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smoking (USDHHS, 2014). Over the last 50 years, there has been a decline in the rate and incidence of smoking in the general population. There are more than 50 million former smokers—a greater number of former smokers now than actual smokers (Sanford & Goebel, 2014). The prevalence of smoking among adults has decreased from 42% in 1965 to 18% in 2012 (USDHHS, 2014). For men during this same period, the prevalence has decreased from 51. 9% to around 21% (CDC, 2015; Giovino, 2002). More recently, the overall rate of smoking in the United States has declined from almost 21% of adults in 2005 to around 18% of adults in 2013 (CDC, 2015). This downward trend corre-sponds to the implementation of the 2009 T obacco Control Act, which increased federal taxes on cigarettes and used that money to fund prevention and cessation policy and programs. Although rates have gone down considerably, it is important to recognize that there is variability in demo-graphics and regions across the country. For example, smok-ing rates are 20. 5% in the Midwest and 13. 6 % in the West, are highest in West Virginia at 27. 3%, and lowest in Utah at 10. 3%. Smoking prevalence is higher in men than women, highest among non-Hispanic multiple race individuals and American Indians/Alaska Natives, and lowest in the Asian population (CDC, 2015). The highest rates of smoking (29. 2%) are found in those living below the poverty level (CDC, 2015). T o achieve the Healthy People 2020 goal of less than or equal to 12%, more needs to be done to target these groups with the highest prevalence of smoking. D. History of tobacco, smoking, and health policy Smoking has a long history in the United States; the ear-liest settlers adopted smoking from Native Americans who smoked tobacco in ritual traditions. A cigarette roll-ing machine invented in the late 1800s allowed the mass production of cigarettes. During World War I and World War II, tobacco was considered as indispensable as food and included in ration packets to soldiers in the field. The Journal of the American Medical Association (JAMA) and the popular media marketed cigarettes for their taste and I. Intr oduction and background A. The problem Smoking is the most popular form of tobacco use world-wide. T obacco smoking is a global epidemic responsible for 5 million preventable deaths a year (World Health Organization, 2008). Smoking “remains the leading pre-ventable cause of premature disease and death in the United States” (U. S. Department of Health and Human Services [USDHHS], 2014, p. iii). According to the World Health Organization's 2008 MPOWER report, an antici-pated 1 billion deaths will occur in this century second-ary to tobacco-related illnesses. As the Oxford Medical Companion notes, “T obacco is the only legally available consumer product which kills people when it is used as intended” (Walton, Barondess, & Lock, 1994, p. 908). B. Health effects of smoking In the United States, smoking has caused 20 million deaths over the last 50 years. Cigarette smoking kills 480,000 people each year and there are currently 16 million Americans suffering from smoking-related chronic disease conditions (USDHHS, 2014). Smoking-related deaths result from three main diseases: lung cancer, cardiovas-cular disease (CVD), and chronic obstructive pulmonary disease (COPD). Cigarette smoking causes 87% of lung cancer but is also responsible for 30% of all cancers, includ-ing cancer of the bladder, kidney, mouth, oral pharynx, esophagus, stomach, uterus, cervix, and pancreas as well as acute myeloid leukemia (American Cancer Society [ACS], 2014a). The direct healthcare costs of these chronic dis-ease conditions are estimated at $132. 5-175. 9 billion per year (USDHHS, 2014). C. Incidence prevalence An estimated 40 million Americans currently smoke ciga-rettes (Centers for Disease Control and Prevention [CDC], 2015). The year 2014 marked the 50th anniversary of the 1964 Surgeon General Report on the harmful effects of Kellie Mc Nerney and Lewis Fannon SMo KINg Ce SSat Io N© Eliks/Shutterstock; © donatas1205/Shutterstock 672 67Chapt Er

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know about e-cigarettes is recommended along with tradi-tional nicotine replacement products, not e-cigarettes. The perceived safety of e-cigarettes may be the most dangerous aspect of e-cigarettes and the problem in getting people not to start as well as to quit. Unfortunately, the perceived safe-ty and the direct targeting of adolescents by the e-cigarette industry may encourage young people to start (Dutra & Glantz, 2014; Mc Carthy, 2014). The National Y outh T obacco Survey (NYTS) showed that e-cigarette use in junior high and high school age groups doubled from 2011 to 2012 (Dutra & Glantz, 2014). A recent JAMA Pediatrics article reported young people who tried e-cigarettes were six times more likely to take up smoking than those who did not try e-cigarettes (Dutra & Glantz, 2014). E. Special populations Those living below the poverty level, those with mental health disorders, those with other alcohol and drug use dis-orders, and adolescents deserve special attention as these groups remain most at risk compared to the general adult population. More research is needed to determine and overcome the barriers to effective cessation and preven-tion strategies in these high-use populations (Christiansen, Reeder, Hill, Baker, & Fiore, 2012). Nicotine dependence is the most common substance use disorder among people with mental illness. Rates of smoking among people with mental health disorders are at least twice as high as in the general population and among the seriously mentally ill even higher. Cigarette use in those with schizophrenia, bipolar disorder, alcohol, and illicit drug substance use disorders are among the high-est and likely account for almost half of the U. S. cigarette market. Studies of adolescents and young adults with substance use disorders find that more than 80% report current smoking behavior and daily smoking and many go on to become highly addicted long-term smokers (Hall & Prochaska, 2009). Nicotine is the ingredient that keeps people smoking despite their desire to quit and the obvious safety hazards and known health risks of smoking. There are many rea-sons for the high rates of smoking co-occurring with mental health disorders, many are related to the neurobiological effects of nicotine and some are related to psychosocial fac-tors. The reasons are multifactorial: the prioritization of mental health treatment, an individual health provider's belief that people with mental illness will not be able or will-ing to quit smoking, the reduced ability of the person with mental illness to cope with smoking cessation, or the lack of understanding of the health effects of smoking among men-tally ill people All are cited as reasons that the mental health population has higher rates of smoking (Hall & Prochaska, 2009). Death rate among smokers over a 24-year study of long-term drug users was twice as high as that of the long-term drug users who did not smoke (Moss et al., 2010). impact on relaxation and even audaciously suggested “improved health” (Houston, 1992; Sheehan, 2004). In 1950, two British surgeons published a well-designed study linking cigarette smoking with bronchogenic car-cinoma (Wynder & Graham, 1950). Despite more than 60,000 documents proving the relationship between smoking and lung cancer, the tobacco industry continued to deny and question the evidence. The tobacco industry remains a powerful lobby that prevented the Food and Drug Administration (FDA) from regulating tobacco and the sale of cigarettes. It took major litigation, congres-sional hearings, and 45 years before the FDA was granted the power to regulate tobacco products when President Obama signed HR 1256, Family Smoking Prevention and T obacco Control Act in 2009 (Food and Drug Administration, 2012). Now electronic cigarettes (e-cigarettes) are exploding on the market; e-cigarettes are being used by 6 million Americans, producing $6 billion in sales (Sanford & Goebel, 2014). First created and sold in China in 2004, they became available in the United States in 2007. E-cigarettes are not yet regulated by the FDA. Two years after becoming available in the United States, the FDA tried to ban them as unapproved drug device combination devices. Electronic cigarette manufacturers filed a law-suit, and the court overturned the ban. In April 2014, the FDA proposed “deeming” authority, which means it has taken steps to regulate e-cigarettes and additional tobacco products such as cigars, water pipes, and gel tobacco. This would then allow them to restrict the sale to minors and put health warnings on them. As yet e-cigarettes are still not regulated (FDA, 2015; Palazzolo, 2013). E-cigarettes are small, cylindrical, battery-operated devices, colorfully marketed, often with flavor additives, that are “smoked,” mimicking a cigarette. The battery heats up liquid that contains nicotine and vaporizes it so the vapor is inhaled (vaped) and not smoked. E-cigarettes are promoted as less dangerous than smoking because they are smokeless. Cigarette smoke contains 7,000 chemicals, 69 of which are known carcinogens such as benzene, arsenic and vinyl chloride to name a few. Though fewer chemicals are pres-ent in e-cigarettes than in tobacco cigarette smoke, it is not clear that they are safe just because they are smokeless (Meo & Al Asiri, 2014; Walton et al., 2015). In one brand of e-cigarettes, the liquid to vaporize nicotine was found to have diethylene glycol, an ingredient in antifreeze (“The Battle over E-Cigarettes,” 2014). It remains controversial whether e-cigarettes help peo-ple quit smoking. Current National Institutes of Health guidelines recommend further study regarding the issue (Walton et al., 2015). From a traditional harm reduction point of view, a healthcare provider may choose to work with a client using e-cigarettes to help them quit smoking. Preferably education regarding what we know and do not 673 Introduction and background

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There is an historical connection to smoking and peo-ple with mental illness; as late as 2006, 59% of state psy-chiatric hospitals in the United States allowed patients to smoke. The tobacco industry even provided tax-free ciga-rettes to psychiatric facilities, homeless shelters, and drug treatment programs (Hall & Prochaska, 2009). Smoking in alcohol and drug treatment programs has a long inter-twined history that normalized smoking behavior as a safer alternative and thus was not addressed in treatment centers despite the fact that the leading cause of substance-related death among alcohol-and drug-dependent persons is tobacco-related illnesses. Freud and both of the cofound-ers of Alcoholics Anonymous, Bill Wilson and Dr. Bob Smith, smoked heavily and died of tobacco-related causes. The harm reduction model was used as an explanation to allow smoking while people were quitting other drugs. Because smoking has few immediate symptoms when quit-ting, compared to alcohol or illicit substances, many treat-ment programs delayed smoking cessation or made it a low priority. The American Psychiatric Association (APA) first recommended the treatment of nicotine dependence in patients with mental health disorders and/or substance abuse in 1996, but stronger guidelines were updated in 2006 and acknowledge that, although the efforts may be more difficult and need to be more intensive, inpatient episodes can be an appropriate time to initiate smoking cessation efforts (APA, 2006; Moss et al., 2010). In 2008, Fiore's 2000 Practice Guidelines for Smoking Cessation were updated and specifically emphasized that providers need to treat all smokers with mental health and substance abuse diagnoses and that these patients be provided the same smoking cessation treatments as the general popula-tion (Fiore et al., 2008). F. The health benefits of quitting Stopping smoking is associated with multiple health benefits: a lowered risk for lung cancer and many other types of cancer; a reduced risk for coronary heart disease, stroke, and peripheral vascular disease; and reduced respi-ratory diseases such as COPD and reduced respiratory symptoms, such as coughing, wheezing, and shortness of breath. The rate of decline in lung function is slower among people who quit smoking than those who continue to smoke. For women there is a reduced risk of fertility issues and difficulty in conception, fewer miscarriages, less risk of preterm labor, fewer low-birth-weight babies, less incidence of sudden infant death syndrome (SIDS), and a reduced risk for cervical cancer (Schoendorf & Kiely, 1992; USDHHS, 2014). G. How to get your patients to quit smoking Around 70% of smokers say they want to quit. More than 55% of smokers have made at least one attempt to quit smoking in the past year. Most smokers try to quit “cold turkey. ” Relapse rates are high, less than 10% of smokers are able to quit without some form of nicotine replace-ment therapy (NRT) (Patel, Fencht, Reid, & Patel, 2010; USDHHS, 2014). Of those who do quit > 75% relapse within the first year. Nicotine replacement with bupropion or varenicline is the most effective way to help with ces-sation. Brief advice to quit smoking by the provider done routinely at each office visit increases the rates of smoking cessation (USDHHS, 2014). Three categories of pharmacotherapy have proved help-ful in smoking cessation: (a) nicotine replacement therapy, (b) bupropion, and (c) varenicline. Three nicotine replace-ment products are sold over the counter: (a) nicotine patches, (b) nicotine gum, and (c) nicotine lozenges. The other nicotine replacement products (the nicotine nasal spray and the nicotine inhaler) require prescriptions. There are few studies comparing which product is more efficacious than another but several studies show all nico-tine products are better compared to placebo and double cessation rates. Because e-cigarettes have an unknown, unregulated nicotine content as well as other unknown, unregulated additives they are not considered a nicotine replacement product for cessation purposes, though some patients will want to use them (Meo & Al Asiri, 2014). All products also increase cessation rates when used in con-junction with a behavior modification program (Rennard & Doughton, 2014; USDHHS, 2014). T o use any nicotine replacement product the smoker is counseled to pick a quit date and start the product on the quit date. Most products are recommended for 2-3 months of use. But most providers continue the nicotine replace-ment as long as needed if stopping the medication means returning to smoking. The FDA is considering removing all recommendations regarding duration of use (V. Smith, personal communication, July 27, 2015). It is important to know that treatment needs to be individualized, clients may need to start before their quit date and some may require two 21 mg patches, as higher doses are required for heavier smokers. It is also considered safe to use the patch and the gum or lozenge together (Peereboom, Evers-Carey, & Leone, 2014; Rennard & Doughton, 2014). Combining nicotine replacement products is considered a safe strategy for nicotine-dependent persons trying to quit. Using a “controller” medication (patch) with a “reliever” (gum, lozenge, or inhaler) medication can be more effec-tive to induce quitting than either medication formulation alone. The differences in pharmacology action and dura-tion of each product make this possible. A slow-onset and long-acting product, such as the patch, can be safely com-bined with the use of a shorter-acting product, such as gum or lozenge (Patel et al., 2010; Peereboom et al., 2014). Nicotine replacement is considered safe for use even in smokers with known CVD. Experts say the benefits 674 CHAPTER 67 | Smoking Cessation

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of quitting smoking far outweigh any risk of the nicotine replacement product, although few studies exist (Fiore et al., 2008; Rennard & Doughton, 2014). Bupropion has been available in the United States as an antidepressant since 1989. Smokers who were on bupro-pion recognized a decreased desire to smoke as an inter-esting side effect. A sustained-release form of bupropion was developed and marketed as a smoking cessation aid, Zyban®. Large studies demonstrate that the use of bupro-pion doubles the success rate of smoking cessation (Patel et al., 2010; Rennard & Doughton, 2014). Varenicline (Chantix®) is hypothesized to both bind to nicotine receptors in the brain and block the nicotine in cigarette smoke from attaching to the receptor in the brain. It is hypothesized that this action reduces the reward-ing sensation of nicotine, thus decreasing the desire to smoke. Multiple studies show efficacy. In February 2008 the FDA issued an alert that an increase in suicidal think-ing and “aggressive and erratic behavior” was associated with patients being treated with Varenicline (FDA, 2008). Most experts recommend taking a careful psychiatric his-tory before starting the medication and not prescribing the medication for known patients with any current or past history of unstable depression or suicidality. It is impor-tant to note that neuropsychiatric side effects have been reported even in patients with no known history. It is rec-ommended to use with caution with careful follow-up in 1 and 2 weeks. Patients should be told to contact their pro-vider or the office and stop the drug if they or their family notice any unusual mood or behavior symptoms. The majority of cigarette smokers quit without using evidence-based treatments. The following treatments are evidence-based methods, shown to be effective for smok-ers who want help to quit. These brief clinical interven-tions include: 5 As—Ask, Advise, Assess (readiness to quit), Assist, and Arrange follow-up (Fiore et al., 2008) Motivational interviewing techniques (Peereboom et al., 2014) Individual and group classes or counseling, telephone support, Internet groups, programs to deliver treat-ment/support using social media and mobile phones (Fiore et al., 2008; Zhang, Yang, & Li, 2012). H. Concluding remarks T o date, almost one in five patients smoke. Smoking remains an undertreated chronic disease well suited for clinician counseling and management. Highest risk groups are mentally ill individuals and those living in poverty or disability. The goal for the adolescent client is prevention, especially preventing use of the e-cigarette. Individualized treatments consisting of medication and counseling at every visit improve cessation rates. II. Database A. Subjective 1. Obt ain a smoking history a. A sk: Do you smoke? For how long? How much do you smoke? How soon do you smoke your first cigarette in the morning? Are you interested in quitting? Have you ever quit before? What made you start again? b. I f patient has quit, ascertain prior smoking his-tory because recent cessation (within the year) increases the risk for relapse. 2. P ast health history a. M edical history: i. Il lnesses specific to cancer, such as lung, head and neck, mouth, larynx, esophagus, blad-der, kidney, pancreas, brain, cervix, breast ii. Il lnesses specific to the cardiorespiratory system, such as myocardial infarction, car-diovascular disease (CVD) or coronary artery disease (CAD), peripheral vascular disease (PVD), Reynaud's disease, hyper-tension (HTN), hypercholesterolemia, blood clots, COPD, bronchitis, sinusitis, pneumonia, allergies, asthma, and gastritis or peptic ulcer disease. b. P sychiatric disorders: prior history of depres-sion, anxiety, or other mental health diagnosis. c. S ubstance use disorders: screen with a stan-dardized screening tool, such as CAGE-AID or other brief screening tool, and for depression using PHQ-9 or other depression screening tool (Brown & Rounds, 1995; Spitzer, Kroenke, & Williams, 1999). d. G ynecological history: infertility, abnormal pap smears, low-birth-weight babies, and complica-tions of pregnancy. e. E xposure history: passive smoking or asbestos. f. M edication history: prior use of nicotine replace-ment, bupropion, varenicline, or other medica-tions related to cessation, depression, or seizures. 3. F amily history: Cancer, CVD, PVD, COPD, asthma, or other respiratory symptoms. 4. P ersonal and social history a. I dentify social supports and living situations in terms of other smokers. b. A ssess coexistent stressors and coping strategies. c. I dentify need for possible referrals. d. U se of alcohol and other substances. e. U se of telephone, Internet, or office-based support groups. 675 Database

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5. R eview of systems a. C onstitutional for sign or symptoms as related to cancer, infection, and CVD. Generally, no signs or symptoms present. b. S kin, hair, and nails: Cosmetic changes noted, such as early skin wrinkling, impaired wound healing, and finger and teeth staining. c. Ea r, nose, mouth, and throat: allergic or irritant symptoms, postnasal drip, frequent infections, den-tal complaints, dysphagia or any unusual lesions on the buccal mucosa, tongue, floor of mouth. d. C ardiovascular: chest pain, leg pain when walk-ing short distances, excessively cold hands, or feet with color change. Chest pain or change in activity tolerance, paroxysmal nocturnal dys-pnea, or peripheral edema. e. R espiratory: shortness of breath, productive or nonproductive cough, postnasal drip, wheezing, decreased exercise tolerance, frequent colds, and allergy symptoms, mucus production, dyspnea, and paroxysmal nocturnal dyspnea. f. G astrointestinal: abdominal burning or pain, acid indigestion, heartburn, constipation, diar-rhea; frequent use of antacids; and food intoler-ance. Use of smoking to regulate bowels. g. Ge nitourinary: sexual or erectile dysfunction. h. M usculoskeletal: claudication or peripheral edema. i. N eurologic: paresthesias j. P sychiatric: screen for depression/substance abuse with CAGE-AID tool B. Objective 1. P hysical examination: generally there are no signs unless an illness-related visit a. V ital signs: may include normal or increased heart rate or blood pressure b. Ge neral appearance: may appear older than stated age; clothes and hair may smell of cigarette smoke c. S kin, hair, nails: facial wrinkles and yellow stains on teeth and fingers d. H ead, eyes, ears, nose, and throat: assess for peri-odontal disease, include bimanual examination of mouth, assess for oral lesions that may be malig-nant or premalignant, leukoplakia, evidence of upper respiratory irritants, infection, or allergies e. L ymphatic: generally, there are few findings but look for lymphadenopathy in presence of any head, eyes, ears, nose, and throat symptoms f. C hest: generally, there are few findings unless illness is present, but assess respiratory rate, quality of cough if observed, anteroposterior diameter, presence of adventitious sounds; office spirometry or peak expiratory flow rates are usu-ally normal g. C ardiovascular: generally, few findings are observed but evaluate cardiac rate, rhythm, extra heart sounds, and pulses h. E xtremities: note color, temperature and pulses, note hair distribution because there is a decrease in lower extremities of those with PVD i. N eurologic: generally, few findings but evalua-tion needed if any paresthesias j. P sychiatric: PHQ9 and CAGE-AID tool 2. S upporting data from relevant diagnostic tests a. I f screening for CVD labs, CBC, blood glucose/ HBA1C, lipid profile, and kidney function. If lab test abnormalities, may be able to educate client regarding effects of smoking on health. b. I f indicated: electrocardiogram, pulmonary function tests, and chest radiograph, consider annual lung cancer screening with low dose chest CT for patients > 55 years old at higher risk for lung cancer, i. e., a 30 pack-year history or greater (Moyer, 2014; USPSTF, 2014). III. a ssessment A. List related ICD-10 codes (e. g., 305. 1 Tobacco use disorder or V15. 82 History of tobacco use) B. Former, current risk of relapse C. Significance of smoking history, smoking index, or pack-year in terms of disease risk D. Identify comorbid illnesses or disease states E. Stage of readiness to quit F. Rule out concomitant physical illness Examples: “Persistent and recurrent cough due to aller-gies versus asthma flares complicated by > 35 pack-year history of smoking in 62 yo male at high risk for lung cancer recently quit smoking 1 month ago at high risk for relapse”“Uncomplicated URI in young adult smoker not ready to quit”“New dx of cervical dysplasia in 42 yo woman ready to try to quit smoking” IV. g oals of clinical management Stop smoking; reduce risks for tobacco-related conditions; prevent and manage relapse; and eliminate secondhand smoke exposure. 676 CHAPTER 67 | Smoking Cessation

