development in children ing an erect posture. While primates evidently developed The phylogenetic development of the back is imitated the mechanism for maintaining the trunk in an upright during maturation from the fetus to the child and then position at a very early stage, only humans are capable of from the child to the adult. In the uterus, the fetus is in standing and walking upright on two legs for prolonged a flexed position and the spinal column is completely ky- periods. The neonate also holds the shoulders, elbows, hips up the hands so that humans could use these for tasks and knees in flexion, causing the spine, apart from the other than locomotion. In fact, this discriminating use of cervical section, to be held in kyphosis, as is also the case the hand was probably the very first evolutionary step. A secondary consequence of the discovery that hands could be used not just for locomotion was the development of the brain and upright walking. The use of hands as tools and also the use of tools with the hands was therefore the first step in the evolution of man, some 5 million years ago, from primate to homo erectus, the precursor of today’s homo sapiens. This upright posture caused the eyes to be shifted forwards, thereby widening the field of vision and even- tually producing binocular, stereoscopic vision. Com- pared to quadrupeds and the climbing anthropoid ape, humans have better visual, acoustic and tactile spa- tial orientation. From the phylogenetic standpoint, the adoption of an erect posture in humans did not simply involve a rotation of 90° at the hip, but primarily around the lumbosacral junction as a result of the cuneiform shape of the 5th lumbar and 1st sacral vertebrae. The sa- crum is the resting point about which this erect posture is achieved. The development of the upright posture requires a specially-shaped spinal column.

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The actions of the mind were buy kamagra super 160 mg otc, in Cartesian thinking buy kamagra super 160 mg visa, the workings of the soul purchase 160 mg kamagra super with amex. Descartes held that the awareness of pain discount kamagra super 160mg without a prescription, like awareness of other bodily sensations buy generic kamagra super 160mg on line, must take place in a special location where the mind observes the body. Dennett (1991) termed this hypothetical seat of the mind the Carte- sian theater. In this theater, the mind observes and interprets the constantly changing array of multimodality signals that the body produces. The body is a passive environment; the mind is the nonphysical activity of the soul. Scien- tifically, the activity of the brain and the mind are inseparable. Nonetheless, Cartesian dualism is endemic in Western thought and culture. Classical ap- proaches to emotion and pain stemmed from Cartesian thinking, as did psychophysics. Early work on psychosomatic disorders focused on mind– body relationships. Today, much of the popular movement favoring alterna- tive medicine emphasizes “the mind–body connection,” keeping oneself healthy through right thinking, and the power of the mind to control the im- mune system. It is hard to avoid Cartesian thinking when the very fabric of our language threads it through our thinking as we reason and speak. Cartesian assumptions erect a subtle but powerful barrier for someone seeking to understand the affective dimension of pain. Relegating emotions to the realm of the mind and their physiological consequences to the body is classical Descartes. It prevents us from appreciating the intricate interde- pendence of subjective feelings and physiology, and it detracts from our ability to comprehend how the efferent properties of autonomic nervous function can contribute causally to the realization of an emotional state. What we call the mind is consciousness, and consciousness is an emergent property of the activity of the brain. In a feedback-dependent manner, the brain regulates the physiological arousal of the body, and emotion is a part of this process. Descartes (1649) introduced the term emotion in his essay on “Passion of the Soul. Understanding pain as an emotion must begin with an appreciation for the origins and purposes of emotion. In fact, emotions are primarily physiological and only secondarily subjective. To the extent that they are subjective, we experi- ence them in terms of bodily awareness and judge the events that provoke them as good or bad according to how our bodies feel. Because they can strongly affect cardiovascular function, visceral motility, and genitourinary function, emotions can have an important role in health overall and espe- cially in pain management. Simple negative emotional arousal can exacer- bate certain pain states such as sympathetically maintained pain, angina, and tension headache. It contributes significantly to musculoskeletal pain, pelvic pain, and other pain problems in some patients. Emotions are complex states of physiological arousal and awareness that im- pute positive or negative hedonic qualities to a stimulus (event) in the internal or external environment. A rich and complex literature exists on the nature of emotion, with many compet- ing perspectives. I cannot cover it here and instead offer what is necessarily an overly simplistic summary of the field, as I think it should apply to pain research and theory. One objective aspect of emotion is autonomically and hormonally medi- ated physiological arousal. The subjective aspects of emotion, “feelings,” are phenomena of consciousness. Emotion represents in consciousness the bi- ological importance or meaning of an event to the perceiver. Va- lence refers to the hedonic quality associated with an emotion: the positive or negative feeling attached to perception.