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V. Plan A. Diagnostic 1. P ulmonary function tests are usually normal unless respiratory illness is present and are therefore not recommended. 2. A nnual low-dose chest CT to rule out early lung cancer if patient is high risk, i. e., > 55 years old with 35 pack-year history, currently smoking or quit within 15 years (Moyer, 2014) 3. C VD screening lipid panel 4. Add itional testing as indicated by history and physical examination B. Treatment and management goals 1. Ad vise patient to stop smoking. If evidence of concomitant illness or sign of abnormality on examination, use this as a teachable moment, as an indication of harmful effects of tobacco and the benefit of cessation. Inform patients in a nonjudgmental way: “Stopping smoking is the single most important thing you can do to improve your health. ” 2. A ssess patient's readiness to quit and individualize treatment plan based on assessment a. P recontemplative: advise to quit, acknowledge lack of readiness, state availability to assist in quitting when they are ready; evaluate readiness at every visit. b. C ontemplative: advise to quit, acknowledge their consideration, and provide written pamphlet or resources for review. State availability to assist in quitting when ready to try or set quit date. 3. A ssist patient to quit smoking: educate regarding medications available, OK to start ahead of quit date, help pick quit date, review behavior modification strategies, recommend nicotine replacement therapy (NRT)—both patch (at proper dose) and with gum or lozenge for back up with or without bupropion or varenicline. Know it is safe to use medications prior to anticipated quit date to reduce patient anxiety regarding abstinence for 2-4 weeks before quit date for example. 4. M edications a. N icotine replacement products i. N icotine patch is a transdermal sys-tem absorbed through the skin over 16-24  hours depending on the brand. It is recommended that a patient start use on their quit date, but there is evidence that pretreatment is both safe and effec-tive in helping cessation (Peereboom et al., 2014). Apply every morning on a dry area of upper arm, stomach, or but-tock. Remove at bedtime because the nicotine may interrupt sleep. However, persons who smoke immediately on wak-ing may find it beneficial to wear the patch during sleep. Rotate sites, reusing the same site no more frequently than every 7 days. Change every day. The different brands are generally similar in dosage. May taper over 2 months (e. g., 21 mg/day for 4 weeks, 14 mg/day for 2 weeks, and 7 mg/day for 2 weeks). The 21-mg patch is equivalent to trough concentrations (i. e., lowest level of blood nicotine) in smok-ers averaging one pack per day. Recognize that it is safe to use two patches at once for a two pack a day smoker, for example. And know that you may need to taper over a much longer period of time. It is consid-ered safe to avoid deadlines for cessation. Many people require 6 months or a year of treatment with nicotine replacement, and it should be noted that the FDA is considering removing all timelines for use of the patch (www. fda. gov/downloads/For Consumers/Consumer Updates/UCM346012. pdf). NRT is well tolerated, although 50% of patch users experience some local skin irritation. It is acceptable to use topical ste-roid and continue use with rotation of sites. The patch can cause excessive or unusual dreams; may be removed at bedtime ii. N icotine gum or lozenge is an oral product containing nicotine bound to a polacrilex resin. When the gum is chewed or sucked, it releases nicotine, which is absorbed through the oral mucosa. It takes 20 minutes for the nicotine level in the blood to rise. Advise the client to bite the gum slowly, not to chew, or the nicotine will be released faster than it can be absorbed and swallowed. Swallowing the nicotine causes stomach or esophageal irritation. Nicotine from the gastrointestinal tract is metabolized by the liver and essentially is ineffective. May be  used with patch or after patch for “just in case. ” For nicotine gum, “bite and park. ” Bite until it tastes (radish or peppery taste) and then bite again after taste disappears. It lasts approximately 20-30 minutes. Avoid coffee and carbonated drinks for up to 20 minutes before use, because this lowers 677 Plan

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the absorption of nicotine. Use 2-mg gum for most smokers; can use 4 mg for those who smoke more than 25 cigarettes per day. Use as often as an urge occurs, up to 20 pieces per day. T aper after 6 weeks; taper one to two pieces per week. Dependence on gum is not common because the delivery system essentially acts to wean the smoker. NRT is still considered safer than smoking and may need to be used intermittently for 6-12 months or longer. iii. F or nicotine lozenges, do not chew; can be used for those with dentures or no teeth. Place in mouth and let dissolve for 30  minutes. Use the 2-mg dose for most smokers but 4 mg is recommended for those who smoke within 30 minutes of awakening. May use one to two per hour for the first 4-6 weeks. Consider tapering after 6  weeks; dependence issues are not likely and may need to continue for 6-12 months as needed to manage the compulsion to smoke (Peereboom et al., 2014). iv. N icotine inhaler (available only by pre-scription): the nicotine inhaler is a plas-tic mouthpiece with a nicotine cartridge placed inside. When the smoker inhales through the device, nicotine vapor, not smoke is released into the mouth and throat and absorbed through the oral mucosa. The vapor mostly does not reach the lungs and is pharmacologically more similar to gum or lozenge than a cigarette. Plasma levels of nicotine are approximately one-third that of a cigarette. May be helpful in smok-ers to address the behavioral and sensory aspects of cigarette smoking or in those who failed gum or lozenges. Recommended dose is 6-16 cartridges per day for the first 6-12 weeks. T aper dose over the next 6-12 weeks. Avoid or use with caution in those with a history of severe reactive air-way syndromes because it may cause bron-chospasm. Nicotrol inhalers differ from the e-cigarette in that the nicotine dose is a known dose and there are no additives. Studies are currently being done to com-pare e-cigarettes with nicotrol inhalers for smoking cessation. v. N icotine nasal spray (available only by pre-scription): delivers nicotine to nasal muco-sa via an aqueous solution. It is more rapidly delivered with peak concentration within 10 minutes but not as rapid as a cigarette. One to two sprays per hour for the first 3  months. A high rate of nasal and throat irritation limits its use. b. B upropion i. Ge nerally is started 1-2 weeks before quit date, but may start 4 weeks before ii. S tart with bupropion sustained release, 150 mg once daily for 3-7 days. iii. I ncrease to twice a day for 7 days. If side effects occur on the 300-mg dose, continue at 150 mg daily. iv. R ecommended treatment duration is 7-12 weeks, but may continue longer up to 12 months. v. C ommon side effects are insomnia, dry mouth, and headache. vi. R ule out bipolar affective disorder (BAD) and consult for use with patients with BAD diagnosis. There is some discussion as to whether bupropion can trigger mania especially with bipolar I (Pacchiarotti et al., 2013). Bupropion is the antidepressant of choice in BAD because it is least likely to induce mania; however, no antidepressant should be used alone in BAD treatment. vii. S erious side effect is seizure. Clinical trial risk of seizure is 0. 1%. Contraindicated in seizure disorder or predisposition to seizures. viii. R ule out an anorexia-type eating disorder as bupropion has an FDA black box warning about anorexia because of its potential for appetite suppression. c. V arenicline (Chantix®) i. S tart 0. 5 mg daily for 3 days then increase to 0. 5 mg twice a day for 4 days, then 1 mg twice a day for remainder of the 12-week course, may use for longer periods up to 6-12 months. ii. Adv ise to take with food and a full glass of water to avoid the side effect of nausea. iii. Quit s moking 1-3 weeks after start of medication. iv. C ommon side effects are nausea, insomnia, and abnormal dreams. v. Be cause of concern regarding serious neu-ropsychiatric side effects, counsel patients to call office and stop medication if they or their family notice any unusual mood or behavior symptoms. vi. U se with caution with renal insufficiency and any history of depression. 678 CHAPTER 67 | Smoking Cessation

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5. A ssist and Arrange follow-up/behavior modifica-t ion and patient education a. E ncourage patient to think of quitting smoking as “learning a musical instrument or foreign lan-guage. ” Both efforts require practice. If a relapse occurs, encourage patient not to give up and to try again. Smoking cessation may take a while to master. It typically takes multiple attempts before a smoker stays quit for good (ACS, 2014b). b. E ncourage smokers not to feel as if they have a character defect because they did not succeed in the past. Encourage them to try again. c. H ave smokers write on a 3 × 5 file card the three most important reasons to quit, to keep this card in the same place they used to keep cigarettes, and to pull out the card and read it whenever they have an urge. d. H ave patient practice quitting a little every day, at different times of day. For example, on Monday, advise patient not to smoke from 6:00  a. m. until 9:00 a. m. ; on Tuesday, not to smoke from 9:00  a. m. until 12 noon; on Wednesday, not to smoke from noon until 3:00 p. m., and so on. Once the week is completed, the smoker will learn which cigarettes were most important and then will know which cigarettes might prove to be harder to quit. e. Or h ave patient keep a smoking diary, noting time of day, urge level, circumstances, and what mood or feeling was present that triggered urge. f. I dentifying what triggers smoking (this is key to determine alternate behaviors to smoking). Think of three different activities they might do instead of smoking. g. R eward nonsmoking behaviors. Rewarded behavior is repeated. h. E ncourage patient to join a class on quitting smoking, Internet-based group, cellphone reminder group, or social media. i. A sk patient to read as much as possible about the health effects of smoking, the benefits of quit-ting, and the tobacco industry. j. E ncourage plenty of rest, fresh air, exercise, and nutrition. k. A sk patients to reach out to nonsmokers, to find a “buddy” in their quit smoking campaign. People with more social support have higher success rates. l. T ell patient to expect a small weight gain. Bupropion may help prevent weight gain. m. Bein g overweight generally is healthier than smoking. n. A sk patient to consider walking as a way to deal with urges/triggers. o. Adv ise patient to be wary of relapse. Advise patient to avoid high-risk situations initially, and to learn and practice positive imagery, medita-tion, or self-hypnosis techniques. Buddy up in at-risk situations. p. A sk patient to identify other situations of success and confidence, offer strength-based support. q. Onc e patient has quit for 6 months, encourage community involvement (e. g., volunteer on “for-mer smoker” panels, teach a quit smoking class, be a buddy for other “newly quit” smokers). r. I t is helpful to have follow-up scheduled visits; to establish a quit date, quit day appointment, follow-up support at 1 week, 1 month, 3 months. T elephone calls may work as well, individualize treatment. s. R eview strategies for urge control, offer commu-nity or Internet referral sources. t. A sk at every visit about patient's efforts. u. P raise and congratulate any quit effort, and explore what caused any relapse. v. I f quitting is recent, offer printed self-help materials from the American Lung Association (ALA), American Cancer Society community groups, or phone, Internet, and social media sites. w. M ost of the behavior modification techniques here are part of the Freedom from Smoking Classes conducted by the ALA before there were effective medications on the market. Medications with behavior modification are the evidence-based cessation treatments of choice. 6. D ocumentation a. I dentify smoking status on problem list or vital sign record as appropriate b. D ocument assessment of smoking history, readi-ness to quit and cessation strategies in progress notes. c. T reatment plans—include medications/behav-ior modification and patient education goals, include resources for self-help and follow-up. VI. Self-management r esources A. Online/telephone resources 1. 1-800-QUIT-NOW, a national hotline for smoking cessation 2. 1-800-NO-BUTTS, a California hotline for smoking cessation 3. 1-800-LUNGUSA, an American Lung Association phone help line679 Self-management resources

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B. Web-based support groups/social media 1. w ww. ffsonline. org 2. w ww. quitnet. com 3. w ww. smokefree. gov 4. w ww. quitnet. com will connect user to Quit Net Forum, Quit Net Facebook, or Quit Net Twitter VII. Consultation A. In patients with depression or history of depression, additional antidepressant agents other than bupropion may be required. Referral for counseling is recommended. B. In pregnant patients and patients with cerebrovascular, CVD, or seizure disorder, consultation with a physician is advised before the use of pharmacologic adjuncts for smoking cessation. C. Consider smoking cessation specialist. Re Fe Re NCe S American Cancer Society. (2014a). Cancer facts & figures 2014. Atlanta: American Cancer Society. American Cancer Society. (2014b). Guide to quitting smoking. Retrieved from www. cancer. org/acs/groups/cid/documents/webcontent/002971 -pdf. pdf. American Psychiatric Association. (2006). Practice guideline for the treatment of patients with substance abuse disorders (2nd ed. ). Retrieved from http:// psychiatryonline. org/pb/assets/raw/sitewide/practice_guidelines /guidelines/substanceuse. pdf. Brown, R. L., & Rounds, L. A. (1995). Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary care practice. Wisconsin Medical Journal, 94(3), 135-140. Centers for Disease Control and Prevention. (2015). Current cigarette smoking among adults in the United States. Retrieved from www. cdc. gov /tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/. Christiansen, B., Reeder, K., Hill, M., Baker, T. B., & Fiore, M. C. (2012). Barriers to effective tobacco-dependence treatment for the very poor. Journal of Studies on Alcohol and Drugs, 73(6), 874-884. Dutra, L. M., & Glantz, S. A. (2014). Electronic cigarettes and conven-tional cigarettes among US Adolescents: A cross sectional study. JAMA Pediatrics, 168(7), 610-617. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Bennett, G., Neal, L., et al. (2008). Treating tobacco use and dependence: 2008 Update. Clinical prac-tice guideline. Rockville, MD: U. S. Department of Health and Human Services, Public Health Service. Food and Drug Administration. (2008). Public health advisory: Important information on Chantix (varenicline). Retrieved from www. fda. gov/Drugs/Drug Safety/Postmarket Drug Safety Informationfor Patientsand Providers/ucm051136. htm. Food and Drug Administration. (2012). HR1256: Family Smoking Prevention and Control Act. Retrieved from www. fda. gov/T obacco Products/Guidance Compliance Regulatory Information/ucm237092. htm. Food and Drug Administration. (2015). Deeming—extending authori-ties to additional tobacco products. Retrieved from www. fda. gov /T obacco Products/Labeling/ucm388395. htm. Giovino, G. A. (2002). Epidemiology of tobacco use in the United States. Oncogene, 21(48), 7326-7340. Hall, S. M., & Prochaska, J. (2009). T reatment of smokers with co-occurring disorders: Emphasis on integration in mental health and addiction treat-ment Settings Annual Review Clinical Psychology, 5, 409-431. Houston, T. P. (1992) Smoking cessation in office practice. Primary Care, 19, 493-507. Mc Carthy, M. (2014). Y outh exposure to e-cigarette advertising on US tele-vision soars. British Medical Journal, 348, 3703. Meo, S. A., & Al Asiri, S. A. (2014). Effects of electronic cigarette smok-ing on human health. European Review for Medical and Pharmacological Sciences, 18 (21), 3315-3319. Moss, T. G., Weinberger, A. H., Vessicchio, J. C., Mancuso, V., Cushing, S. J., Pett, M., et al. (2010). A tobacco reconceptualization in psychiatry (TRIP): T owards the development of tobacco-free psychiatric facilities, American Journal Addiction, 19(4), 293-311. Moyer, V. A. (2014). Screening for lung cancer: U. S. Preventive Services T ask Force recommendation statement. Annals of Internal Medicine, 160(5), 330-338. Pacchiarotti, I., Bond, D. J., Baldessarini, R. J., Nolen, W. A., Grunze, H., Licht, R. W., et al. (2013). The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders. American Journal of Psychiatry, 170(11), 1249-1262. Palazzolo, D. L. (2013). Electronic cigarettes and vaping: A new challenge in clinical medicine and public health. A literature review. Frontiers in Public Health, 1, 56. doi:10. 3389/fpubh. 2013. 00056 Patel, D. R., Fencht, C., Reid, L., & Patel, N. D. (2010). Pharmacologic agents for smoking cessation. Clinical Pharmacology, 2, 17-29. doi:10. 2147/CPAA. S8788/11/20/14 Peereboom, D., Evers-Casey, S., & Leone, F. (2014). Are you equipped to treat tobacco dependence? Consultant, 54(12), 903-907. Rennard, S. I., & Daughton, D. M. (2014). Smoking cessation. Clinics in Chest Medicine, 35(1), 165-176. Sanford, Z., & Goebel, L. (2014). E-cigarettes: An up to date review and discussion of the controversy. West Virginia Medical Journal, 110(4), 10-15. Schoendorf, K. C., & Kiely, J. L. (1992). Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy. Pediatrics, 90(6), 905-908. Sheehan, K. A. (2004). Smoking cessation. In W. L. Star, L. L. Lommel, & M. T. Shannon, Women's primary health care: Protocols for practice (2nd ed., pp. 14-64-14-68). San Francisco: UCSF Nursing Press. Spitzer, R. L., Kroenke, K., & Williams, J. B. W. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. JAMA, 282(18), 1737-1744. The battle over e-cigarettes. (2014, September 27). The Week. Retrieved from http://theweek. com/articles/443487/battle-over-ecigarettes. U. S. Department of Health and Human Services. (2014). The health conse-quences of smoking—50 years of progress: A report of the Surgeon General. Atlanta, GA: U. S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Centers for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 680 CHAPTER 67 | Smoking Cessation

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U. S. Preventive Services T ask Force. (2014). T alking with your patients about screening for lung cancer. Retrieved from www . uspreventiveservicestaskforce. org/Home/Get File By ID/796. Walton, J., Barondess, J. A., & Lock, S. (Eds. ). (1994). The Oxford medical companion. New Y ork: Oxford University Press. Walton, K. M., Abrams, D. B., Bailey, W. C., Clark, D., Connolly, G. N., Djordjevic, M. V., et al. (2015). NIH electronic cigarette workshop: Developing a research agenda. Nicotine & T obacco Research, 17(2), 259-269. World Health Organization. (2008). WHO report on the global tobacco epidemic, 2008. The MPOWER package. Geneva, Switzerland: Author. Retrieved from www. who. int/tobacco/mpower/mpower_report_full _2008. pdf. Wynder, E. L., & Graham, E. A. (1950). T obacco smoking as a possible etiological factor in bronchiogenic carcinoma. JAMA, 143, 329-336. Zhang, M., Yang, C. C., & Li, J. (2012). A comparative study of smoking cessation internet programs on social media. Lecture Notes in Computer Science, 7227, 87-96. New Y ork: Springer Science+Business Media LLC. 681 References

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lymphocytic] thyroiditis, and subacute thy-roiditis). The initial presentation of thyroiditis, however, may have transient presentation consis-tent with hyperthyroidism. b. R adioiodine-induced or surgically induced hypothyroidism. c. I diopathic thyroid atrophy ( Jameson & Weetman, 2012; Saxe, 2004). 2. P revalence and incidence As reported by Vanderpump (2011), a number of studies have noted the prevalence of hypothyroidism ranges from 0. 6 and 12 per 1,000 in women and between 1. 3 and 4. 0 per 1,000 in men of the popu-lations that were investigated. However, the preva-lence of primary hypothyroidism is higher in the geriatric female population than in women under age 40 (Hollowell et al., 2002; Wang & Crapo, 1997). Additionally, in the United States, hypothy-roidism has been reported to be more common in White Americans and Mexican Americans than in Black Americans (Hollowell et al., 2002). B. Hyperthyroidism 1. D efinition and overview Hyperfunctioning of the thyroid gland can result from a variety of diseases. The most common causes of hyperthyroidism area. Di ffuse toxic (hyperfunctioning) goiter (Graves' disease). b. T oxic multinodular goiter. c. T oxic uninodular goiter. d. Th yroid inflammatory diseases (e. g., Hashimoto's thyroiditis, postpartum thyroiditis, and sub-acute thyroiditis, which may cause a transient thyrotoxicosis [Saxe, 2004; Vanderpump, 2011]). 2. P revalence and incidence Data from the Whickham survey and other studies indicate that the prevalence and incidence of I. Intr oduction and general background The adult thyroid gland is responsible for the production of hormones (L-thyroxine [T 4] and 3,5,3'-triiodothyronine [T3]) that influence a variety of metabolic processes. Its structure and function are contingent on an intact axis between this gland and the hypothalamus and pituitary glands. Specifically, the hypothalamus secretes thyrotropin-releasing hormone, which stimulates the pituitary to produce and release thyroid-stimulating hormone (TSH). TSH triggers the produc-tion and secretion of T 3 and T4 from the thyroid. Through a positive-negative feedback loop, these glands, when normally functioning, regulate T 3 and T4 secretion so that metabolic homeostasis is ensured. The thyroid gland is affected by a number of other extra-thyroidal factors, such as the status of the immune system. Thus, alterations in the synthesis, secretion, and circulation of thyroid hormones may be caused by an array of primary or secondary thyroid disorders. Globally, iodine deficiency is the most common cause of thyroid dysfunction, which leads to the  formation of a goiter and hypothyroidism. In regions where there is sufficient iodine supply, most thy-roid disorders are due to an underlying autoimmune disease (Vanderpump, 2011). The most common thyroid conditions seen in primary care settings are primary hypothyroidism, hyperthyroidism, and thyroid nodules (Saxe, 2004). A. Primary hypothyroidism 1. D efinition and overview This is a condition in which there is loss of thyroid function as a result of the intrinsic thyroid pathology. Primary hypothyroidism accounts for 95% of all cases of hypothyroidism ( Jameson & Weetman, 2012). The most common causes of primary hypothyroidism in the United States are:a. Th yroid inflammatory diseases (e. g., chronic [Hashimoto's] thyroiditis, postpartum [subacute Jo Anne M. Saxe Thyro Id d ISorder S© Eliks/Shutterstock; © donatas1205/Shutterstock 682 68Chapt Er

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hyperthyroidism in men are low (Vanderpump, 2011; Wang & Crapo, 1997). In women, the preva-lence of overt hyperthyroidism is between 0. 5% and 2% (Vanderpump, 2011). Like primary hypothy-roidism, hyperthyroidism is more commonly seen in older women than in women before the fourth decade (Cooper, Greenspan, & Ladenson, 2011; Wang & Crapo, 1997), yet with significant variability in prevalence noted in different regions of the world (Vanderpump, 2011). C. Thyroid nodules 1. D efinition and overview Thyroid nodules may be functional (secrete thyroid hormones) or nonfunctional. The vast majority of functional and most nonfunctional thyroid nodules are benign. However, a malignancy should be sus-pected particularly if an individual has the follow-ing risk profile: being relatively young (< 45 years of age); previous external head or neck irradiation; a predominant nodule or recent growth of a nodule, particularly if it does not alter thyroid functions; asso-ciated hoarseness and dysphagia; and a family history of medullary cancer of the thyroid (Cooper et al., 2011; Ward, Jemal, & Chen, 2010). 2. P revalence and incidence Thyroid nodules are common entities. The preva-lence rates of nodules vary by detection method with rates of up to 50% of individuals who have had a thyroid ultrasound (Cooper et al., 2011). Most of the detected nodules are benign and are more com-monly noted in women than in men (Cooper et al., 2011). With the exception of malignant nodules, thyroid nodules are more prevalent with increasing age as noted by incidence rates (Cooper et al., 2011; Howlader et al., 2014). Since 1980, however, there has been a rising incidence of thyroid malignancies. The age-adjusted incidence rate for invasive thyroid cancer was 4. 33/100,000 in 1980 compared to 14. 71/100,000 in 2011 (Howlader et al., 2014). II. d atabase (may include but is not limited to) A. Subjective 1. P rimary hypothyroidism a. P ast health history i. M edical illnesses: assess for autoimmune thyroid disorders that can be associated with other autoimmune diseases, such as type 1 diabetes mellitus, pernicious anemia, rheumatoid arthritis, and systemic lupus erythematosus; and secondary hypothy-roidism caused by pituitary or hypothalamic diseases (low TSH and low free thyroxine [FT 4]). ii. S urgical history: thyroid surgery or pitu-itary surgery iii. Obs tetric and gynecological history: recent pregnancy or parturition iv. T rauma history: brain trauma v. E xposure history: radiation (e. g., radioio-dine therapy or external neck irradiation) vi. M edication history: medications or supple-ments that influence hormone production (e. g., amiodarone, lithium, and iodine) b. F amily history i. Th yroid diseases ii. Othe r endocrinopathies c. O ccupational and environmental history: work-related exposures to radiation or radioactive iodine d. P ersonal and social history: iodine-deficient diet (uncommon because most regions have iodin-ation programs) e. R eview of systems: signs and symptoms vary depending on the degree of thyroid dysfunc-tion. The individual with subclinical hypothy-roidism (a person who has abnormalities in chemical markers, an elevated thyroid-stimulating hormone and normal free levothyrotoxine hor-mone, yet is clinically euthyroid) or mild hypo-thyroidism is usually asymptomatic. Persons with moderate dysfunction often notice constitutional and skin signs and symptoms. The individual with advanced disease often has multisystem symptoms. i. C onstitutional signs and symptoms: fatigue, weight gain, or cold intolerance ii. S kin, hair, and nails: dry skin, puffy and doughy skin, and coarse hair or hair loss iii. Ea r, nose, and throat: decreased hearing, hoarseness, dysphagia, or dysarthria iv. C ardiac: chest pain v. A bdomen: constipation vi. Ge nitourinary: oligomenorrhea and men-orrhagia vii. M usculoskeletal: joint stiffness or pain and myalgias viii. N eurologic: paresthesias, lethargy, less expressive at rest, depressed mood, and/or rarely ataxic gait683 Database

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viii. Ge nitourinary: irregular menses or amenorrhea ix. N eurologic: tremors or nervousness and anxiety 3. Th yroid nodules a. P ast health history i. M edical illnesses: thyroid disorders includ-ing thyroid cancer; and autoimmune disor-ders that may cause a nodular gland (e. g., Graves' disease) ii. S urgical history: thyroid surgery iii. E xposure history: radiation (e. g., radioiodine therapy or external head and neck irradiation) iv. M edication history: medications or supple-ments that influence hormone production (e. g., lithium and iodine) b. F amily history: thyroid diseases including goitrous thyroid conditions and thyroid cancer c. O ccupational and environmental history: work-related exposures to radiation or radioactive iodine d. P ersonal and social history i. I odine-deficient diet or iodine-excessive diet (see primary hypothyroidism and hyperthyroidism for discussion) ii. R egular ingestion of dietary goitrogens (e. g., beets and turnips) e. R eview of systems The nodules may be nonfunctional, in which case the individual is clinically euthyroid. However, the nodules or nodular gland may be hypofunctioning (resulting in signs and symptoms consistent with hypothyroidism) or autonomously functioning (resulting in signs and symptoms of hyperthyroidism). See the previous discussion on “primary hypothyroidism” or “hyperthyroidism,” respectively, if an altered thy-roid hormone status is suspected. It is important to inquire about symptoms, such as dysphagia, caused by an enlarged gland or hoarseness suggestive of malignant vocal cord infiltration (Cooper et al., 2011; Jameson & Weetman, 2012). B. Objective 1. P hysical examination findings (T able 68-1) 2. S upporting data from relevant diagnostic tests (T ables 68-2 and 68-3)2. H yperthyroidism a. P ast health history i. M edical illnesses: Graves' disease, toxic uninodular or multinodular goiter, very rarely pituitary TSH-secreting tumor. ii. S urgical history: thyroid surgery iii. Obs tetric and gynecological history: recent pregnancy or parturition iv. M edication history: medications or supple-ments that influence hormone production (e. g., antithyroid drug use [propylthiouracil (PTU) or methimazole], amiodarone, lith-ium, exogenous thyroid hormone supple-ments, and iodine) b. F amily history i. Th yroid diseases ii. Othe r endocrinopathies iii. N euroendocrine disorders c. P ersonal and social history: a recent intake of an iodine-rich diet in an individual who previously had an iodine-deficient diet (geographic regions that may not have iodination programs and that have limited access to iodine-containing foods are certain regions in South America, Africa, and Asia) d. R eview of systems: signs and symptoms vary depending on the degree of thyroid dysfunction. The individual with subclinical and mild hyper-thyroidism may be relatively asymptomatic. Persons with moderate dysfunction often notice constitutional signs and symptoms, palpitations, increased bowel motility, and neurologic signs and symptoms as depicted next. The individual with advanced disease often has multisystem symptomatology. i. C onstitutional signs and symptoms: weakness, fatigue in the elderly, increased appetite, weight loss, insomnia, or heat intolerance ii. S kin: increased perspiration; pretibial myx-edema in Graves' disease iii. E yes: proptosis in Graves' disease iv. Ea r, nose, and throat: hoarseness or dysphagia v. P ulmonary: dyspnea vi. C ardiac: chest pain or palpitations vii. A bdomen: increased bowel motility that often results in frequent bowel movements684 CHAPTER 68 | Thyroid Disorders

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Table 68-1 Physical Examination Findings Condition Associated Findings (may or may not include): Primary Hypothyroidism Assess: 1. Vital signs: hypothermia and/or bradycardia 2. General appearance: flat af fect and/or dull facial expressions 3. Skin/hair: dry skin (early manifestation) to pasty, rough, and spongy skin (advanced manifestation); coarse hair (early manifestation) to hair loss (advanced manifestation) 4. Eyes: periorbital edema (late manifestation) 5. Ears, nose, and throat: enlarged tongue (advanced manifestation) 6. Thyroid: nonpalpable gland to a symmetrically enlarged and smooth gland to a multinodular enlarged gland 7. Lungs: crackles (advanced manifestation) 8. Cardiovascular: (+) S4, (+) S3, and jugular venous distention (advanced manifestations) 9. Abdomen: diminished bowel sounds 10. Neurologic: decreased tendon reflexes or enhanced relaxation phase, depressed mood, inattentiveness, and/or somnolence Hyperthyroidism Assess: 1. Vital signs: tachycardia 2. General appearance: restless 3. Skin/hair: moist and warm skin; pretibial myxedema (most suggestive of Graves' disease) and/or fine and very smooth hair 4. Eyes: exophthalmos/proptosis due to Graves' disease; and/or eye signs related to sympathetic hyperstimulation (lid lag, lid retraction, diminished blinking, inability to crease the eyebrows on upward stare) 5. Thyroid: single nodule (toxic uninodular goiter); tender or painless, symmetrically enlarged gland (thyroiditis); or dif fusely enlarged (Graves' disease) and/or thyroid bruit (Graves' disease) 6. Lungs: crackles 7. Cardiovascular: systolic murmur; and/or (+) S4, (+) S3, and jugular venous distention 8. Abdomen: enhanced bowel sounds 9. Neurologic: increased tendon reflexes and/or fine tremor of the hands and tongue Thyroid Nodules The associated findings are contingent upon the functional status of the thyroid: 1. Nonfunctional nodule(s): exam will be relevant only for a thyroid gland with the palpable nodule(s) 2. Hypofunctioning multinodular gland: see the Primary Hypothyroidism Associated Findings section 3. Autonomously functioning nodule(s): see the Hyperthyroidism Associated Findings section 4. L ymph nodes: assess lymph nodes of the head and neck (may suggest a malignancy)685 Database

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Table 68-2 Common Thyroid T ests Test d efinition Clinical Implications Comments Serum-free T4 (FT4) Measurement of the metabolically active T4 (unbound to thyroid-binding globulin)Decreased in primary hypothyroidism. Increased in thyrotoxicosis. May be increased by various drugs or conditions in individuals who are clinically euthyroid. Serum T 3Measurement of bound and free serum levels of T 3Increased in T3 thyrotoxicosis. May be increased by various drugs or conditions in individuals who are clinically euthyroid. Highly sensitive thyroid-stimulating hormone (TSH)Measurement of TSH, an anterior pituitary hormone that stimulates growth and function of thyroid cells Sensitive and specific test for the initial assessment of thyroid dysfunction. Increased in primary hypothyroidism. Decreased in most forms of thyrotoxicosis. Values may be altered by certain drugs (e. g., aspirin and lithium). Serum antithyroid antibodies (e. g., antithyroid peroxidase antibodies [also known as antithyroid microsomal antibody], antithyroglobulin antibodies, and anti-TSH receptor antibodies)Measurement of immunologic markers for autoimmune thyroid diseases Increased antithyroid peroxidase antibodies and/or antithyroglobulin antibodies are seen in Hashimoto's thyroiditis and Graves' disease. Anti-TSH receptor antibodies and thyroid-stimulating immunoglobulin (TSI) are commonly seen in persons with Graves' disease. May be increased in clinically euthyroid individuals. Increases in anti-TSH receptor antibodies and thyroid-stimulating immunoglobulin (TSI) are more reliably predictive of Graves' disease than the thyroidal peroxidase antibody test (Cooper et al., 2011). Radioactive iodine uptake Measurement of thyroid function via uptake of radioactive iodine ( 123I) or technetium 99m Tc pertechnetate (99m Tc O4)Used to evaluate defects in thyroid hormone production. Low uptake of radioactive iodine noted with non-iodine-deficient hypothyroidism, thyroiditis, and factitious thyrotoxicosis. Increased uptake is often seen with Graves' disease and toxic multinodular and uninodular goiter. Variety of medications may interfere with uptake of the radioisotope. This test is usually not necessary for the basic evaluation of most thyroid disorders. Contraindications are iodine allergy, pregnancy, and lactation. Thyroid scintiscan Visualization of the thyroid gland via a scintillation camera after the administration of a radioactive isotope (e. g., 123I or 99m Tc O4)This test provides information about the structure and function of the thyroid gland. Increased uptake of the radioactive isotope is noted in a (hot) hyperfunctioning gland or nodule (e. g., Graves' disease and toxic uninodular goiter, respectively). Decreased uptake is seen in hypothyroidism or nonfunctioning (cold) nodule (e. g., thyroid cancer). Variety of medications may interfere with uptake of the radioisotope. This test is usually not indicated for the evaluation of primary hypothyroidism. Contraindications are iodine allergy, pregnancy, or lactation. Reproduced from Saxe, J. M. (2004). Thyroid diseases. In W. L. Star, L. L. Lommel, & M. T. Shannon (Eds. ), Women's primary health care: Protocols for practice (2nd ed., pp. 10-33-10-39). San Francisco, CA: UCSF Nursing Press; reassessed and adapted from Fischbach & Dunning (2014) and Jameson & Weetman (2012). Used with permission from the UCSF Nursing Press. 686 CHAPTER 68 | Thyroid Disorders

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III. Assessment A. Determine the diagnosis 1. P rimary hypothyroidism 2. H yperthyroidism 3. Th yroid neoplasms (benign or malignant) 4. Othe r conditions that may explain the patient's presentation a. P ituitary disease b. H ypothalamic disease c. C ardiovascular disease d. E xtrathyroidal malignancy e. P sychiatric disorder B. Severity Assess the severity of the disease. C. Significance and motivation 1. A ssess the significance of the problem to the patient and significant others. 2. D etermine the patient's willingness and ability to follow the treatment plan. IV. Goals of clinical management A. Screening or diagnosing thyroid disease Choose a cost-effective approach for screening or diagnos-ing thyroid disease. B. Treatment Select a treatment plan that returns the patient to a euthy-roid state in a safe and effective manner. C. Patient adherence Select an approach that maximizes patient adherence. V. Plan A. Screening Some major authorities (Garber et al., 2012) recommend screening for high-risk populations (adults > 35 years of age, older women, individuals with autoimmune diseases or a strong family history of thyroid diseases). However, the U. S. Preventive Services T ask Force (2014) has noted that there is insufficient evidence to support routine screening Table 68-3 Supporting Data from Other Relevant Diagnostics Studies* Condition d iagnostic Test r esults Primary Hypothyroidism Serum sodium Serum cholesterol Complete blood count Electrocardiogram and/or echocardiogram Decreased (advanced disease) Increased Mild normocytic, normochromic anemia Changes secondary to a hypometabolic state and/or congestive heart failure Thyrotoxicosis Complete blood count Erythrocyte sedimentation rate (ESR) Electrocardiogram and/or echocardiogram Elevated white blood count (WBC) with some of the thyroid inflammatory conditions (e. g., subacute thyroiditis) Elevated ESR with some of the thyroid inflammatory conditions (e. g., subacute thyroiditis) Changes secondary to a hypermetabolic state and/or congestive heart failure Thyroid Nodules Hypofunctioning gland (see Primary Hypothyroidism) Hyperfunctioning gland (see Thyrotoxicosis) Fine-needle aspiration (FNA) biopsy Benign, malignant, or suspicious/indeterminate *Not usually indicated for confirming the diagnosis of thyroid disease but rather for assessing target organ damage. 687 Plan

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for thyroid disease in adults. If the clinician determines that screening for thyroid disease is indicated for an individual, the initial screening test should be the highly sensitive TSH because it is more sensitive and specific than the FT 4 and the FT4I ( Jameson & Weetman, 2012). If the highly sensitive TSH is high or low, the clinician should use the suggested diagnostic approach in T able 68-4. B. Diagnostic tests See T ables 68-2 and 68-3 for the description of relevant diagnostic studies and T able 68-4 for the suggested approach for the assessment of thyroid dysfunction. 1. C ommon thyroid studies may include, but are not limited to highly sensitive TSH, free T4 (FT4), free total T3 (FT3), serum antithyroid antibodies (including antithyroperoxidase antibodies and TSH receptor antibodies), radioactive iodine uptake, and thyroid scintigraphy. 2. Th yroid ultrasonography is indicated for an indi-vidual who has a neck mass of questionable thyroid origin. 3. F ine-needle aspiration is necessary to rule out a cancerous nodule. Table 68-4 The Assessment of Thyroid Dysfunction order the highly sensitive thyroid-stimulating hormone (TS h) test Q Q Q Normal TS h R Are secondary causes of hypothyroidism suspected?Increased TS h R o rder a serum FT4decreased TS h R o rder a serum FT4 No R No further testing is indicated. The patient is clinically euthyroid. Decreased FT 4—primary hypothyroidism Increased FT4—primary hyperthyroidism R order anti-TSH receptor antibodies If the antibodies are elevated, the person has an autoimmune thyroid disease (e. g. Graves' disease). If the antibodies are normal, the patient probably has a nonimmune mediated form of thyrotoxicosis (e. g., toxic uninodular goiter). Consult with a physician to determine the need for a thyroid scintiscan Ye s R Order a serum FT4Increased FT4—pituitary (TSH-induced) thyrotoxicosis Normal FT4—subclinical hyperthyroidism or a rare form of primary hyperthyroidism called T 3 toxicosis R Does the patient have signs and symptoms consistent with thyrotoxicosis? Decreased FT 4—Consult with a physician to determine the necessity for a thyrotropin-releasing hormone (TRH) stimulation test (a test for assessing the hypothalamic-pituitary function). Normal FT 4—subclinical hypothyroidism R order thyroid peroxidase antibodies. If the antibodies are elevated, the person has compensated chronic Hashimoto' s thyroiditis (subclinical hypothyroidism). If the antibodies are normal, consult with a physician to determine the necessity for a TRH stimulation test. Ye s R Order FT3 Increased FT3—T3 toxicosis Consult with a physician to determine the need for a thyroid scintiscan Normal R Consult with a physician for other diagnostic considerations Reproduced from Saxe, J. M. (2004). Thyroid diseases. In W. L. Star, L. Lommel, & M. Shannon (Eds. ), Women's primary health care: Protocols for practice (2nd ed., pp. 10-33-10-39). San Francisco, CA: UCSF Nursing Press. Reassessed and adapted from Fischbach & Dunning (2014) and Jameson & Weetman (2012). Used with permission from the UCSF Nursing Press. 688 CHAPTER 68 | Thyroid Disorders

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4. E xtrathyroidal diagnostic studies are warranted for assessing the status of other systems that may be affected by altered thyroid functions (T able 68-3). C. Management (includes treatment, consultation, referral, and follow-up care) 1. P rimary hypothyroidism a. El iminate, if possible, medications (e. g., lithium) or exposures (work-related radiation) that may negatively affect the thyroid gland. b. A rrange a hospital admission for patients with severe cardiopulmonary compromise. c. Be gin oral replacement with L-thyroxine. i. S uggested initial dosing for a young adult without cardiac disorders: 50-100 mcg/day. ii. S uggested initial dosing for an elder or an individual with heart conditions: 25 mcg/day. d. I ncrease dosage by 25-50 mcg every 4-6 weeks until the person's highly sensitive TSH is within normal parameters. The usual replacement dose is 1. 6-1. 7 mcg/kg/day for adults (Cooper et al., 2011). e. S ustain a full replacement of L-thyroxine, which is usually 100-150 mcg daily. f. C heck the person's highly sensitive TSH every 6-12 months or as needed to assess the response to chronic therapy and to determine the need for any adjustment in daily doses (Slovik, 2014b). 2. H yperthyroidism a. R educe the intake of iodine if thought to be a contributing factor. b. S tart the use of β-blocking agents (e. g., proprano-lol, 20 mg every 6 hours) to blunt the symptoms and signs of hyperthyroidism (e. g., palpitations, heat intolerance, nervousness, and tremor) (Slovik, 2014a). c. C onsult with a physician for the use and dosing of antithyroid agents (e. g., thionamide drugs, such as methimazole, PTU, or iodide). PTU should be given to pregnant women because methimazole can cause congenital defects. It is also recommended to give PTU to lactating women because methimazole is excreted in human milk. Although the thionamide drugs have an overall low rate of serious adverse effects, hepatotoxicity, vasculitis, and agranu-locytosis are the most serious adverse sequelae. PTU is more likely to cause fulminant hepatic failure and vasculitis than methimazole. Cholestatic jaundice is more likely to occur with methimazole than PTU. An autoimmune agran-ulocytosis can occur with both agents. Iodide is usually reserved for individuals in thyroid storm and for those being prepared for thyroid surgery (Katz, 2015). d. R efer the patient to a physician specialist for ablative therapy with radioactive agents (e. g., radioactive iodine) or subtotal thyroidectomy. e. F acilitate a hospital admission for the person with severe cardiopulmonary compromise. f. A ssess TSH levels annually or as needed after the individual is in remission to determine the adequacy of treatment and the earliest evidence of overtreat-ment (evidence of hypothyroidism). If the values are abnormal, assess the FT 4 or serum T3 levels. TSH receptor antibodies should also be obtained if the individual has Graves' disease. Consult with or refer to a physician for additional treatment if these tests are abnormal (Slovik, 2014a). g. S creen and treat for osteoporosis in women with hyperthyroidism. 3. Th yroid nodules a. R efer the patient with a solitary nodule or a dominant nodule within a multinodular gland to a physician for further diagnostic evaluation (fine-needle aspiration and possible thyroid scin-tigraphy) and for therapeutic interventions (e. g., L-thyroxine suppressive or replacement therapy or surgical therapy). b. S top goiter-producing medications, if possible (e. g., lithium). c. U se the hypothyroidism treatment guidelines (see the Management section) for the person with a hypofunctioning multinodular goiter (e. g., chronic thyroiditis). d. U se the hyperthyroidism treatment guidelines (see the Management section) for the individual with a toxic multinodular goiter. D. Patient education 1. I nformation Provide verbal and, preferably, written information regarding:a. R isk reduction and screening (e. g., stress man-agement and relapse prevention in autoimmune-mediated hyperthyroidism, and osteoporosis screening for women with hyperthyroidism). b. The d isease process, including signs and symp-toms and underlying etiologies. c. Di agnostic tests that include a discussion about preparation, cost, the actual procedures, and after-care. d. M anagement (rationale, action, use, drug inter-actions, side effects, associated risks, and cost of therapeutic interventions; and the need for adher-ing to long-term treatment plans) (Saxe, 2004). 2. C ounseling: preconception counseling as indicated. 689 Plan