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They can be legitimized through reli- gious explanation as serving constructive religious and social purposes generic kamagra super 160mg with visa. The Hindu ritual of Thaipusam is celebrated annually in Singapore and Malaysia (although banned in India) as an expression of faith and penance discount 160mg kamagra super. On the day of the festival purchase kamagra super 160 mg without prescription, thousands of celebrants march several kilometers from one temple to another carrying substantial metal and wooden frames decorated with peacock feathers buy kamagra super 160 mg fast delivery, paper order 160mg kamagra super visa, and fruit. The frames are suspended by metal rods that pierce the celebrants’ flesh. Others pull weighty trailers with metal hooks skewered through the flesh of their backs. One of the most cited ritu- als of this kind involves a hook swinging ceremony practiced in remote In- 4. The ritual involves steel hooks that are attached to ropes that are inserted in the back of the cel- ebrant who later, during the ceremony, swings freely suspended only by the hooks. Others believe hyp- nosis induces altered states of consciousness, and some choose social psy- chological explanations that refer to social learning of coping skills and pain behavior (Craig, 1986). The medical use of both placebos and hypnosis for analgesic purposes effectively illustrate well-documented, powerful forms of social influence on pain. Placebos are commonly used in evaluations of pharmaceutical inter- ventions because even inert substances can have a major impact on physi- cal symptoms. In the case of pain, inert substances frequently induce re- ports of analgesia when their impact is compared with no intervention controls. For this reason, the gold standard research design for pharmaceu- tical evaluations is the double-blind randomized control design. The recom- mended use of double-blind procedures (where neither the patient nor the experimenter is aware of who is receiving the placebo or the active chemi- cal) provides further evidence of the impact of social influence on physical symptoms. Double-blind procedures control for patient expectancy and im- plicit experimenter influence that could bias the outcome of clinical trials. Research also demonstrates the social impact of the expression and ex- perience of pain. Craig and Weiss (1975), for example, showed that research participants who observe people modeling high levels of pain tolerance re- ported less pain in response to electric shock than research participants who were not exposed to these models. Similarly, observing models with low pain tolerance produced comparable changes in the pain tolerance of observers. A succession of related studies in this and other research cen- ters have replicated the finding and explored features of the phenomenon (cf. Central to the subsequent research were findings indicat- ing that the impact of the models was not only upon the willingness of the research participant to report pain, but there also was an impact on a vari- ety of measures of pain experience (psychophysiological measures of auto- nomic reactivity, derived psychophysical measures of experience, nonver- bal measures that are not usually subject to self-monitoring and self-control for the purposes of impression management) (see Craig, 1986). Other forms of social influence can have a substantial impact on measures of pain expe- rience. Levine and De Simon (1991) found that males report less pain in response to a cold pressor stimulus (i. Moreover, a dental procedure administered in a dental clinic is associated with greater reports of pain than the same proce- dure administered in a research laboratory (Dworkin & Chen, 1982). A re- 96 HADJISTAVROPOULOS, CRAIG, FUCHS-LACELLE cent focus upon the importance of controlling pain in infants and neonates has demonstrated the value of systematically simulating the techniques mothers and other caregivers spontaneously use to control pain in these fragile infants (Johnston, Stremler, Stevens, & Horton, 1997). It seems clear that social contexts and interventions have a potent impact on pain experi- ence; their inclusion in programs of pain intervention have considerable positive potential. Self-report of pain normally requires some self-awareness and attention to the task, whereas nonverbal indices of pain largely occur spontaneously without commanding prior at- tention, although the person may monitor the action. Although some non- human species appear capable of intentionality and can use vocalizations to communicate (Dennett, 1988), they do not have the remarkable capacity for self-expression exercised by humans. This uniquely human form of pain communication is subject to conscious control and the influence of a vari- ety of factors including, but not limited to, social desirability. Although the most common forms of self-reported pain rely on the use of spoken or writ- ten language, other forms of self-reported communication also exist. This includes intentional gestures that indicate that someone is in pain, the use of sign language, and the use of nonverbal self-report measures of pain (e. Self-report includes any deliberate act to communicate pain to another person (Champion, Goodenough, von Baeyer, & Thomas, 1998). When peo- ple are asked for descriptions of pain severity, their accounts represent in- tegrated summations and often retrospective accounts of the complexities of their subjective experiences. Verbal communication and self-report are often described as representing the “gold standard” for understanding the subjective state of pain (Craig, 1992). Unquestionably, self-report can pro- vide a means for describing subjective experiences and it is methodologi- cally convenient, but it should only be used if it is recognized that pain is a complex experience not readily reduced to language, and with awareness of the possibilities for response biases, situational demand, and the risks of conscious distortion (e.