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VI. Self-management r esources and tools A. Patient and client education 1. A merican Thyroid Association The American Thyroid Association's (2015) website has patient and client education brochures and frequently asked question documents in English and Spanish. The documents, albeit useful and accurate, have an average grade 9-10 reading level via the Flesch-Kincaid assessment tool. Additionally, there are very few photographs, figures, or graphs to facilitate further understanding of challenging concepts. 2. Gei singer's Health Library (powered by Krames online) The Geisinger's Health Library (2015) includes consumer-friendly resources on common thyroid problems. The Flesch-Kincaid reading level is approxi-mately grade 7. This educational resource includes colorful illustrations and culturally appropriate images. B. Community support groups 1. Th yroid-Info Thyroid-Info has support groups postings (e. g., How to start a thyroid support group: tips on creating a support organization in your area [Shomon, 2015]). re Fere NCe S American Thyroid Association. (2015). ATA patient education. Retrieved from www. thyroid. org/patient-thyroid-information/ata-patient-education -web-brochures/. Cooper, D. S., Greenspan, F. S., & Ladenson, P. W. (2011). The thyroid gland. In D. G. Gardner & D. Shoback (Eds. ), Greenspan's basic and clinical endocrinology (9th ed., Chap. 7). Retrieved from http://accessmedicine . mhmedical. com/content. aspx?bookid=380&sectionid=39744038. Fischbach, F., & Dunning, M. B., III (2014). A manual of laboratory and diagnostic tests (9th ed. ). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Garber, J. R., Cobin, R. H., Gharib, H., et al. (2012). Clinical practice guidelines for hypothyroidism in adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Retrieved from www. thyroid. org/thyroid-guidelines/hypothyroidism/. Geisinger's Health Library. (2015). Common thyroid problems. Retrieved from www. geisinger. kramesonline. com/3,S,82164. Hollowell, J. G., Staehling, N. W., Flanders, W. D., Hannon, W. H., Gunter, E. W., Spencer, C. A., et al. (2002). Serum TSH, T, and thyroid antibodies in the United States population (1988 to 1994). National Health and Nutrition Examination Survey (NHANES III). Journal of Clinical Endocrinology and Metabolism, 87(2), 489-499. Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Miller, D., Altekruse, S. F., et al. (Eds. ). (2014). SEER cancer statistics review, 1975-2011. Bethesda, MD: National Cancer Institute. Retrieved from http://seer. cancer. gov/archive/csr/1975_2011/. Jameson, J. L., & Weetman, A. P. (2012). Disorders of the thyroid gland. In A. S. Fauci, E. D. L. Longo, A. S. Fauci, D. L. Kasper, S. L. Hauser, J. L. Jameson, et al. (Eds. ), Harrison's principles of internal medicine (18th ed., Chapter 341). Retrieved from http://accessmedicine. mhmedical. com /content. aspx?bookid=331&sectionid=40727146. Katz, M. D. (2015). Thyroid disorders. In M. A. Chisholm-Burns, T. L. Schwinghammer, B. G. Wells, P. M. Malone, J. M. Kolesar, & J. T. Di Piro (Eds. ), Pharmacotherapy: Principles & practice (3rd ed., Chapter 44). New Y ork: Mc Graw-Hill Medical. Saxe, J. M. (2004). Thyroid diseases. In W. L. Star, L. L. Lommel, & M. T. Shannon (Eds. ), Women's primary health care: Protocols for practice (2nd ed., pp. 10-33-10-39). San Francisco, CA: UCSF Nursing Press. Shomon, M. (2015). How to start a thyroid support group: Tips on creating a support organization in your area. Retrieved from www. thyroid-info. com/articles/supportgroup. htm.. Slovik, D. M. (2014a). Approach to the patient with hyperthyroidism. In A. H. Goroll & A. G. Mulley (Eds. ), Primary care medicine: Office evaluation and management of the adult patient (7th ed., Chapter 103). Philadelphia, PA: Wolters Kluwer Health. Slovik, D. M. (2014b). Approach to the patient with hypothyroidism. In A. H. Goroll & A. G. Mulley (Eds. ), Primary care medicine: Office evaluation and management of the adult patient (7th ed., Chapter 104). Philadelphia, PA: Wolters Kluwer Health. U. S. Preventive Services T ask Force (2014). Evidence summary: Thyroid dys-function screening. Retrieved from www. uspreventiveservicestaskforce . org/Page/Supporting Doc/thyroid-dysfunction-screening/evidence -summary7. Vanderpump, M. P. J. (2011). The epidemiology of thyroid disease. British Medical Bulletin, 99, 39-51. Wang, C., & Crapo, L. M. (1997). The epidemiology of thyroid disease and implications for screening. Endocrinology and Metabolism Clinics of North America, 26(1), 189-218. Ward, E. M., Jemal, A., & Chen, A. (2010). Increasing incidence of thyroid cancer: Is diagnostic scrutiny the sole explanation? Future Oncology, 6(2), 185-188. Retrieved from http://www. futuremedicine. com/doi /pdf/10. 2217/fon. 09. 161. 690 CHAPTER 68 | Thyroid Disorders

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The most common cause of neck pain is mechanical injury, often caused by everyday activities such as poor posture, repetitive movements, or nonergonomic work stations. More serious injuries, such as acute trauma or injury, can occur during sports or motor vehicle accidents (MVAs). Nonmechanical causes of pain are less common and are often of an inflammatory or infectious nature, often presenting with “red flags” that should be considered in any differential of neck pain. Other causes of neck pain that should not be over-looked include referred pain and other visceral conditions that can present acutely. Women seem to have an increased inci-dence of spinal conditions, such as scoliosis in adolescence, osteoporosis with vertebral body fractures, and increased kyphosis after menopause. Men, however, have an increased incidence of kyphosis in adolescence and ankylosing spondy-litis in adulthood (Green, 2001). The anatomical arrangement provides for structural pro-tection for the vital organs of the heart, lungs, and liver. It also forms a cavity for the lungs to expand and contract safely (Magee, 2008). The thoracic spine has very limited motion because the ribs are very firmly attached to both the posterior spine and the sternum anteriorly. The lower three ribs do not join together anteriorly but do function to protect the vital organs while still allowing for slightly more motion. The joints between the thoracic vertebra (T12) and the lumbar vertebra (L1) allow for twisting movements from side to side. Although the thoracic spine is relatively stable due to its solid construction, this does not prevent it from being a source of radicular symptoms and pain. Muscular thoracic pain is mostly caused by irritation or ten-sion of the muscles, such as myofascial pain. The cause of this pain may be poor posture, mechanical injury, or referred pain from the neck. Joint dysfunction where the ribs attach to the spine can also be a source of symptoms in the thoracic spine. Genetic or injury-related conditions such as vertebral fractures, kyphosis, and scoliosis can also greatly affect the individual's well-being. Compression fractures of the vertebra at the tho-racic level can be due to osteoporosis especially in the elderly. I. Intr oduction and general background The cervical and thoracic spine can be the source of many pain syndromes that affect the neck, the thorax, and the upper extremities. Given their anatomical proximity and the frequency of misattribution of the symptom origin, the pur-pose of this chapter is to focus on the most common cervical and thoracic pain syndromes. The cervical (C) spine is a complex structure composed of vertebrae, intervertebral discs, joints, the spinal cord, nerve roots, blood vessels, muscles, and ligaments. The atlanto-occipital joints (C0-C1) are the two uppermost joints, which are responsible for flexion, extension, and side flexion. The atlantoaxial joint (C1-C2) is the most mobile joint of the spine, rotation being its primary movement. The facet joints, also known as apophyseal joints, allow flexion and extension. This mobility can cause degeneration, most often seen at the C4-C7 levels. About 25% of the height of the cervical spine is from the intervertebral discs, which are responsible for the spine's lordotic shape. The nucleus pulposus of the disc acts as a cushion to axial compression; the disc's annulus fibrosus withstands tension within the disc. The cervical vertebrae support the weight of the head and neck (approximately 15 lb. ). The vertebral arch protects the spinal cord. Cervical nerve roots are named for the vertebra below each root (e. g., the C5 nerve root is between C4 and C5 vertebrae). In the rest of the spine, the nerve root is named for the vertebra above (Magee, 2002). Given the cervical spine's complex structure, it is vulner-able to injuries and disorders that produce pain and restrict mobility. Neck pain is generally perceived as originating from the inferior aspect of the occiput and the superior aspect of the last cervical vertebra. This forms an imaginary line that is called the “nuchal line” (Bogduk, 2003). The causes of neck pain are various and can be classified as acute (duration ≤ 3 months) or chronic (lasting ≥ 3 months). Rossana Segovia Uppe R Back and neck pa I n Synd R ome S© Eliks/Shutterstock; © donatas1205/Shutterstock 69169Chapt Er

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Kyphosis and scoliosis in the thoracic area can be due to poor posture or deformity causing a great deal of chronic pain. Some common spinal disorders, such as a herniated disc, spinal stenosis, degenerative disc disease, or spinal instability, are not as common in the thoracic spine due to the great stability of this section of the spine. A. Mechanical spine disease (acute) 1. D efinition and overview a. C ervical spine pain: Cervical spine problems that provoke pain account for thousands of primary care evaluations each year. Most patients suffer from acute cervical strains or osteoarthritis (OA). Neck pain can be caused by muscle strains, ligament sprains, arthritis, or nerve impingement. Most strains and sprains recover in 2-4 weeks with conservative treat-ment. Arthritic neck pain also often responds to medication and physical therapy in the acute phase. Acute musculoskeletal neck pain is a com-mon problem in the general population that is frequently evaluated in emergency departments. About 71% of Americans remember at least one episode of neck pain or stiffness during their lifetimes (Mc Reynolds & Sheridan, 2005). b. Thor acic spine pain: The thoracic spine has not been studied as much as the cervical or lumbar spine in regard to both genetic and epidemiologic studies. However, pain in the thoracic spine can be just as disabling, causing major physical burdens on the individual and his or her participation in the workforce (Briggs, Smith, Straker, & Bragge, 2009). Conditions such as osteoporosis, hyper-kyphosis, and ankylosing spondylitis have been linked to thoracic spine pain and dysfunction (Briggs, Smith, et al., 2009). Other common con-ditions such as thoracic nerve impingement often correlate with the size and location of the disc her-niation. Occupations and recreational activities that require prolonged sitting may predispose indi-viduals to thoracic spinal pain. For example, there was an 8% incidence of exertional thoracic pain compared to 10% in lumbar spine pain in an army military training program. Additionally, there was a 15% prevalence of thoracic pain or chest discom-fort compared to 47% of lumbar pain or stiffness in a group of sportsmen. Lastly, there was a 28% prevalence of thoracic pain in bus drivers com-pared to 10% in nondrivers (Manchikanti, Singh, Datta, Cohen, & Hirsch, 2009). 2. P revalence and incidence a. C ervical spine pain: Neck pain is a common condition and the prev-alence rises with age. Lifetime prevalence of neck pain is estimated at 71%. Twelve to 34% of adults experience neck pain annually. Neck pain is especially common in the middle-aged population, with the prevalence of shoulder and neck pain being highest by ages 45 to 60. Pain from the shoulder and neck region now seems to occur more frequently (Ostergren et al., 2005). According to an article in Pain Physician journal, the prevalence of cervical facet joint pain in patients with chronic pain after whip-lash has been determined to be 54% to 60% (Manchikanti, Singh, Rivera, & Panpati, 2002). A study by Gordon, T rott, and Grimmer (2002) reported the prevalence of cervical pain and stiff-ness to be between 9. 5% and 71% of the popula-tion. Furthermore, the study pointed out that one in every five patients who went to an orthopedist suffers from a cervical syndrome. In both the United States and Japan, cervical pain syndrome is the second most common cause for consultations and in pain clinics (Gordon et al., 2002). b. Thor acic spine pain: There is limited research on prevalence and risk factors for thoracic spine disorders, which may provoke a belief that the clinical and public health significance of thoracic spine disorders is less compared to other spinal levels. However, it has been countered in some of the literature that there is a need for research on thoracic pain and disorders especially in the young population. There is also evidence to suggest that pain or dysfunction in the thoracic spine is not uncommon in the adult population (Briggs, Smith, et al., 2009). There have been reports describing 3% to 23% of patients evaluated in interventional pain management settings have acute thoracic pain syndromes. A prevalence of thoracic pain was estimated in 13% of the population compared to 43% in the lumbar spine and 44% in the cervical spine during a 1-year period when this study was done (Manchikanti et al., 2009). A survey of factory workers found a 5% prevalence of thoracic pain, which did not show any association with age. This evaluation also showed the prevalence of cervical and lum-bar pain to be 24% and 34%, respectively, with increasing prevalence with age in both cases (Manchikanti et al., 2009). B. Cervicothoracic myofascial pain syndrome 1. D efinition and overview Myofascial pain syndrome is also known as regional pain syndrome, which is characterized by hyperirri-tability areas in the body called trigger points. These 692 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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trigger points arise from taut bands in the skeletal muscle. The syndrome usually accompanies some peculiar pain pattern that is specific to the muscle area involved. Eventually, the muscle becomes weak and stiff, due to the chronicity of the symptoms, which leads to decreased range of motion. This pain is usu-ally undertreated due to the lack of awareness of the clinicians ( Jalil, Awang, & Omar, 2009). Not all of the motor and sensory symptoms of myofascial pain syndrome have to be present in order to be clinically diagnosed. The presence of the taut band with its zone of tenderness in the muscle involved is one important feature of myofascial pain that distinguishes it from other types of muscle pain. The ability to reproduce pain in the individual while examining the tender zone and its taut band is very important (Gerwin, 2001). a. P rimary and secondary cervicothoracic myofas-cial pain syndrome: In an unpublished article by Gerwin (2001), it was reported that 100% of the individuals with chronic tension-type headaches and migraine symptoms of nausea and photosen-sitivity had active myofascial trigger point pain. Neck and shoulder muscles such as sternoclei-domastoid, scalenes, levator scapulae, trapezius, suboccipital, and posterior cervical muscles can directly cause neck pain. Postural stress, such as forward head and anteriorly rotated shoulders, is a known factor causing trigger point related neck pain. Both shoulder pain and decreased or restricted range of motion can be directly related to primary trigger point myofascial pain due to overuse of certain muscles. For example, the subscapularis muscle can be triggered by poor body posture, biomechanics, and injury. b. C ervical whiplash: Cervical whiplash injuries can become chronic pain in 20-40% of cases and 50% of these cases are related to injury to one or more cervical facet joints (Gerwin, 2001). c. C hronic myofascial cervical and/or thoracic pain syndrome: Chronic myofascial pain syn-drome involves other muscles groups and regions because of stresses that develop along the skeletal chain. When a muscle in this functional unit does not work effectively due to tender trigger points it becomes weak and loses its ability to lengthen, which allows for a normal range of motion. This in turn creates a chain reaction and the other muscles try to compensate for this loss and become overused and chronically shortened (Gerwin, 2001). 2. P revalence and incidence Unfortunately, the prevalence of myofascial pain syndrome in the general population is not known. It has been reported that separating myofascial trigger points into active and inactive states causes epide-miologic confusion. The prevalence between active and inactive clinical conditions is greater in the later. Myofascial pain studies making a distinction between these two clinical conditions are few. These studies do not usually address the prevalence of inactive clini-cal conditions. There are also no specific data on the prevalence among women and men (Gerwin, 2001). C. Scalene muscle pain and thoracic outlet syndrome 1. D efinition and overview Both scalene muscle pain and thoracic outlet syn-drome have been overlooked by providers due to their characteristics of symptoms mimicking cervical radic-ulopathy resulting from herniated discs. These have also been associated with other neuropathic diseases such as carpal tunnel syndrome and peripheral poly-neuropathy due to their presentation of referred pain to the distal extremities. a. S calene myofascial pain syndrome: Scalene myofascial pain syndrome is a regional pain that originates over the neck area and radiates down to the arm. It may present as primary or second-ary to underlying cervical pathology. b. Thor acic oulet syndrome: Thoracic outlet syn-drome is caused by compression of nerves or blood vessels in the thoracic outlet, which includes the area between the neck and the axilla including the anterior shoulders and anterior chest. An important distinction that has been identified in studies is the categorization of vas-cular versus neurogenic presentations (Hooper, Denton, Mc Galliard, Brismee, & Sizer, 2010). 2. P revalence and incidence a. S calene myofascial pain syndrome: In one study it was found that 31% of patients complaining of scalene muscle pain had acute trigger points, which have been also described in all age groups and in both sexes. The syndrome most often occurs between the ages of 30 and 60 years; prevalence declines with advancing age. A study done in the 1950s studied asymptomatic Air Force recruits and found tender spots indica-tive of latent trigger points in 54% of the women and 45% of the men. The study also noted referred pain with palpation in 5% of the recruits (Fomby & Mellion, 1997). 693 Introduction and general background

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of the neck caused by prolonged or repetitive neck extension or flexion. This is often related to poor pos-ture at work, such as repetitive leaning or bending of the neck, and nonergonomic work stations, or during hobbies, such as knitting or crocheting. Repetition of the motion causes constant insult to the affected area and prevents healing (Steinberg et al., 1999). 2. P revalence and incidence According to a recent study published by Cohen, “neck pain is the fourth leading cause of disabil-ity, with an annual prevalence rate exceeding 30%” (2015, p. 284). This rate includes all types of causes of neck pain; however, most episodes of acute neck pain will resolve with or without treatment as in the case of strains. “Nearly 50% of individuals will continue to experience some degree of pain or frequent occur-rences” (Cohen, 2015, p. 284). A review article done by Briggs et al. (2009) reported the range of prevalence estimates of tho-racic back pain in the general population to be very broad because of many factors, including the differ-ent types and causes as well as duration. These data ranged from 4. 0-72. 0% (at any one time), 0. 5-51. 4% (7 days), 1. 4-34. 8% (1 month), 4. 8-7. 0% (3 month), 3. 5-34. 8% (1 year), and 15. 6-19. 5% (lifetime). There was a higher prevalence for thoracic back pain in children and adolescents, especially for females. In children and adolescents, thoracic back pain was associated with female gender, postural changes asso-ciated with backpack use, backpack weight, other musculoskeletal symptoms, participation in specific sports, chair height at school, and difficulty with homework. In adults, thoracic back pain was associat-ed with other concurrent musculoskeletal symptoms and difficulty in performing activities of daily living (Briggs et al., 2009). F. Spinal deformities 1. D efinition and overview Spinal deformities refers to conditions in which the spine has an abnormal curvature or alignment. The two most common spinal deformities are scoliosis and hyperkyphosis. a. S coliosis: Scoliosis is defined as a lateral curva-ture of the spine that may occur in children or adults. Scoliosis may cause back pain, abnormal gait, uneven hips, and different leg lengths for adolescents and even more severe symptoms when found in adults. Most cases of scoliosis are mild, but some children develop spine defor-mities that continue to get more severe as they grow. Severe scoliosis can be disabling. An espe-cially severe spinal curve can reduce the amount of space within the chest, making it difficult for b. Thor acic outlet syndrome: A survey done in 2009 on factory workers and their prevalence of thoracic pain demonstrated a 5% prevalence of thoracic pain, which was not associated with age. The same authors demonstrated a prevalence of 24% cervical pain and 34% lumbar pain, which were associated with increased age (Manchikanti et al., 2009). Thoracic outlet syndrome is generally diag-nosed between 20 and 50 years of age; however, it can be found in teenagers and most rarely in children. Neurogenic thoracic outlet syndrome is found three to four times more commonly in women compared to the vascular type, which is more equal between nonathletic women and men. This, however, is not the same in athletic individuals in whom there is a greater incidence in men than women (Hooper et al., 2010). D. Osteoarthritis 1. D efinition and overview a. O steoarthritis (OA) (also called degenerative joint disease or osteoarthrosis): OA is the most common form of arthritis and occurs when car-tilage in the joints wears down over time. There is no cure but treatment can relieve pain and help patients maintain their activities of daily living. Spondylosis is degeneration of the discs and vertebrae causing compression of the spinal cord in the neck. OA is the most common cause, most often affecting middle-aged and older people. This is the most common cause of spinal cord dysfunction in the older than 55 population (Steinberg, Akins, & Baran, 1999). 2. P revalence and Incidence In a study by Hirpara, Butler, Dolan, O'Byrne, & Poynton (2012), it was noted that the prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males. Moreover, spondylotic changes in the cervical spine occurred at solitary disc space levels in about 15-40% of patients; however, in 60-85% of patients, this occurred at mul-tiple levels. Furthermore, the discs between the third and seventh cervical vertebrae are most commonly affected. Repeated occupational trauma may also contribute to the development of cervical spondylo-sis. For example, there was an increased incidence in patients who carried heavy loads on their heads or shoulders as well as in dancers, gymnasts, and patients with spasmodic torticollis (Hirpara et al., 2012). E. Strains and sprains 1. D efinition and overview Musculoskeletal strains and sprains (sports or work related) occur when there is an injury to the muscles 694 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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than the back sections. This occurs during a period of rapid bone growth, usually between the ages of 12 and 15 years of age in males or a few years earlier in females. iv. T raumatic kyphosis occurs most commonly in the thoracolumbar and lumbar regions. This type of kyphosis is most common in patients with severe neurologic deficits such as quadriplegia or paraplegia. 2. P revalence and incidence a. S pinal deformities A 2005 study mentioned by the Bone and Joint Initiative (BJI), USA, reported that mild to severe adult scoliosis has a prevalence as high as 68% in healthy individuals aged 60 and older (Correa & Watkins-Castillo, n. d. ). Many cases of degenerative scoliosis are undiagnosed, but elderly patients often seek care because of back and leg pain that may be caused by scoliosis and associated spinal stenosis. However, the preva-lence of adult spinal deformity and scoliosis is not well established, with estimates ranging from 2. 5% to 25% of the population. “ According to 2010 U. S. Census Population Estimate, there were 235,205,658 people in the U. S over the age of 18 years. Prevalence of adult scoliosis cited in the literature ranges from 2. 5% to 60%, depending on severity” (Correa  & Watkins-Castillo, n. d., para. 2). Moreover, a conservative estimate of 2. 5% of the prevalence of adult scoliosis reported yields an incidence of a minimum of 5. 88 million adults in the United States with adult scoliosis. In 2010-2011 alone, there were an estimated 1. 61 million of these adults who received treatment either as an inpatient or outpatient. Estimates for prevalence of kyphosis was approximated to 17% as the primary diagnosis  in hospital and emergency depart-ments (Correa & Watkins-Castillo, n. d. ). II. d atabase (may include but is not limited to) Because cervical, thoracic, and/or cervicothoracic pain are usually multifactorial, it is important to determine if the pain is caused by spinal or extra spinal (soft tissue) injury or a serious infectious or inflammatory disorder. A. Subjective 1. H istory of presenting illness: Description of the pain including onset; location; duration; radiation; the lungs to function properly. There are four types of scoliosis:i. C ongenital scoliosis, caused by a bone abnormality present at birth. ii. N euromuscular scoliosis is the result of abnormal muscles or nerves. Most fre-quently seen in people with spina bifida or cerebral palsy or in people with various con-ditions that are accompanied by, or result in, paralysis. iii. D egenerative scoliosis may result from traumatic injury or illness such as bone collapse, previous major back surgery, or osteoporosis. iv. I diopathic scoliosis is the most common type of scoliosis and has no specific iden-tifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2015). b. H yperkyphosis: The forward bend of the spine is called kyphosis and is considered to be “failure of formation or failure of segmentation” of the front aspect of one or more vertebral bodies or discs that occurs during the embryonic development. It is usually a convex curvature of the spine that causes “hunchback” and other degrees of spinal distress depending on the degree of curvature and location in the spine. There are three types of kyphosis: congenital, developmental, and traumatic. There are two types of congenital kyphosis. Type I deformity is the failure of formation and failure of segmentation of a portion of one or more vertebral bodies that usually worsens with growth. The deformity is usually visible at birth as a lump or bump on the infant's spine. Type II deformity is the failure of segmentation that occurs as two or more vertebrae fail to separate and to form normal discs and rectangular bones. This type of kyphosis is often more likely to be diagnosed later, after the child is walking. i. D evelopmental kyphosis is defined as hyperkyphosis and classified as either pos-tural or structural in origin. ii. P ostural kyphosis is corrected when the patient stands up straight. Patients with postural kyphosis have no abnormalities in the shape of the vertebrae. iii. S cheuermann's kyphosis is defined as rigid (structural) kyphosis because the front sections of the vertebrae grow slower 695 Database

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character, quality, and timing; and aggravating and alleviating factors. Determine modifying factors, such as rest, activity, changes in position, course of symptoms, and accompanying symptoms, such as numbness, tingling, weakness, paresthesias, and incontinence. If a traumatic injury, determine the exact mechanism of the injury. Additional important questions: Ask if pain with inspiration or expiration or both. Is the pain affected by coughing or sneezing or straining? Is there any par-ticular posture that intensifies or eases the pain? Is the skin in the thoracic area intact? If a traumatic injury, determine the exact mechanism of the injury. 2. P ast health history a. M edical illnesses: cardiovascular, diabetes mel-litus, carpal tunnel syndrome, cancer, osteo-porosis, rheumatoid arthritis, scoliosis, OA, fibromyalgia, herpes zoster, prior neck or low back disorders (work-related or not), motor vehi-cle accident, risk factors for aneurysm, infection, immuno-suppressive disorder, injection drug use, or trauma. b. S urgical history (prior surgery to cervical, shoulder, chest or lumbar spine, recent surgery) c. E xposure history (e. g., recent exposure to neuro-toxins if paresthesias present) d. M edication history: medications for the symp-toms or any other disorders e. A llergic reactions: to medications or food 3. F amily history: history of any musculoskeletal disorders (e. g., scoliosis, kyphosis, spondylosis, stenosis) 4. O ccupational and environmental history: a work history is important to establish work-relatedness. If working, type of work, specific tasks, frequency of task, length of time performing same task, and length of time doing the same jobs. Note ergonomics of work station, prior jobs, prior work-related injuries, and job satisfaction. 5. P ersonal and social history and health-related behaviors: housing situation (alone or accompanied), support system, smoking, drinking, substance use, and sexual lifestyle 6. R eview of systems a. C onstitutional signs and symptoms: fever, chills, weight loss, and poor appetite (infectious or malignancy) b. Ea r, nose, and throat: worsening of neck pain when swallowing (esophageal disorders), head-ache, visual changes, nuchal rigidity (infectious or malignancy) c. S kin: rash, pain, numbness or tingling, itching in area d. C ardiac and pulmonary: cough, dyspnea, wors-ening with inspiration, chest pressure, pain, arm pain, anxiety, or diaphoresis (myocardial infarc-tion, angina, or lung cancer) e. A bdomen: anorexia, nausea, vomiting, heart burn, gas/flatulence, and change in bowel function or stool function (gastrointestinal disorders) f. M usculoskeletal: active range of motion, activi-ties of daily living, pain with or without move-ment, swelling, redness, warmth, clicking, or locking. g. N eurologic: depressive symptoms, fatigue, head-aches (multifactorial mechanical pain), numb-ness, tingling, weakness, vertigo, or balance disturbances. B. Objective 1. P hysical examination findings (See T ables 69-1 through 69-3) Table 69-1 Physical Examination Findings Inspection Overall spinal and total body posture to determine if asymmetry contributes to problems. Check for hyperkyphosis (round back, humpback, flat back or dowager's hump) and scoliosis and the level of the deformity. Observe for breathing patterns. Observe for chest deformities such as pigeon chest, funnel chest, or barrel chest. Observe for scapular and clavicular symmetry and muscle atrophy. Loss of cervical lordosis is present with painful acute sprains, fractures, and infectious or neoplastic processes. Palpation Palpate the spinous process to define the alignment of the spine. Determine tenderness level, muscle tightness, spasms. Palpation pressure provoking paresthesias or numbness and tingling. Palpate anterior and posterior thoracic area including neck and shoulders. Palpate the spinous process to define the alignment of the spine. C7 is the most prominent spinous process. Top of thyroid cartilage is parallel to C4, and the cricoids cartilage is parallel to C6. Paraspinous muscles, trapezii, the medial border of the scapula, and sternocleidomastoid muscles palpation may provoke tenderness. 696 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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Table 69-1 Physical Examination Findings Range of motion (ROM) Stabilize the trunk so motion does not occur in the thoracic spine but in the neck only. Flexion and extension are estimated visually in degrees. Flexion limitation can also be measured as the distance the chin lacks in touching the sternum. Rotation and lateral bending of neck: the degree of motion is the angle between the vertical axis and midaxis of the face. Rotation is estimated in degrees. Limited range of motion of the neck is usually common and may present in all planes. Forward flexion (normal ROM 20-45 degrees) and extension (normal ROM 25-45 degrees). Flexion limitation can also be measured with a tape measure. Measure the spine while patient is in normal standing position from C7 to T12, then ask the patient to bend forward and measure again. A 2. 7-cm (1. 1-inch) difference in length is considered normal. Lateral flexion is about 20-40 degrees to each side. A tape measure can be used to measure the distance from the floor. The distance should be equal bilaterally. Rotation is about 35-50 degrees. Ask the patient either to cross the arms in front or place the hands on opposite shoulders and then rotate to both sides. To avoid lumbar and hip rotation, the patient can be asked to perform this part of the exam while sitting. Costovertebral expansion is measured by chest expansion using a measuring tape at the level of the fourth intercostal space. The patient is asked to exhale as much as possible to take the measurement. Then the patient is asked to inhale as much as possible and hold the breath while measuring again. The normal difference between the two is 3-7. 5 cm (~1-2. 75 inches). Neurologic and motor Assess: C5 Level Deltoid—C5 axillary nerve. (Abduct the shoulder to 90 degrees. Push down on the arm to resist activity of the deltoid. True weakness of this muscle should be a uniform giving way motion. ) Biceps—C5-C6 musculocutaneous nerve (ask patient to flex the elbow in the supinated position against resistance). Biceps reflex. Sensation—lateral arm: axillary nerve. C6 Level Wrist extensor group—C6 radial nerve. Biceps—C6 musculocutaneous nerve brachioradialis reflex. Sensation—lateral forearm: musculocutaneous nerve. C7 Level Triceps—C7 radial nerve (patient supine and the shoulder flexed about 90 degrees, ask the patient to extend the elbow against resistance). Wrist flexor group—C7 median and ulnar nerves. Finger extensor—C7 radial nerve. Triceps reflex. Sensation—middle finger. C8 Level No reflex. Examination is limited to muscle strength and sensation tests. Finger flexors (stabilize the long, index, and little fingers in extension and ask the patient to flex the fingers as you apply resistance). Sensation—ring and little fingers of the hands and distal half of the forearm ulnar side. Neurologic examination is usually normal in cervical strain. Resisted isometric movements are a gross test and subtle alterations in strength are hard to determine. If the muscles tested have been injured, contracting them will provoke pain. This exam is done while the patient is in sitting position. The examiner must be standing with one leg behind the patient's buttocks and with the arms around the patient's chest and back (hugging). Tell the patient “don't let me move you” and proceed with forward flexion, extension, side flexion (right/left), and rotation (right/left). Nerve root tested, Flexion: T6-T12Nerve root tested, Extension: T1-T12Nerve root tested, Rotation and Side bending: T1-T12 and L1Nerve root tested, Elevation of the ribs: C3-C8, T1-T12, and intercostals 2-5. Nerve root tested, Depression of the ribs: T6-T12, L1-L3. Data from Magee, D. (2008). Orthopedic physical assessment (5th ed. ). Musculoskeletal Rehabilitation Series. St. Louis, MO: Saunders Elsevier. (Continued)697 Database

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Table 69-2 Special T ests Spurling test Have patient extend the neck while tilting the head to the side. This narrows the neural foramen and increases or reproduces radicular arm pain that is associated with disc herniation or cervical spondylosis (Green, 2001). Axial Loading Test (compression test)Push down on the patient's head. This provokes neck pain in some patients with disc problems; however, increased low back pain indicates nonorganic finding (Green, 2001). Hoffmann Test With the patient relaxed in supine position and the hand cradled in the clinician's hand, flick the third fingernail and look for index finger and thumb flexion. If present, it is a sign of long-tract spinal cord involvement in the neck (Green, 2001). Distraction Test Place one hand with palm open under the patient's chin, the other hand on the occiput, gradually lift the head to remove its weight from the neck. If the patient experiences a relief in symptom, it demonstrates the effect of neck traction, by widening the neural foramen (Hoppenfeld, 1976). Adson Test Take the patient's radial pulse, abduct, extend, and externally rotate the patient's arm. Ask the patient to take a deep breath and to turn his or her head toward the arm being tested. If there is compression of the subclavian artery, you will feel a marked diminution or absence of the radial pulse (Hoppenfeld, 1976). Passive Scapular Approximation Test Have the patient lie prone while lifting the shoulder up and back to approximate the scapulae. If pain in this area, it indicates possible T1 or T2 nerve root problem on the side of where the pain originates. First Thoracic Nerve Root Stretch Test Have the patient abduct and pronate the arm to 90 degrees. There should be no complaints of symptoms during this motion. Have the patient fully flex the elbow and put the hand behind the neck. This movement stretches the ulnar nerve and T1 nerve root. If pain is triggered into the scapula or arm, this is a positive test for T1 nerve root. If the patient has upper extremity symptoms at the same time as the thoracic symptoms, upper extremity tension tests should be also considered to rule out referred symptoms from the thoracic area. Sitting Arm Lift (SAL) Test Have the patient sit on the exam table with the hands resting on the thighs. Ask the patient to lift one arm (unaffected side) for shoulder flexion with the arm straight and the thumb up. Repeat the same with the opposite arm. Ask the patient if one arm feels heavier to lift than the other. If the answer is yes, the first part of the test is positive. Ask the patient to repeat this movement several times while palpating the spinous process along the ribs noting if there is any shifting in movements of the ribs especially at 90 degrees. If any shifting of movement is noted, it is a positive test for the second part of this test. This test can also be used to check stabilization of the scapula. Prone Arm Lift (PAL) Test Have the patient lie prone with the arms overhead at about 140 degrees of flexion and fully supported on the exam table. Ask the patient to lift one arm 2 cm and then lower it. Repeat on the other side. If one arm is heavier than the other, it is considered a positive for that side of the arm. Rationale: used to assess the ability of the arm to take a load in a higher angle of the shoulder flexion. Useful testing patients who do overhead work activities or who complain of problems when lifting heavy loads. Slump Test (Sitting Dural Stretch Test)Patient should be sitting on the exam table. Patient is asked to slump (the spine flexes forward and the shoulders sag forward) while the examiner holds the chin and head of the patient erect. If no symptoms are produced, flex the neck of the patient and hold the head down; if no symptoms are produced, passively extend one of the patient's knees; if no symptoms are produced, passively dorsiflex the foot of the same leg. Reproduction of sciatic pain or symptoms is a positive slump test. This is repeated on the other side of the leg. Rationale: this maneuver increases the stress on the intercostal nerves. The pain is usually produced at the site of the injured area. Data from Magee, D. (2008). Orthopedic physical assessment (5th ed. ). Musculoskeletal Rehabilitation Series. St. Louis, MO: Saunders Elsevier. 698 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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neurologic symptoms or fracture). (See Table 69-4 for Red Flag Conditions. ) C. Determine if the condition is work related. D. Assess the patient's ability to perform his or her usual activities. E. Assess the patient's pain control and coping abilities. III. a ssessment A. Determine the cause of the neck pain, if acute or chronic. B. Determine if the patient needs immediate referral for consultation (e. g., progressive Table 69-3 Referred Pain Patterns Referred pain pattern m uscle Involved Spine to the line along the medial border aspect of the scapula Iliocostalis muscle Adjacent to the spine Multifidus muscle Scapular area to posterior anterior arm down to the fifth finger Serratus superior muscle Medial border of the arm to medial fourth and fifth fingers Serratus posterior muscle Lateral chest wall to lower medial border of the scapula Serratus anterior muscle Medial border of the scapula Romboids muscle Upper thoracic spine to medial border of the scapula Trapezius muscle Inferior angle of the scapula to posterior shoulder and iliac crest Latissimus dorsi muscle Neck/shoulder angle to posterior shoulder and along medial edge of the scapula Levator scapula muscle Data from Magee, D. (2008). Orthopedic physical assessment (5th ed. ). Musculoskeletal Rehabilitation Series. St. Louis, MO: Saunders Elsevier. Table 69-4 Red Flag Conditions presentation e tiologies c omments Possible cauda equina syndrome Possible tumor, fracture, or infection Saddle anesthesia Major trauma, such as MVA or fall from height Age > 50 or < 20 Recent onset of bladder dysfunction, such as urinary retention, increased frequency, or overflow incontinence Tumor or minor trauma (even strenuous lifting in older or potentially osteoporotic patient) Severe or progressive neurologic deficit in the lower extremity Pain that worsens when supine; severe nighttime pain Spinal infection: recent bacterial infection (e. g., urinary tract infection); intravenous drug abuse; or immune suppression (from steroids, transplant, or HIV), tumor/cancer Assess for constitutional symptoms, such as recent fever or chills or unexplained weight loss Unexpected laxity of the anal sphincter or perianal or perineal sensory loss Major motor weakness: quadriceps (knee extension weakness), ankle plantar flexors, evertors, and dorsiflexors (foot drop)Nerve root impingement Data from U. S. Agency for Health Care Policy and Research. (1994). Acute low back problems in adults: Assessment and treatment. Quick reference guide for clinicians: Clinical practice guideline #14. Rockville, MD: Author. 699 Assessment

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and symptoms, and not responding to standard treatment within expected time period. 4. Ele ctromyelogram or nerve conduction study to rule out other structures causing the neurologic symptoms when the diagnosis is unclear. C. Treatment (see Table 69-6) D. Patient education 1. Di scuss nature of condition and expected time of recovery. 2. Di scuss proper posture and body mechanics. 3. E xplain proper use of supportive devices such as neck pillows. 4. Di scuss need for a lifelong stretching and conditioning exercise program, including use of foam roller, for maintenance and prevention of further disability. 5. Di scuss stress reduction techniques. 6. Di scuss medication use and compliance and other symptom relief modalities. 7. I f determined to be work elated, discuss process of reporting the injury to the employer and assuming care with the employer's occupational health system. E. Follow-up (acute and chronic) Follow-up time frame is based on the plan of care and acu-ity and severity of the patient's presentation. If imaging has been ordered, follow-up should be prompt to communi-cate the results to the patient. If patient is taken off work, appropriate follow-up is necessary to determine whether the patient is ready to return to work and at what capacity. IV. Goals of clinical management A. Evidence-based management of the patient's cervical and/or thoracic pain presentation B. Cost effective plan of treatment C. Appropriate management of the patient's condition if work related D. Selection of management approach that maximizes the patient's adherence to the plan of care V. p lan A. Diagnostic criteria non-red flag conditions (see Table 69-5) B. Other diagnostic tests that may be included 1. B lood tests: erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibody if suspecting systemic, infectious, and inflammatory conditions; cardiac enzymes, if indicated. 2. T uberculosis screening (tuberculin skin test or Quanti FERON®) test, if indicated. 3. I maging: cervical/thoracic spine radiograph series, shoulder radiograph series, chest radiograph if indicated based on clinical pulmonary presentation, computerized axial tomography, or magnetic resonance imaging if patient presents with soft tissue, disc signs Table 69-5 Diagnostic Criteria Non-Red Flag Conditions probable diagnosis m echanism c ommon Symptoms c ommon Signs Tests and Results Regional neck pain Unknown Diffuse pain None None indicated Cervical strain Flexion-extension or rotation force, blow to the head or neck Neck pain, difficult or decreased motion Limited range of motion because of pain None indicated Cervical nerve root compression with radiculopathy Degenerative condition, trauma Dermatomal sensory changes, motor weakness Specific motor, sensory, and reflex changes None indicated for 4-6 weeks, unless progressive motor weakness Spinal stenosis Older patients: degenerative disc disease Younger patients: congenital stenosis Neck, shoulder, and posterior arm pain, paresthesias in the same distribution as the pain Weakness of the shoulder girdle and upper arms Signs worse with extension, improved with flexion of the neck Computed tomography or magnetic resonance imaging shows spinal stenosis Data from Glass, L. S., & Harris, J. S. (2004). Occupational medicine practice guidelines: Evaluation and management of common health problems and functional recovery in workers (2nd ed. ). Beverly Farms, MA: OEM Press. 700 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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Table 69-6 Clinical Characteristics and Management of Cervicothoracic Spine Pain condition c linical c haracteristics m anagement Cervical strain and sprain Most patients can report specific mechanism of injury. May not notice pain immediately but after several hours may have tightness in the neck. Some may report nausea. Physical examination may only show mild abnormalities. May have tenderness, edema, spasms, headaches, and dizziness. With moderate injuries may present with radicular symptoms. Diagnostic work-up: cervical radiograph to rule out fracture or dislocation if suspected. Treatment: rest in comfortable position, soft cervical collar is appropriate for 1 or 2 days if in the acute phase. Cold packs applied for 15 minutes four to six times a day, then heat. May also alternate cold and heat if combination promotes better relief. Gentle stretches of the neck and shoulders (early movements of the stable spine promote recovery). Analgesics according to symptoms especially for nighttime pain. Muscle relaxants are appropriate in the acute phase to relieve spasms and aid with nighttime sleep. Physical therapy that includes cervical traction, massage, and ultrasound can be helpful especially in the first 4 weeks. Encourage early return to normal activities, including work if appropriate. Acute disc herniation Pain is usually aggravated by cough, sneeze, straining, and other activities that prolong static position of the neck, especially in flexion-extension and rotation. Lifting, pushing, and pulling may also aggravate the pain. Usually, there is tenderness to palpation of the spinous process. Distraction test relieves the pain; compression test increases the pain. Usually there are associated muscle spasms and trigger point tenderness. Diagnostic work-up: radiograph may be normal or show degenerative disc disease. May need magnetic resonance imaging (MRI), CT, or electromyogram/nerve conduction studies (EMG/NCS) if indicated based on presenting symptoms. Treatment: conservative treatment in the acute phase, absent major progressing symptoms. Rest by limiting activities, soft pillows, elevation of the head of the bed, and soft collar. Physical therapy can be helpful and may possibly include traction as well as exercises for functional range of motion and strength. Heat or cold compress to the neck for 15 minutes as tolerated can also be recommended. Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants used in the acute phase. Patients should be reassured that most disc herniations resolve without residual problems. If symptoms do not resolve within 3-6 weeks, epidural injection may be appropriate depending on presentation of symptoms and degree of limitation on activities of daily living. Chronic disc degeneration (spondylosis or osteoarthritis)Most common presentations are stiffness and chronic pain that worsens with upright activity. Some patients may report grinding or popping in the neck region. Referred pain to shoulder and arm, paraspinous process spasms, headaches, fatigue, and sleep disturbances. Difficulty with basic activities of daily living. Diagnostic tests: anteroposterior and lateral radiograph shows sclerosis in the intervertebral disc area with osteophytes (bone spurs) projecting anteriorly. Osteophytes may also project posteriorly causing stenosis of the cervical canal. Anterior subluxation of one vertebra over the other may also be appreciated. Degenerative findings usually at the C5-C6 and C6-C7 levels. Treatment: usually responsive to traction. NSAIDs and muscle relaxants are helpful especially at nighttime. Cervical pillow, cervical roll, and physical therapy. Epidural injection may also be appropriate. In chronic cases without resolution of major symptoms and with radicular involvement, decompression and fusion surgery may be appropriate. 701 Plan (continues)