If a pain symptom is mild or transient in older adults kamagra super 160 mg lowest price, it is likely to be at- tributed to the normal aging process generic kamagra super 160 mg on-line, be more readily accepted order kamagra super 160mg with amex, and be ac- companied by a different choice of strategy to cope with pain buy kamagra super 160mg line. These fac- tors are likely to diminish the importance of mild aches and pains buy cheap kamagra super 160mg on line, and actually alter the fundamental meaning of pain symptoms. More stoic atti- tudes to mild pain and a stronger belief in chance factors as the major de- terminant of pain onset and severity are likely to lead to the under- reporting of pain symptoms by older segments of the adult population. However, many of the age differences in coping, misattribution, and be- liefs disappear if pain is persistent or severe. There is some limited evidence of an age-related decline in the physiologic function of peripheral, spinal, and central nervous system nociceptive mechanisms. For instance, a marked decrease in the density of myelinated and unmyelinated nerve fibers has been found in older adults (Ochoa & Mair, 1969). Moreover, the neuronal content of the pain-related neuropep- tides substance P and calcitonin gene-related peptide (CGRP) are known to fall with advancing age (Helme & McKernan, 1984; Li & Duckles, 1993). Nerve conduction studies indicate a prolonged latency and decreased amplitude of sensory nerve action potentials in apparently healthy older adults (Adler & Nacimiento, 1988; Buchthal & Rosenfalck, 1966). Studies of the perceptual experience associated with activation of nociceptive fibers indicate a selec- tive age-related impairment in A fiber function and a greater reliance on C- fiber information for the report of pain in older adults (Chakour, Gibson, Bradbeer, & Helme, 1996). Given that A fibers subserve the epicritic, first warning aspects of pain, while C-fiber sensation is more prolonged, dull, and diffuse, one might reasonably expect some changes in pain quality and intensity in older adults. Three recent studies have shown that the temporal sum- mation of noxious input may be altered in older persons (Edwards & Fil- lingim, 2001; Gibson, Chang, & Farrell, 2002; Harkins, Davis, Bush, & Price, 1996). Temporal summation refers to the enhancement of pain sensation as- sociated with repeated stimulation. It results from a transient sensitization of dorsal horn neurons in the spinal cord and is thought to play an impor- tant role in the development and expression of postinjury tenderness and hyperalgesia. Zheng, Gibson, Khalil, McMeeken, and Helme (2000) extended these observations by comparing the intensity and time course of post- injury hyperalgesia in young (20–40) and older (73–88) adults. Although the intensity and area of hyperalgesia were similar in both groups, the state of mechanical tenderness persisted for a much longer duration in the older group. As mechanical tenderness is known to be mediated by sensitized spinal neurons, these findings may indicate a reduced capacity of the aged CNS to reverse the sensitization process once it has been initiated. The clin- ical implication is that postinjury pain and tenderness will resolve more slowly in older persons. However, in combination with the studies of tem- poral summation, these findings provide strong evidence for an age-related reduction in the functional plasticity of spinal nociceptive neurons follow- ing an acute noxious event. PAIN OVER THE LIFE SPAN 135 Variations in pain sensitivity depend not only on activity in the afferent nociceptive pathways but also endogenous pain inhibitory control mecha- nisms that descend from the cortex and midbrain onto spinal cord neu- rons. A recent study has shown that the analgesic efficacy of this endoge- nous inhibitory system may decline with advancing age (Washington, Gibson, & Helme, 2000). Following activation of the endogenous analgesic system, young adults showed an increase in pain threshold of up to 150% whereas the apparently healthy older adult group increased pain thresh- old by approximately 40%. Such age differences in the efficiency of endog- enous analgesic modulation are consistent with many earlier animal stud- ies (see Bodnar, Romero, & Kramer, 1988, for review) and would be expected to reduce the ability of older adults to cope with severe or per- sistent pain states. There are widespread morphological and neurochemical changes to the central nervous system with advancing age, although few studies have ex- amined those areas specifically related to the processing of nociceptive in- formation (see Gibson & Helme, 1995, for review). An investigation of the cortical response to painful stimulation has documented some changes in adults over 60 years. Using the pain-related encephalographic response in order to index the central nervous system processing of noxious input, older adults were found to display a significant reduction in peak amplitude and an increased latency of response (Gibson, Gorman, & Helme, 1990). These findings might suggest an age-related slowing in the cognitive proc- essing of noxious information and a reduced cortical activation. There has also been one report of a more diffuse topographic spread in the post- stimulus electroencephalogram (Gibson, Helme, & Gorman, 1993). Although this finding could indicate a wider recruitment of CNS neurons during the cortical processing of noxious input, more recent neuroimaging techniques, with better temporal and spatial resolution, would be needed to confirm this suggestion. Age Differences in Pain Assessment During the Adult Years Three main approaches have been used to assess clinical pain in the adult population: self-report psychometric measures, behavioral–observational methods, and third-party proxy ratings. The vast majority of research into pain measurement has been conducted on young and middle-aged adults and there is a huge literature on this topic (for review see Katz & Melzack, 1999; Lee, 2001; Williams, 2001). In order to consider pain measurement from a developmental perspective there need to be direct comparative studies between young and older adults. There is no literature on age differ- ences in pain assessment, although issues of measurement reliability and 136 GIBSON AND CHAMBERS validity have been investigated within specific age segments of the adult population.

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