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Table 69-6 Clinical Characteristics and Management of Cervicothoracic Spine Pain condition c linical c haracteristics m anagement Cervical radiculopathy Patients present with neck pain along with radicular pain associated with numbness and paresthesias in the upper extremity along the distribution of the nerve root involved. Muscle spasms or fasciculations may also be present in the myotomes involved. Other symptoms may be weakness, lack of coordination, difficulty with handwriting and performing fine manipulative tasks, dropping objects, and decreased strength. If stenosis of the cervical canal, patient may present with lower extremity symptoms and bowel or bladder dysfunction. Diagnostic tests: plain radiographs may identify spondylosis or degeneration of the disc and the facet. Magnetic resonance imaging or computed tomography with intrathecal contrast confirms the diagnosis. However, this is not routine care unless progressive symptoms. Electromyelogram or nerve conduction study helps determine the location of the neurologic dysfunction and is commonly used presurgically. Treatment: in most cases, it resolves spontaneously within 6-12 weeks. Nonnarcotic analgesic is usually helpful. May also use short course of oral steroids if appropriate. Physical therapy, which may include traction, is useful in the first 2-4 weeks. Cervical fracture Patient may present with severe neck pain, paraspinous muscle spasms, and point tenderness to the area of fracture. Pain radiates to the shoulder or arm and may be associated with radicular symptoms if nerve root involvement is present. Diagnostic tests: Anteroposterior, lateral, and odontoid views are the standard. Lateral radiograph should include the occiput superiorly and the top of T1 inferiorly. Swimmer's view may also be indicated to visualize the cervicothoracic junction. If no fracture is seen, it should be evaluated for instability. Treatment: immobilization of cervical spine during transportation to emergency department. Patients whose initial radiograph was negative for fracture, but continues to have pain, may use cervical collar. Repeat radiograph if symptoms persist past 7-10 days. NSAIDs and analgesics are also appropriate. Cervicothoracic myofascial syndrome Deep aching pain in a muscle, pain that persists or worsens Cervical spine range of motion is often limited and painful May be described as lumpiness or painful bump in the trapezius or cervical paraspinal muscles Massage is often helpful, as is superficial heat Patient's sleep may be interrupted because of pain The cervical rotation required for driving is difficult to achieve Patient may describe pain radiating into the upper extremities, accompanied by numbness and tingling, making discrimination from radiculopathy or peripheral nerve impingement difficult Dizziness or nausea may be a part of the symptomatology The patient experiences typical patterns of radiating pain referred from trigger points Diagnostic work-up: Diagnosis is typically made after diagnosis of cervical disc prolapse has been ruled out. + Spurling's test will indicate cervical disc prolapse. Cervical radiograph and MRI can be done to assist with ruling out cervical presentation. Treatment:Manual therapy such as myofascial trigger point massage or active release therapy (Edmondston & Singer, 1997). Trigger point injections. Acupuncture. Edgelow Program has been used for neurovascular entrapment of the upper extremity but also for physical rehabilitation for posture usually recommended by physical medicine specialties NSAIDs, muscle relaxants, foam roller, and heat therapy702 CHAPTER 69 | Upper Back and Neck Pain Syndromes (Continued)

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Table 69-6 Clinical Characteristics and Management of Cervicothoracic Spine Pain condition c linical c haracteristics m anagement Scalene muscle pain Pain in cervical region radiating to occiput, nuchal muscles, shoulders, and upper extremities Stiffness Tenderness to the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus. Unilateral neck/shoulder pain. Diagnostic work-up:Same as previously. Treatment:Same as previously. Thoracic outlet syndrome (TOS)Symptoms are often vague and variable. Paresthesias from the neck to the shoulder, arm, medial forearm, and fingers. If vascular, intermittent swelling and discoloration of the arm. Aching, fatigue, and weakness. Symptoms can worsen if arm is in overhead position. Tenderness. Diagnostic work-up: Venous ultrasound studies, Doppler ultrasound and angiography in the seated position for arterial TOS, EMG/NCS Treatment:Physical therapy, Edglow Program, NSAIDs, lifestyle changes, ergonomic changes. Surgical recommendation:Depending on nature of disease. Scoliosis Pain localized to area of deformity. Radicular pain, if associated with compression. Diagnostic work-up: Weight-bearing full-length PA and lateral x-rays. EMG/NCS is rare but can be done if suspecting neuropathy. NSAIDs, exercise programs, swimming, bracing in children only. Physical therapy can be helpful as well if the condition is painful. Hyperkyphosis Pain related to activity if poor posture Diagnostic work-up: Weight-bearing anterior-posterior and lateral x-rays. Treatment:Observation or exercise program and physical therapy. Bracing only in noncongenital situations. Surgery depending on severity of deformity. Data from Green, W. B. (2001). Essentials of musculoskeletal care (2nd ed. ). Rosemont, IL: American Academy of Orthopaedic Surgeons; Griffin, L. Y. (2005). Essentials of musculoskeletal care (3rd ed. ). Rosemont, IL: American Academy of Orthopaedic Surgeons and American Academy of Pediatrics; Steinberg, G., Akins, C., & Baran, D. (1999). Orthopaedics in primary care (3rd ed. ). Hagerstown, MD: Lippincott Williams & Williams. VI. Self-management r esources and tools A. Patient and client education Internet-based materials 1. Or tho Info, www. orthoinfo. org, for spine conditioning program exercises. 2. D ynamic Chiropractic, www. dynamicchiropractic . com, for corrective exercises for thoracic kyphosis. 3. N ational Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), www. niams. nih. gov/, for back pain management and exercises. 4. N eck Injuries and Disorders (U. S. National Library of Medicine, 2015): www. nlm. nih. gov/medlineplus /neckinjuriesanddisorders. html 5. C ongenital kyphosis (Scoliosis Research Society, 2015): www. srs. org/patients-and-families/conditions -and-treatments/parents/kyphosis/congenital -kyphosis 6. N eck and back: http://orthoinfo. aaos. org/menus /spine. cfm Community support groups 7. W eb MD® Health Community: http://exchanges . webmd. com 8. B ack Pain Support Group: http://back-pain . supportgroups. com/703 Self-management resources and tools (Continued)

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9. H ealia Health Communities and Support Groups: http://us. wow. com/wiki/Healia 10. e H ealth Forum: http://ehealthforum. com Re Fe Rence S Agency for Health Care Policy and Research. (1994). Acute low back problems in adults: Assessment and treatment. Quick reference guide for clinicians: Clinical practice guideline #14. Rockville, MD: Author. Bogduk, N. (2003). The anatomy and pathophysiology of neck pain. Physical Medicine and Rehabilitation Clinics of North America, 14(3), 455-472. Briggs, A. M., Bragge, P., Smith, A. J., Govil, D., & Straker, L. M. (2009). Prevalence and associated factors for thoracic spine pain in the adult working population: A literature review. Journal of Occupational Health, 51(3), 177-192. Briggs, A. M., Smith, A. J., Straker, L. M., & Bragge, P. (2009). Thoracic spine pain in the general population: Prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskeletal Disorders, 10(77). doi: 10. 1186/1471-2474-10-77 Cohen, S. P. (2015). Epidemiology, diagnosis, and treatment of neck pain. Mayo Clinic Proceedings, 90(2), 284-299. Correa, A., & Watkins-Castillo, S. I. (n. d. ). Prevalence of adult scoliosis: Spinal curvature. Bone and Joint Initiative USA. Retrieved from http://www . boneandjointburden. org/2014-report/iiid21/prevalence-adult-scoliosis. Edmondston, S. J., & Singer, K. P. (1997). Thoracic spine: Anatomical and bio-mechanical considerations for manual therapy. Manual Therapy, 2(3), 132-143. Fomby, E. W., & Mellion, M. B. (1997). Identifying and treating myofascial pain syndrome. Physician and Sports Medicine, 25(2), 67-75. Furman, M., & Simon, J. (2009). Cervical disc disease. Retrieved from http:// emedicine. medscape. com/article/305720-print. Gerwin, R. D. (2001). Classification, epidemiology, and natural history of myofascial pain syndrome. Current Pain Headache Reports, 5(5), 412-420. Glass, L. S., & Harris, J. S. (2004). Occupational medicine practice guidelines: Evaluation and management of common health problems and functional recovery in workers (2nd ed. ). Beverly Farms, MA: OEM Press. Gordon, S. J., T rott, P., & Grimmer, K. A. (2002). Waking cervical pain and stiffness, headache, scapular or arm pain: Gender and age effects. Australian Journal of Physiotherapy, 48(1), 9-15. Green, W. B. (2001). Essentials of musculoskeletal care (2nd ed. ). Rosemont, IL: American Academy of Orthopaedic Surgeons. Griffin, L. Y. (2005). Essentials of musculoskeletal care (3rd ed. ). Rosemont, IL: American Academy of Orthopaedic Surgeons and American Academy of Pediatrics. Hirpara, K. M., Butler, J. S., Dolan, R. T., O'Byrne, J. M., & Poynton, A. R. (2012). Nonoperative modalities to treat symptomatic cervical spondylosis. Advances in Orthopedics. Retrieved from www. hindawi . com/journals/aorth/2012/294857/. Hooper, T. L., Denton, J., Mc Galliard, M. K., Brismee, J-M., & Sizer, P. S. Jr. (2010). Thoracic outlet syndrome: A controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. Journal of Manual & Manipulative Therapy. 18(2), 74-83. Hoppenfeld, S. (1976). Physical examination of the spine and extremities. East Norwalk, CT: Appleton-Century-Crofts. Jalil, N. A., Sulaiman, Z., Awang, M. S., & Omar, M. (2009). Retrospective review of outcomes of a multimodal chronic pain service in a major teaching hospital: A preliminary experience in Universiti Sains Malaysia. Malaysian Journal of Medical Sciences, 16, 55-65. Magee, D. J. (2002). Orthopedic physical assessment (4th ed. ). Philadelphia, PA: W. B. Saunders. Magee, D. J. (2008). Orthopedic physical assessment (5th ed). Musculoskeletal Rehabilitation Series. St. Louis, Missouri, Saunders Elsevier. Manchikanti, L., Singh, V., Datta, S., Cohen, S., & Hirsch, J. (2009). Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician, 12(4), E35-E70. Manchikanti, L., Singh, V., Rivera, J., & Pampati, V. (2002). Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician, 5(3), 243-249. Mantyselka, P., Kautiainen, H., & Vanhala, M. (2010). Prevalence of neck pain in subjects with metabolic syndrome—A cross-sectional population-based study. BMC Musculoskeletal Disorders, 11(171). doi: 10. 1186/1471-2474-11-171 Mc Reynolds, T. M., & Sheridan, B. J. (2005). Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: A randomized clinical trial. Journal of the American Osteopathic Association, 105(2), 57-68. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2015). What causes scoliosis. Retrieved at http://www. niams. nih. gov /Health_Info/Scoliosis/default. asp#causes Ostergren, P. O., Hanson, B. S., Balogh, I., Ektor-Andersen, J., Isacsson, A., Orbaek, P., et al. (2005). Incidence of shoulder and neck pain in a working population: Effect modification between mechanical and psychosocial exposures at work? Results from a one year follow up of the Malmö shoulder and neck study cohort. Journal of Epidemiology and Community Health, 59(9), 721-728. Steinberg, G., Akins, C., & Baran, D. (1999). Orthopaedics in primary care (3rd ed. ). Hagerstown, MD: Lippincott Williams & Williams. Scoliosis Research Society. (2015). Congenital kyphosis. Retrieved from www. srs. org/patients-and-families/conditions-and-treatments /parents/kyphosis/congenital-kyphosis. U. S. National Library of Medicine. (2015). Neck injuries and disorders. Retrieved from www. nlm. nih. gov/medlineplus/neckinjuriesanddisorders . html. 704 CHAPTER 69 | Upper Back and Neck Pain Syndromes

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In response to this trauma, localized pain, warmth, swelling, and crepitus may occur in the affected region with associated functional impairment. Most commonly, mechanisms of injury include extrinsic factors, many of which are the biomechanical compressive forces, including heavy loads/handling tools, repetition, over-use, awkward postures, contact stress, or cold temperature (van Rijn, Huisstede, Koes, & Burdorf, 2009). Intrinsic factors, such as anatomy (e. g., narrowed acromium space) and excessive physical training with inadequate rest periods, also contribute to injury. T reatment with fluoroquinolones (e. g., ciprofloxacin) is associated with tendinopathy and tendon rupture, thought to be caused by inhibition of tenocyte metabolism. T enocytes are undifferentiated fibroblasts critical to the tendon healing process (Davenport et al., 2005; Sharma & Maffulli, 2005). Psychosocial work factors, such as high psychological job demands, may contribute to soft tissue complaints by increas-ing the speed of work or assuming a tense posture, thereby increasing extrinsic biomechanical risks (Bongers, Ijmker, van den Heuvel, & Blatter, 2006). Low job control and low social support at work are also associated with soft tissue com-plaints, for example, lateral epicondylitis (van Rijn et al., 2009). A. Diagnosis: biceps tendinopathy 1. D efinition and overview Biceps tendinopathy is defined by anterior shoulder pain, worse with overhead reaching. T enderness is located in the bicipital groove of the proximal humerus between the greater and lesser tuberosities, where the tendon of the long head of the biceps brachii inserts at the glenoid labrum. This tendon helps to stabilize the humeral head, especially during abduction and external rotation. Risk factors for bicipital tendinopathies includea. R epetitive overhead motion, especially throwing sports b. N ormal aging with degenerative changes to soft tissue and bony structures I. Intr oduction and general background Acute and chronic injury to upper extremity tendon struc-tures is a common health condition, often called tendonitis, which implies an inflammatory process. However, most tendon disorders are thought to be degenerative and nonin-flammatory involving mechanical stress to tendon structures, and are often referred to as tendinopathies (Fedorczyk, 2012; Mc Auliffe, 2010;Sharma & Maffulli, 2005). Inflammation may be present in tendinopathies, but it is unclear whether inflammation is the primary cause or a response to stenosis or mechanical stress (Mc Auliffe, 2010). Common sites of tendinopathy in the upper extremity include the shoul-der (e. g., bicipital tendinopathy), the elbow (e. g., lateral epicondylitis/epicondylalgia/epicondylosis or elbow tendi-nopathy), and the wrist (e. g., de Quervain's tenosynovitis/tendinopathy). T endons connect muscles to bones and “provide the inter-face to transmit muscle force to bone to create joint move-ment” (Fedorczyk, 2012, p. 191). There are two tendon sites at risk for acute or cumulative injury: the myotendinous junction, where the muscle and tendon join, identified as the weakest point of the muscle tendon unit (Davenport, Kulig, Matharu, & Blanco, 2005; Sharma & Maffulli, 2005); and the osteotendinous junction, the site where the tendon inserts into the bone. The injury may be caused by an acute trauma or repetitive force, a chemically induced injury (e. g. fluoroquino-lone antibiotics), or an infectious process (Fedorczyk, 2012). Repetitive strain at these sites, because of altered tendon load-ing from extrinsic forces or intrinsic factors, may cause inflam-mation to tendon sheaths and changes to the tendon cells (e. g., collagen disorganization and altered cell healing with adhesion formation) leading to tendon degeneration (Davenport et al., 2005; Sharma & Maffulli, 2005). Regardless of inciting trauma, there is a state of “protracted fibroplasia” and “failed healing” (Fedorczyk, 2012, p. 194) leading to persistent symptoms. Barbara J. Burgel Upper extrem Ity t end I nopathy: B I c I p I tal t end I nopathy, l ateral e p I condyl I t I s, and de Q U erva I n's t enosynov I t I s© Eliks/Shutterstock; © donatas1205/Shutterstock 70570Chapt Er

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c. Othe r pathology of the rotator cuff or the labrum may contribute by placing extra force on the biceps insertion site d. S pecific occupations, for example fish process-ing workers, have a higher prevalence of bicipital tendinopathy when compared to other occupa-tions such as caretakers and community garden and parks workers (van Rijn, Huisstede, Koes, & Burdorf, 2010). 2. P revalence and incidence Due to variable case definitions, the prevalence of bicipital tendinopathy is unknown. In the general population, the 12-month prevalence of “shoulder complaints” ranges from a low of 4. 7% to a high of 46. 7% (van Rijn et al., 2010). In a large population-based study in the United Kingdom, the prevalence of physician-diagnosed “shoulder tendinitis” was found to be 4. 5% for men and 6. 1% in women, with bicipital tendinitis prevalence for both men and women docu-mented to be 0. 7% (Walker-Bone, Palmer, Reading, Coggon, & Cooper, 2004). B. Diagnosis: lateral epicondylitis/elbow tendinopathy 1. D efinition and overview Lateral epicondylitis is defined as pain in the lateral epicondyle region of the elbow, which is provoked by extension of the wrist extensors against resistance (Walker-Bone et al., 2004). The most common risk factors for lateral epicondylitis are:a. R epetitive and forceful movements of hands and wrists at work (Shiri, Viikari-Juntura, Varonen, & Heliovaara, 2006; van Rijn et al., 2009), including awkward postures (e. g., hands bent or twisted), handling tools weighing over 1 kg, handling vibrating tools, handling tools used to turn and screw, and frequently handling heavy loads over 20 kg more than 20 times per year at work (van Rijn et al., 2009). b. H igh-impact sports, with force and repetition of the wrist in extension (“tennis elbow”) c. F ormer or current smoking (Shiri et al., 2006) d. I ncreasing age (Shiri et al., 2006) 2. P revalence and incidence Physician-diagnosed lateral epicondylitis prevalence was 1. 3% in a community-based sample of adults between the ages of 30 and 64 in Finland (Shiri et al., 2006). Likewise, in a large population-based study of adults in the United Kingdom, 1. 3% of men and 1. 1% of women were diagnosed by physical exami-nation with lateral epicondylitis (Walker-Bone et al., 2004). Prevalence of lateral epicondylitis in work-ers is reported at up to 12. 2% (van Rijn et al., 2009). There is, however, variable prevalence based on case definition. For example, 12% of workers from a wide range of industries had lateral epicondylalgia if the case definition included pain only; however, when the definition included pain, tenderness, and a positive resistive maneuver, the prevalence dropped to 3. 5% (Hegmann et al., 2014). C. Diagnosis: de Quervain's tenosynovitis/ tendinopathy 1. D efinition and overview De Quervain's tenosynovitis/tendinopathy is caused by entrapment of the extensor pollicis brevis and abductor pollicis longus tendons and is characterized by pain over the radial styloid and tender swelling over the first extensor compartment, which is con-firmed by pain in this location with resisted thumb extension or a positive Finkelstein's test (Fedorczyk, 2012; Mc Auliffe, 2010; Walker-Bone et al., 2004). Difficulty in undoing lids on jars and bottles was reported by 28. 3% of those diagnosed with de Quervain's tendinopathy (Walker-Bone et al., 2004). Risk factors include:a. R epetitive, forceful, wrist or thumb motion (American College of Occupational and Environmental Medicine [ACOEM], 2011a) b. Dir ect pressure or blunt trauma, although these are less common (ACOEM, 2011a) c. P regnancy and lactation (Ashraf & Devadoss, 2014) d. P ersons with rheumatoid arthritis have a higher prevalence of de Quervain's tendinopathy (Ashraf & Devadoss, 2014; Mc Auliffe, 2010) 2. P revalence and incidence In a large population-based study in the United Kingdom, the prevalence of de Quervain's tenosy-novitis/tendinopathy was 0. 5% for men and 1. 3% in women (Walker-Bone et al., 2004). II. d atabase (may include but is not limited to) A. Subjective 1. F or all soft tissue complaints a. P ast health history: any prior soft tissue com-plaints, any past or current workers' compensa-tion claims b. M edical illnesses: inflammatory or degenerative arthritis, diabetes, or thyroid disorders; history of a gastrointestinal bleed and/or liver or kidney disease may assist in drug therapy choices706 CHAPTER 70 | Upper Extremity Tendinopathy

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c. S urgical history: any prior surgery to affected area d. Obs tetric and gynecological history: current pregnancy and lactation e. T rauma history: acute or cumulative f. M edication history: nonsteroidal anti-inflammatory medication (oral or topical), history of cortisone injections, any allergies or sensitivity to aspirin or nonsteroidal medications g. F amily history: arthritis, thyroid disease, or diabetes h. O ccupational or environmental history (previ-ous and current): work-related exposuresi. A ny work activity that involves repetitive or awkward postures; lifting, pushing, or pull-ing; contact stress; vibration; and/or cold temperature (past and current) ii. C omputer and telephone work: ergonomic adjustment of workstation, percentage of time on computer and number of key-strokes, mouse clicks, 10-key entry; any wrist rest breaks iii. P sychosocial work factors: high psycho-logical demand, low decision latitude, low coworker and low supervisor social sup-port; rewards (esteem, respect, salary, or future job opportunities), job satisfaction; job security iv. W ork scheduling: number of hours worked per day and per week, overtime v. P rotective equipment used: splints or smart gloves, forearm or wrist rests vi. C oworkers with similar symptoms vii. S ymptoms relieved on days away from work or made worse by certain work activities i. H obbies and sports i. A ny hobby and/or sport involving repeti-tive or awkward postures; lifting, pushing, or pulling; contact stress; vibration; and/or cold temperature (past and current) ii. H igh-risk sports (e. g., tennis and racquet-ball), musical instruments, needlework (e. g., crocheting, knitting, needlepoint, or embroidery), home computer use, motor-cycling and dirt biking j. P ersonal and social history i. F unctional impact of symptoms: assess-ment of activities of daily living to include dressing, bathing, shopping, housework, cooking, caregiving, and use of assistive devicesii. S ubstances: smoking and alcohol use; intravenous drug use (if presenting with a red, hot joint) iii. S leep quality and quantity iv. F requency and type of exercise (stretch-ing and flexibility, strength, endurance conditioning, overtraining, and postural awareness) v. A ny exposure to intimate partner violence k. R eview of systems i. C onstitutional signs and symptoms: fatigue, fever, weight loss or gain, and night sweats ii. S kin, hair, and nails: erythema or warmth in affected area iii. M usculoskeletal: hand dominance; pain level on a 0-10 numerical or visual analogue scale; quality of pain (e. g., burning, aching, or electric shock pain); pain at rest or with activ-ity, stiffness, limitations in motion (abrupt or chronic); presence of swelling; crepitus; locking of digits; giving way of joints; night-time wakening with symptoms; and pres-ence of pain in distal or proximal joints iv. N eurologic: paresthesias or motor weakness B. Objective 1. P hysical examination findings a. H eight and weight, overall conditioning b. Ge neral appearance, noting pain and posture c. S kin: erythema, warmth, bogginess, swelling, crepitus, and tenderness d. M usculoskeletal: bony deformity, muscle atrophy, localized tenderness and pain on palpation, ana-tomic distribution of pain and paresthesias, range of motion, and special maneuvers (T able 70-1) e. N eurologic: sensory loss mapping, motor strength, deep tendon reflexes, and special maneuvers (T able 70-1) 2. S upporting data from relevant diagnostic tests a. F asting blood sugar, hemoglobin A1C (if suspect glucose impairment or diabetes) b. R heumatoid factor, antinuclear antibody, eryth-rocyte sedimentation rate (if suspect an inflam-matory rheumatologic condition) c. Th yroid-stimulating hormone (if suspect hypothyroidism) d. R adiograph (e. g., for acute trauma to rule out any underlying bony fracture) e. N erve conduction studies (if suspect a periph-eral nerve entrapment syndrome)707 Database

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f. Ele ctromyogram (if suspect a cervical radiculopathy) g. U ltrasound (e. g., for imaging of the biceps ten-don if rupture is suspected) h. M agnetic resonance imaging (if symptoms per-sist beyond 4-6 weeks of conservative treatment, and there may be a surgical intervention [e. g., a shoulder arthroscopy]) III. a ssessment A. Determine the diagnosis based on anatomic location and mechanism of injury 1. B icipital tendinopathy a. F ocal tenderness over long head of biceps inser-tion with palpation between the greater and less-er proximal humeral tuberosities (T able 70-1) b. P ositive Y ergason's test (T able 70-1) 2. L ateral epicondylitis/elbow tendinopathy a. F ocal tenderness over lateral epicondyle of elbow b. P ain over lateral epicondyle with resisted wrist extension (T able 70-1) 3. de Que rvain's tenosynovitis/tendinopathya. F ocal tenderness distal to the lateral aspect of radial styloid and proximal to the anatomic snuff box (T able 70-1) b. P ositive Finkelstein's test (T able 70-1) 4. Othe r conditions that may explain the patient's presentation a. R eferred pain from another system (e. g., Pancoast tumor in the lung with referred pain to the shoulder versus bicipital tendinopathy) b. P eripheral nerve entrapment (e. g., radial nerve entrapment versus lateral epicondylitis/elbow tendinopathy) c. C ervical radiculopathy (e. g., C6 radiculopathy versus de Quervain's tenosynovitis) d. Other musculoskeletal conditions (e. g., acromio-clavicular joint synovitis or carpal metacarpal [thumb] arthritis) B. Severity 1. A ssess the severity of the disease, and ability to work and do activities of daily living. 2. A ssess the significance of the problem in terms of health-related quality of life and impact on productivity at work and at home. 3. S creen for depression and treat if symptoms are protracted and functional recovery is delayed. Table 70-1 Provocative Physical Examination Maneuvers for Selected T endinopathy Diagnosis provocative test—compar e affected to unaffected side d iagnosis h ow to Palpation of bicipital groove: https://meded. ucsd. edu /clinicalmed/joints2. htm Bicipital tendinopathy Palpate between the greater and lesser proximal humerus tuberosities with the affected arm flexed in 90 degrees; internally and externally rotate the arm while palpating; examiner will feel the tendon roll under his/her fingers. A positive test is tenderness with palpation in this region. Yergason's test: https://meded. ucsd. edu/clinicalmed/joints2. htm Bicipital tendinopathy The patient's arm begins pronated and flexed by his/her side at 90 degrees. The patient then attempts to supinate arm against examiner resistance. For a positive test, pain is reproduced in the region of the long head of the biceps muscle. Resisted wrist extension: https://meded. ucsd. edu /clinicalmed/joints4. htm Lateral epicondylitis/elbow tendinopathy Resisted extension of the wrist reproduces pain in the lateral epicondyle region for a positive test Finkelstein's test: https://meded. ucsd. edu/clinicalmed /joints3. htmde Quervain's tenosynovitis/tendinopathy Patient makes a fist around flexed thumb and gently ulnar deviates the wrist. Pain is reported over the first extensor compartment (i. e., distal to the lateral aspect of radial styloid and proximal to the anatomic snuff box) for a positive test708 CHAPTER 70 | Upper Extremity Tendinopathy

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Iv. Goals of clinical management A. Diagnosing tendinopathy In the absence of red flags, most upper extremity soft tissue disorders can be safely diagnosed with a thorough history and physical examination. After conservative treatment for 4-6 weeks, if there is no improvement, additional diagnos-tic studies may be ordered or specialty referral considered. B. Treatment Select a treatment plan that returns the client to the prein-jury functional state in a safe and timely manner. Modify work and home activities to remove trigger events to pre-vent recurrence and also protect other coworkers, either through work redesign, tool redesign, or other ergonomic interventions. Use the worksite as part of the therapeutic treatment and rehabilitation plan. Establish a plan that minimizes disability and promotes recovery. C. Patient adherence Emphasizes a self-care, sports medicine approach, tailor-ing to lifestyle and exercise patterns. T reat all work as ath-letic endeavors, with need for stretching and warm-up and cool-down activities. v. p lan A. Diagnostic tests 1. I nitial laboratory and diagnostic studies Most initial tendinopathy work-ups do not include diagnostic studies unless there is a history of trauma and/or there are red flags. 2. F ailure of conservative therapy After 4-6 weeks of conservative therapy, if the patient is not showing improvement, additional diagnostics may be ordered, and/or the client is referred for spe-cialty consultation. a. I maging may be ordered sooner in the course of treatment in the presence of red flags. Red flags, in the discussion of shoulder complaints, include:i. H istory of cancer (especially lung), includ-ing pain at rest, history of immunosuppres-sion, history of smoking ii. I nfection, including systemic symptoms, and/or presence of immunosuppression iii. H istory of significant trauma, including prior joint dislocation, and/or presence of deformity iv. P rogressive neurologic and/or vascular compromise (ACOEM, 2004)B. Management 1. The rapeutic interventions a. F or the first 4-6 weeks, if nonallergic, with nor-mal kidney and liver function, prescribe anti-inflammatory therapeutic doses of a nonsteroidal anti-inflammatory agent, either orally or topical-ly (ACOEM, 2011a, 2011b, 2012; Pattanittum, Turner, Green, & Buchbinder, 2013). b. A COEM recommends, with strong evidence, prescribing cytoprotective medications (proton pump inhibitors and misoprostol) for anyone at an increased risk for gastrointestinal bleeding (ACOEM, 2011a, 2011b, 2012). c. Ac etaminophen may be added for pain control and is recommended, in addition to aspirin, as initial therapy for those with cardiovascular dis-ease risk factors. d. N arcotics are rarely indicated for tendinopathy, with insufficient evidence to support their use in soft tissue disorders but may be prescribed short term for acute, severe pain (ACOEM, 2011a, 2011b, 2012). e. A COEM additionally recommends the consid-eration of topical capsicum and muscle relaxants for acute and subacute pain, and norepinephrine reuptake inhibiting antidepressants for chronic pain, although there is insufficient evidence (ACOEM, 2011b). f. C ortisone injections to the tendon sheath may be indicated if patient is intolerant of nonsteroi-dal anti-inflammatory agents, if there is one spe-cific site of pain, or if conservative treatment is ineffective. i. The us ual recommendation is conservative therapy for at least 3-4 weeks before cor-tisone injection (ACOEM, 2011a, 2011b, 2012). ii. R isks of cortisone injection include not only the risk of infection but also tendon rupture (Nichols, 2005). iii. A lthough cortisone injections may be appropriate for de Quervain's tendinopa-thy, those with lateral epicondylitis/elbow tendinopathy who receive cortisone injec-tions have poorer long-term outcomes (Washington State Department of Labor and Industries, 2014); conservative care recommendations are the best approach for elbow disorders. 2. R ICE: rest, ice, compression, and elevation a. R elative rest: reduce or restrict any specific motion that produces symptoms by modifying 709 Plan

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work or sports activities (ACOEM, 2011a, 2011b, 2012; Davenport et al., 2005; Fedorczyk, 2012). There is limited evidence for rest breaks during repetitive tasks at work (e. g., 5-minute wrist rest break for every 1 hour of repetitive hand activities, or a 30-second pause for every 20 minutes of intensive work) to prevent upper extremity musculoskeletal disorders (Kennedy et al., 2010). Despite insufficient evidence, rest breaks are recommended for shoulder disorders (ACOEM, 2011b). b. I ce: there is a consensus recommendation to use ice in the first 48 hours after initial injury to reduce inflammation and swelling, although there is currently insufficient evidence support-ing this recommendation (ACOEM, 2011a, 2011b, 2012). Self-administered heat for acute, subacute, and chronic pain, despite insufficient evidence, is recommended (ACOEM 2011a, 2011b, 2012), and can be alternated with ice. c. C ompression: compression by ace wraps, taping, splints, braces, or casting aids healing by keeping the body part in neutral position and unloading specific forces to decrease pain (Davenport et al., 2005). Recommendations include beginning with more rigid and graduating to more flexible orthotic interventions, depending on patient preferences (Fedorczyk, 2012). There are, how-ever, risks with any compressive device, includ-ing ischemia and pressure ulcers. Likewise, prolonged immobilization may lead to muscle atrophy and joint stiffness (Boyd, Benjamin,  & Asplund, 2009). Short-term splint use is rec-ommended, with patient education to include a weaning schedule for the splint over time. Splinting during sleep prevents inappropriate wrist and thumb movements, allows for long periods of rest, and may decrease overall patient resistance to splint use. i. F or bicipital tendinopathy: shoulder immo-bilization may be indicated for 1-2 days only. Prolonged shoulder sling use could lead to a frozen shoulder (ACOEM, 2011b). ii. F or lateral epicondylitis/elbow tendinopathy: splinting at the elbow with a dynamic extensor/elbow strap brace or splinting at the wrist is a consensus recommendation (although there is currently insufficient evi-dence) (ACOEM, 2012). Cock-up wrist splints are also recommended for elbow tendinopathies, with the goal to prevent repetitive wrist extension (ACOEM, 2012) iii. F or de Quervain's tenosynovitis: a wrist and thumb splint is usually indicated during the acute treatment phase (ACOEM, 2011a). A systematic review of de Quervain's tenosynovitis/tendinopathy found cortisone injections more effective than splinting alone (Ashraf & Devadoss, 2014). d. Ele vation: elevation may relieve any distal swelling. 3. R eferral and consultation a. R eferral for physical or occupational therapy to aid in return to preinjury function. i. U ltrasound is recommended for lateral epicondylitis (ACOEM, 2012) and for cal-cific shoulder tendinitis (ACOEM, 2011b) but not for de Quervain's tenosynovitis (ACOEM, 2011a) ii. I ontophoresis with administration of medi-cations (e. g., corticosteroids) is recom-mended for lateral epicondylitis (ACOEM, 2012) and de Quervain's tenosynovitis (ACOEM, 2011a). iii. M yofascial release and soft tissue friction massage may be helpful, although there is insufficient evidence to support deep fric-tion massage (ACOEM, 2012; Loew et al., 2014). iv. Ge ntle stretching during the acute treat-ment phase may be indicated, with intro-duction of a strengthening exercise program for home or work (ACOEM, 2011a, 2011b, 2012; Davenport et al., 2005; Kennedy et al., 2010). Eccentric exercise is effective in the treatment of lateral epicondylitis (Cullinane, Boocock, & T revelyan, 2014). Postural and neuromuscular reeducation is critically important to improve function and reduce pain by identifying and modi-fying contributing intrinsic (e. g., postural) and extrinsic (e. g., biomechanical) factors (Davenport et al., 2005). b. R eferral for ergonomic consultation is recom-mended to include workstation evaluation and adjustment with ergonomic training, rest breaks, new chairs, tool redesign to minimize forceful pinch grips, alternative keyboards, alternative pointing devices, and forearm and wrist supports (ACOEM, 2011a, 2011b, 2012; Kennedy et al., 2010). The goal is to reduce risk factors of awk-ward posture, force, repetition, vibration, contact stress, and cold temperature. c. R efer the patient to a rehabilitation or physician specialist if a more tailored rehabilitation plan or surgical intervention is needed (e. g., shoulder arthroscopy). 710 CHAPTER 70 | Upper Extremity Tendinopathy

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d. R eferral for acupuncture for lateral epicondy-litis/elbow tendinopathy may be beneficial for short-term pain relief, although there remains insufficient evidence to support this recom-mendation (ACOEM, 2012; Washington State Department of Labor and Industries, 2014). e. Aut ologous whole blood or platelet-rich plasma injections, via guided ultrasound, may enhance tissue healing by restoring “cytokine/growth factor equilibrium into the area of tendinosis” (Fedorczyk, 2012, p. 194) and has been shown to reduce pain in the short term, but not pro-longed pain relief in patients with lateral epicon-dylitis/elbow tendinopathy (Washington State Department of Labor and Industries, 2014). The ACOEM guidelines currently recommend these therapies for chronic lateral epicondylalgia (ACOEM, 2012). f. R eturn-to-work programs are particularly important (ACOEM, 2011b) to facilitate recov-ery, with the goal to prevent delayed recovery, associated wage loss, and potential job loss. Primary care providers need to be cautious when writing work restrictions, focusing on what the individual can do at work (for example: patient can lift up to 10 pounds; able to use left arm above shoulder, but no use of right arm above shoulder). However, removal from a specific job task that causes de Quervain's, for example, may be needed as part of the treatment plan (ACOEM, 2011a). Please note that this recom-mendation does not automatically translate to taking the patient off work. There may be alter-nate work assignments available at the work-place that can be safely done within the work restriction. C. Client education: review 1. S elf-care activities to improve overall physical conditioning include stretching, core strengthening, and postural awareness. Additionally, taking intermittent rest breaks throughout any repetitive task at work and at home is important to prevent and treat tendinopathy. Reinforce that injuries of this nature generally occur over an extended period of time and that they should not expect immediate resolution of symptoms. 2. M anagement plan, including medication, potential side effects, and follow-up care 3. S tate-specific workers' compensation procedures, including any mandatory reporting, if symptoms are caused by work activities. Support using the workplace as part of the therapeutic treatment plan, to avoid prolonged disability and wage loss, if the injury occurred at work. 4. E ncourage primary prevention of injuries, including ergonomic interventions at work and at home, to prevent reinjury and injury to others. v I. s elf-management resources and tools A. Patient and client education 1. O ccupational Safety and Health Administration Ergonomics e T ools Consumer-oriented self-help tools to reduce work-related risk factors, including an e T ool for baggage handling, computer work stations, and sewing:https://www. osha. gov/dts/osta/oshasoft/index. html 2. C anadian Centre for Occupational Health and Safety www. ccohs. ca/oshanswers/diseases/tendon_disorders . html 3. N ational Institute of Arthritis and Musculoskeletal and Skin Diseases Clearinghouse: a. B ursitis and tendinitis: www. niams. nih. gov /Health_Info/Bursitis/default. asp 4. M edline Plus www. nlm. nih. gov/medlineplus/tendinitis. html 5. A rthritis Foundation www. arthritis. org/arthritis-facts/disease-center /tendinitis. php B. Community support groups There are online self-management and support groups for those with tendinopathies or for those who develop chronic pain from soft tissue injuries. Contact the Arthritis Foundation (www. arthritis. org/we-can-help /online-tools). references American College of Occupational and Environmental Medicine. (2004). Shoulder complaints. In Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers (2nd ed., pp. 195-224). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. American College of Occupational and Environmental Medicine. (2011a). Hand, wrist, and forearm disorders, not including carpal tunnel syn-drome. In K. T. Hegmann (Ed. ), Occupational medicine practice guide-lines. Evaluation and management of common health problems and functional recovery in workers (3rd ed. ). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. Retrieved from www. guideline. gov/content. aspx?id=34435. 711 References

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American College of Occupational and Environmental Medicine. (2011b). Shoulder disorders. In K. T. Hegmann (Ed. ), Occupational medicine prac-tice guidelines. Evaluation and management of common health problems and functional recovery in workers (3rd ed. ). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. Retrieved from www. guideline. gov/content. aspx?id=36626. American College of Occupational and Environmental Medicine. (2012). Elbow disorders. In K. T. Hegmann (Ed. ), Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers (3rd ed. ). Elk Grove Village, IL: American College of Occupational and Environmental Medicine. Retrieved from www. guideline. gov/content. aspx?id=38447. Ashraf, M. O., & Devadoss, V. G. (2014). Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults. European Journal of Orthopaedic Surgery and Traumatology, 24, 149-157. Bongers, P. M., Ijmker, S., van den Heuvel, S., & Blatter, B. M. (2006). Epidemiology of work related neck and upper limb problems: Psychosocial and personal risk factors (part I) and effective inter-ventions from a bio behavioural perspective (part II). Journal of Occupational Rehabilitation, 16(3), 279-302. Boyd, A. S., Benjamin, H. J., & Asplund, C. (2009). Splints and casts: Indications and methods. American Family Physician, 80(5), 491-499. Retrieved from www. aafp. org/afp/2009/0901/p491. html. Cullinane, F. L., Boocock, M. G., & T revelyan, F. C. (2014). Is eccentric exer-cise an effective treatment for lateral epicondylitis? A systematic review. Clinical Rehabilitation, 28(1), 3-19. Davenport, T. E., Kulig, K., Matharu, Y., & Blanco, C. E. (2005). The Ed URe P model for nonsurgical management of tendinopathy. Physical Therapy, 85(10), 1093-1103. Fedorczyk, J. M. (2012). T endinopathies of the elbow, wrist, and hand: his-topathology and clinical considerations. Hand Therapy, 25(2), 191-200. Hegmann, K. T., Thiese, M. S., Wood, E. M., Garg, A., Kapellusch, J. M., Foster, J., et al. (2014). Impacts of differences in epidemiological case definitions on prevalence for upper-extremity musculoskeletal disorders. Human Factors, 56(1), 191-202. Kennedy, C. A., Amick, B. C., Dennerlein, J. T., Brewer, S., Catli, S., Williams, R., et al. (2010). Systematic review of the role of occupational health and safety interventions in the prevention of upper extremity musculoskel-etal symptoms, signs, disorders, injuries, claims and lost time. Journal of Occupational Rehabilitation, 20(2), 127-162. Loew, L. M., Brosseau, L., Tugwell, P., Wells, G. A., Welch, V., et al. (2014). Deep transverse friction massage for treating lateral elbow or lateral knee tendinitis. Cochrane Database of Systematic Reviews, 11, CD003528. Mc Auliffe, J. A. (2010). T endon disorders of the hand and wrist. Journal of the American Society for Surgery of the Hand, 35(5), 846-853. Nichols, A. W. (2005). Complications associated with the use of cortico-steroids in the treatment of athletic injuries. Clinical Journal of Sports Medicine, 15(5), 370-375. Pattanittum, P., Turner, T., Green, S., & Buchbinder, R. (2013). Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults. Cochrane Database of Systematic Reviews, 5, CD003686. Sharma, P., & Maffulli, N. (2005). T endon injury and tendinopathy: Healing and repair. Journal of Bone and Joint Surgery America, 87, 187-202. Shiri, R., Viikari-Juntura, E., Varonen, H., & Heliovaara, M. (2006). Prevalence and determinants of lateral and medical epicondylitis: A population study. American Journal of Epidemiology, 164(11), 1065-1074. van Rijn, R. M., Huisstede, B. M., Koes, B. W., & Burdorf, A. (2009). Associations between work-related factors and specific disorders at the elbow: A systematic literature review. Rheumatology, 48(5), 528-536. van Rijn, R. M., Huisstede, B. M., Koes, B. W., & Burdorf, A. (2010). Associations between work-related factors and specific disorders of the shoulder: A systematic review of the literature. Scandinavian Journal of Work, Environment & Health, 36(3), 189-201. Walker-Bone, K., Palmer, K. T., Reading, I., Coggon, D., & Cooper, C. (2004). Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis and Rheumatology, 51(4), 642-651. Washington State Department of Labor and Industries. (2014). Conservative care options for work-related epicondylosis. Olympia, WA: Author. Retrieved from www. guideline. gov/content. aspx?id =48216&search=epicondylosis. 712 CHAPTER 70 | Upper Extremity Tendinopathy

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A. Acute wounds 1. D efinition and overview Acute wounds are those that have an abrupt onset with a short duration, recognizing that the duration is disease or condition specific (Lazarus et al., 1994). Acute wounds occur suddenly and move predictably through the repair process (Bryant & Nix, 2012). Surgical wounds and traumatic wounds are the most common acute wounds. Surgical wounds are deliber-ately made incisions. T raumatic wounds result from any foreign body impact that results in tissue damage. These include wounds caused by both blunt and pen-etrating trauma. Examples of traumatic wounds are crush injuries, degloving wounds, gunshot wounds, stab wounds, and lacerations. They occur abruptly, usually with significant impact, and cause tissue dam-age. The mechanism of injury in traumatic wounds determines the extent of damage and risk of infection. The environment of the injury and the time since injury are important factors in the development of complications including infection. A contaminated wound that is evaluated more than 6 hours after injury is at increased risk of infection. 2. P revalence and incidence In the United States, annually there are about 50 million incisions from elective surgeries and 50 million traumatic wounds (Franz et al., 2008). Each year trauma accounts for 41 million emergency department visits and 2. 3 million hospital admissions across the nation (Centers for Disease Control and Prevention [CDC], 2014). B. Chronic wounds 1. D efinition and overview Chronic wounds are those that fail to proceed through the healing process in an orderly and timely fashion to produce sustained functional and anatomic continuity (Lazarus et al., 1994). Chronic wounds are frequently caused by vascular compromise, chronic I. Intr oduction and general background A wound is a break in the integrity of the skin. Wound healing is restoration of the functional and anatomic integrity of tissue (Lazarus et al., 1994). Wound healing occurs in all structures of the body. This chapter focuses on the skin and soft tissues. Burns and pressure ulcers are not included in this chapter. There are two types of tissue injury, partial and full thick-ness. Partial-thickness wounds include skin damage that does not penetrate below the dermis and may be limited to the epi-dermal layers only. The major components of partial-thickness repair include an initial inflammatory response to injury, epi-thelial proliferation and migration (resurfacing), and reestab-lishment and differentiation of the epidermal layers to restore the barrier function of the skin. Full-thickness wounds have tissue damage involving total loss of epidermis and dermis and extending into the subcutaneous tissue and possibly into muscle or bone. Healing of full-thickness wounds occurs through the processes of hemostasis, inflammation, prolifera-tion of new tissue, and remodeling of scar tissue (Bryant & Nix, 2012). There are normal skin changes that occur with age. For example, there is a decrease in Langerhans cells, leading to a decreased inflammatory response and increased risk of cancer. Epidermal-dermal junction changes such as flattening of the prominent dermal papillae and rete ridges cause skin to tear more easily from mechanical trauma, including use of tape on skin. Skin elasticity decreases from changes in collagen and elastin fibers. A loss of skin barrier function occurs with less secretion of lipids to the skin along with reduction of dermal hydration. Due to these skin changes, aging skin is more fragile and wounds are acquired more easily. Wound healing is delayed and response to infection is decreased (Bryant & Nix, 2012). Wounds are commonly divided into acute and chronic wounds. In this chapter, we discuss acute wounds and the two most common chronic wounds, venous leg ulcers and diabetic foot ulcers. Cynthia Johnson and Patricia Mc Carthy-Horton Wound Care© Eliks/Shutterstock; © donatas1205/Shutterstock 71371Chapt Er

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inflammation, or repetitive insults (Bryant & Nix, 2012). The most common types of chronic wounds are venous leg ulcers and diabetic foot ulcers. a. V enous leg ulcer: Venous leg ulcer (VLU) is defined as an open skin lesion of the leg or foot that occurs in an area affected by venous hyper-tension. VLU is the most common etiology of lower extremity ulceration and accounts for 70% of all leg ulcers (O'Donnell et al., 2014). Chronic venous disease (CVD), a debilitat-ing condition that affects millions of individuals worldwide, is the leading cause of VLU. Both reflux and obstruction account for the patho-physiologic mechanism of CVD. The funda-mental basis for CVD and venous ulceration is inflammation within the circulation that is sub-jected to increased hydrostatic pressure resulting in increased ambulatory pressure. Inflammation has a significant effect on the vein wall, venous valve, endothelium, and the surrounding tissue, which leads to destruction of the dermis and eventual skin changes and ulcer formation (O'Donnell et al., 2014). More common in women and older persons, VLUs are often recurrent and can persist for weeks to several years. Severe complications include cellulitis, osteomyelitis, and malignant change (Collins & Seraj, 2010). b. Di abetic foot ulcer: Diabetic foot ulcer (DFU) is a complex, chronic wound, which has major long-term impact on the morbidity, mortality, and quality of patients' lives (Chadwick, Edmonds, Mc Cardle, & Armstrong, 2013). They are usually located at increased pressure points on the bottom of the feet (Yazdanpanah, Nasiri, & Adarvishi, 2015); however, neurotropic ulcers related to trauma can occur anywhere on the foot (Cleveland Clinic, 2015). The major component of nearly all DFUs is the loss of protective sensation from periph-eral neuropathy (Chadwick et al., 2013). Ninety percent of DFUs are from neuropathy and 10% from ischemia (Yazdanpanah et al., 2015). A DFU is a marker of serious disease and comor-bidities. Without early and optimal interven-tion, the wound can rapidly deteriorate, leading to amputation of the affected limb (Chadwick et al., 2013). A DFU is the most common complication of diabetes mellitus (DM) (Yazdanpanah et al., 2015), and DFUs are responsible for more hos-pitalizations than any other complication of diabetes (Rowe, 2014). Early management can prevent complications such as amputation, thus improving quality of life (Yazdanpanah et al., 2015). If infected, a DFU can increase the risk of hospitalization by nearly 56 times and amputation by nearly 155 times (Kimmel & Regler, 2011). In diabetic people with neuropathy, even if successful management results in healing of the foot ulcer, the recurrence rate is 66% (Rowe, 2014). 2. P revalence and incidence a. V enous leg ulcer: Approximately 7 million indi-viduals worldwide have CVD with 3 million of those people progressing to ulceration (Wound Ostomy and Continence Nurses Society [WOCN], 2011). The overall prevalence of VLUs in the United States is estimated to be approximately 1% of the population (Collins & Seraj, 2010). Approximately 2. 5 million people in the United States suffer from chronic venous insufficiency, and of those, approximately 20% will develop VLUs (O'Donnell et al., 2014). The refractory nature of these ulcers increase the risk of morbidity and mortality and have a significant impact on quality of life. The financial burden of VLUs is estimated to be $2 billion per year in the United States (Collins & Seraj, 2010). b. Di abetic foot ulcer: In 2012, 29. 1 million Americans or 9. 3% of the population had diabetes. Approximately 1. 25 million American children and adults have type 1 diabetes (American Diabetes Association [ADA], 2014). The percentage of Americans age 65 and older with diabetes remains high, at 25. 9%, or 11. 8 million seniors. Prevalence of lower extremity peripheral neuropathy is 2. 4% per 100,000 of the U. S. population and increases with aging to 9%. Among diabetics, 40% have peripheral neuropathy with loss of protective sensation and 15% will develop foot ulceration (Yazdanpanah et al., 2015). According to the WOCN (2012), 14-24% will require ampu-tation. The incidence of ulcers is 1-4. 1%, and the lifetime incidence is estimated to be 25% (Wu, Driver, Wrobel, & Armstrong, 2007). II. d atabase A. Acute wounds 1. S ubjective a. P ast medical history: trauma, cardiovascular disease, diabetes b. S urgical history: recent surgery c. T rauma history: recent trauma and mechanism of injury714 CHAPTER 71 | Wound Care

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d. F amily history: diabetes e. S ocial history: poor nutrition, tobacco, alcohol, and illicit substance use, homelessness f. O ccupational history: job-related injury g. M edications and allergies: medications and supplements that suppress inflammation (e. g., immunosuppressive drugs, steroids, chemotherapy) h. R eview of systems i. C onstitutional signs and symptoms: fatigue, fever, chills, general malaise ii. S kin: rash, erythema, warmth, wound sepa-ration, drainage, odor, pain iii. C ardiac and circulatory: chest pain, edema, mottling, pallor, and cyanosis iv. M usculoskeletal: pain, swelling, alteration in range of motion, loss of strength v. N eurologic: numbness, paresthesias, gait changes 2. Obj ective a. P hysical examination findings (T able 71-1) b. S upporting data from diagnostic tests (T able 71-2) B. Venous ulcers 1. S ubjective a. P ast medical history and risk factors: advanced age, obesity, venous thromboembolism, super-ficial thrombophlebitis, varicose veins, venous insufficiency, leg trauma, thrombophilia, restricted range of motion of the ankle, impairment of calf muscle pump (WOCN, 2011). Other nonvenous causes of leg ulcers should be identified. Examples include arterial insuf-ficiency, vasculitis, lymphedema, exogenous factors, pyoderma gangrenosum, infection, neo-plasia, calciphylaxis, and drug-induced causes (O'Donnell et al., 2014). Other conditions that affect ulcer healing should be identified. Examples include DM, infection, atherosclerosis, renal failure, immune diseases, and malignancy. b. S urgical history: previous venous operative interventions (O'Donnell et al., 2014) c. T rauma history: recent or remote leg trauma d. F amily history: venous ulcers, venous throm-boembolism, varicose veins (O'Donnell et al., 2014) e. S ocial history: intravenous drug use, tobacco use, alcohol abuse, sedentary lifestyle f. O ccupational history: prolonged standing, inability to work g. M edications and allergies: medications that influence immune function (corticosteroids, chemotherapy, biologic response modifiers), recent or current antibiotics, anticoagulants, analgesics h. R eview of systems i. C onstitutional symptoms: fatigue, tired, heavy legs ii. S kin: drainage, malodor, pruritus, dry or scaly skin, hyperpigmentation iii. C ardiovascular: dependent or chronic edema iv. M usculoskeletal: pain described as burn-ing, aching, throbbing, often exacerbated by limb dependence and relieved by elevation or rest, restless legs (O'Donnell et al., 2014) v. P sychiatric: depression, anxiety, social isolation vi. Obs tetric and gynecological history: pregnancy (multiple or close together) (WOCN, 2011) 2. Obj ective a. P hysical examination findings (T able 71-1) b. S upporting data from diagnostic tests (T able 71-2) C. Diabetic foot ulcers 1. S ubjective a. P ast medical history and risk factors: diabetes, uncontrolled hyperglycemia, duration of dia-betes, history of previous ulcer, blindness or visual loss, advanced age, chronic renal disease (Yazdanpanah et al., 2015), foot trauma, restricted range of motion of the ankle. Other conditions that affect ulcer healing should be identified, including DM management, infec-tion, atherosclerosis, renal failure, immune diseases, and malignancy b. S urgical history: amputation with loss of part of foot or extremity c. T rauma history: inappropriate shoe wear, self-inflicted injury from trimming nails or calluses d. F amily history: diabetes with DFU, amputations, venous ulcers e. S ocial history: tobacco use, alcohol abuse, illicit drug use, sedentary lifestyle, poor self-efficacy in their healthcare management, i. e., diabetes control f. O ccupational history: prolonged standing or walking on affected foot. g. M edications and allergies: compliance with dia-betic medications, medications that influence immune function (corticosteroids, chemotherapy, biologic response modifiers), recent or current antibiotics, anticoagulants, analgesics715 Database

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Table 71-1 Physical Examination Findings Condition a ssociated Findings (may or may not include) Acute wounds Assess: 1. Vital signs: assess for changes from baseline. Assess for signs of infection and screen for sepsis. Assess for ongoing levels of pain 2. Damage to underlying soft tissue, organ, bony structures, and neurovascular bundles (compartment syndrome or occult bleeding) 3. Cardiovascular and circulatory: distal mottling, pallor, coolness, cyanosis, loss of pulses or unilateral decrease in pulse amplitude 4. Skin: tissue disrupted with open wound; note wound location, size (length, width, and depth), exudate, nature of tissue (color and consistency), odor, level of pain, uncontrolled bleeding. Assess for visualized and/or palpable underlying structures 5. Neurologic: sensory defect caused by nerve damage from trauma, compartment syndrome, and pain V enous leg ulcers Assess: 1. Vital signs: assess for changes from baseline. Assess for signs of infection and screen for sepsis. Assess for ongoing levels of pain 2. Skin: wound characteristics include typical location superior to medial malleolus but can occur anywhere on the lower leg; wound is often shallow with irregular wound edges; wound bed ruddy red, often with yellow fibrinous slough; exudate can be mild to heavy; may be malodorous; bleeding may or may not be present (WOCN, 2011) 3. W ound measurement: serial VLU wound measurements and documentation are important to determine baseline markers and the effect of subsequent treatment measures on healing parameters. Documentation should include number and position of ulcers on leg, the size of each ulcer, description of the wound base, wound edges, amount and type of drainage, and signs of infection (O'Donnell et al., 2014) 4. Periwound: skin may display chronic venous skin changes such as dermatitis, hyperpigmentation, hemosiderosis, lipodermatosclerosis, atrophie blanche, scarring from healed wounds (WOCN, 2011) 5. Cardiovascular: presence of lower extremity pulses (dorsalis pedis and posterior tibial), edema, varicose veins, venous cord, telangiectasia, malleolar flare, corona phlebectatica (O'Donnell et al., 2014) 6. Musculoskeletal: decrease ankle mobility (O'Donnell et al., 2014) 7. Pain increased with leg dependency and decreased with leg elevation 8. Psychiatric: anxiety and depression Diabetic foot ulcer Assess: 1. Vital signs: assess for changes from baseline. Assess for signs of infection and screen for sepsis. Assess for ongoing levels of pain 2. W ound measurement: Serial DFU wound measurements and documentation are important to determine baseline markers and the effect of subsequent treatment measures on healing parameters 3. General appearance: signs of poor nutrition (e. g., wasting or lethargy) 4. Skin: description of wound bed, location, presence of necrotic debris, exudate including color, amount and odor, wound edges, callus formation, periwound description, erythema, swelling, increased warmth, maceration, dry, darkened pigmentation, fissured skin dystrophic nails 5. Cardiovascular: presence of lower extremity pulses (dorsalis pedis and posterior tibial), presence of arterial or venous disease in lower extremities 6. Musculoskeletal: exam includes muscle strength, gait analysis, range of motion of the foot and ankle, as well as visual inspection for any structural deformities such as bunions, hammertoes, or charcot (Kimmel & Regler, 2011). Compare both extremities 7. Neurologic: distal symmetrical polyneuropathy with loss of protective sensation (use monofilament for testing), change in foot structure (i. e., charcot) 8. Psychiatric: anxiety and depression 9. Endocrine: glycemic control * Assess for infection with each visit and treat aggressively. Signs of infection can be subtle in the diabetic with a foot ulcer. In addition pain, as a presenting symptom, may not be present because of the loss of protective sensation. However, it may present as a change in sensation. 716 CHAPTER 71 | Wound Care

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Table 71-2 Common W ound-Related Tests Test: Ankle-brachial index (ABI) Definition: ABI is a ratio of Doppler-recorded systolic blood pressure in the lower and upper extremities. ABI is a noninvasive test to detect peripheral artery disease (PAD; Mc Dermott et al., 2013). Clinical Implications: Normal range = 1. 10-1. 40 (Mc Dermott et al., 2013). ABI < 0. 90 at rest suggests PAD. For patients with VLU and concomitant PAD, use of standard compression has been shown to be safe if ABI is 0. 80 or higher. Modified compression with lower pressure ratings can be used for ABI 0. 50 with close monitoring, but only after consultation with a vascular specialist (O'Donnell et al., 2014). ABI < 0. 50 is considered to be indicative of severe arterial disease. In patients with VLU and underlying arterial disease, compression is not suggested if the ABI is 0. 50 or less or if absolute ankle pressure is less than 60 mm Hg (O'Donnell et al., 2014). In patients with diabetes, renal insufficiency, or other diseases that cause vascular calcification, tibial vessels at the ankle become noncompressible, leading to a false elevation of the ABI. In these patients, additional noninvasive testing, such as pulse volume recordings or toe pressure measurement, should be performed to evaluate for PAD (O'Donnell et al., 2014). Comments: Arterial pulse examination and measurement of ABI is recommended on all patients with VLU (O'Donnell et al., 2014). ABI is critical to evaluate before applying compression in venous disease. If undiagnosed arterial disease is present, compression may result in ischemia and potentially result in ischemic limb and amputation. Test: Color flow venous duplex ultrasound Definition: Used to evaluate for venous obstruction, DVT, and venous reflux and includes the following components: direct visualization of deep, superficial, and perforator venous anatomic segments; compressibility; phasic venous flow; and documentation of venous reflux with measurement of valve closure time. Clinical Implications: Comprehensive venous duplex ultrasound examination of the lower extremity is recommended in all patients with suspected VLU. Comments: Identifies patterns of venous disease that may have therapeutic implications (O'Donnell et al., 2014). Test: Wound culture There is no evidence to support routine surface cultures of VLU in the absence of clinical signs of infection as these wounds are usually colonized with multiple microorganisms. If there are no clinical signs of infection and the wound is responding to treatment, there is no indication to culture the wound (O'Donnell et al., 2014). Test: Wound biopsy Tissue biopsy is recommended for lower extremity ulcers that do not improve with standard therapy after 4 to 6 weeks of treatment and for all ulcers with atypical features (O'Donnell et al., 2014). Test: Lab testing Standard blood work to assess for infection and glycemic control, monitor anticoagulation, and assess renal function. Laboratory evaluation for thrombophilia is suggested for patients with a history of recurrent venous thrombosis and chronic venous leg ulcers (O'Donnell et al., 2014). Test: Simms-Weinstein monofilament Assess peripheral neuropathy in the foot and ankle. Assess the level of loss of protective sensation. Test: Plain film x-ray X-ray of DFU if suspicious of osteomyelitis Can detect osteomyelitis, osteolysis, fractures, dislocations, arterial calcifications, soft tissue gas, foreign bodies, structural deformities, and arthritis. h. R eview of systems i. C onstitutional symptoms: fever, chills, or malaise ii. S kin: callus, hyperpigmentation indicative of neuropathy or previous infection, ery-thema, warmth, drainage, odor, painiii. C ardiovascular: dependent or chronic edema, atherosclerosis, decreased pulses iv. M usculoskeletal: limited joint mobility, prolonged pressure to the foot from walk-ing without proper shoe gear, structural foot deformity, charcot, toe deformities717 Database

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B. Develop mutually acceptable goals. C. Select a treatment plan that promotes wound healing and minimizes the chance of complications such as infection or amputation. 1. R outinely reassess goals and plan of care and adjust treatment accordingly. If the wound has no expectation of healing, i. e., malignant tumors, then palliation may be an appropriate goal. V. Plan A. Diagnostic tests (See Table 71-2 for common diagnostic tests as appropriate) B. Management 1. Ac ute wounds a. C leanse: At each dressing change, cleanse the ulcer with a neutral, nonirritating, nontoxic solu-tion performed with a minimum of chemical or mechanical trauma (O'Donnell et al., 2014). Water, normal saline, or a commercial wound cleanser may be used. b. B ite wounds and trauma wounds that are heavily contaminated can be cleansed with high-pressure irrigation (e. g., using a #18 angiocatheter with 35-m L syringe) and monitored carefully for infection. c. P uncture wounds are left open to heal by secondary intention. Some bite wounds can be closed after cleansing with high-pressure irrigation. d. C lose lacerations when appropriate with adhe-sive glue, sutures, or staples after appropriate local analgesia is provided. Analgesia with epi-nephrine may result in ischemia depending on the site used (i. e., ears, nose, genitalia, fingers, and toes). e. P rovide an optimally moist wound bed for all wounds. The choice of dressing depends on etiology, size, location, type of tissue in the wound, exudate, level of contamination, and bioburden. Avoid excessively wet dressings that result in maceration of tissues. f. S ystemic prophylactic antibiotics are not a routine part of acute wound care but may be indicated for bite wounds or some traumatic wounds, depending on the mechanism of injury. g. U pdate tetanus immunization, if needed. h. D eep traumatic wounds and those that have not improved after appropriate treatment may require referral to a specialist. v. N eurologic: peripheral neuropathy with loss of protective sensation to feet, neuro-pathic pain vi. P sychiatric: depression, anxiety, social isolation vii. E ndocrine: glycemic control, Hg A1c 2. Obj ective a. P hysical examination findings (T able 71-1) b. S upporting data from diagnostic tests (T able 71-2) III. a ssessment A. Determine the diagnosis 1. Ac ute wound: history of surgery or trauma 2. C hronic wound: history and underlying pathology a. V enous ulcers b. Di abetic ulcers 3. Othe r conditions that may explain the patient's presentation especially if failure to progress or heal with appropriate therapy or if the patient has an unusual presentation or appearance a. I nfection of bacterial or fungal origin b. A rterial ulcer c. V asculitis d. P yoderma gangrenosum e. N eoplasm f. S ickle cell ulcer g. C utaneous granulomatous disease B. Severity Assess the severity of the disease, especially examine for infection and limb-threatening presentation (e. g., compartment syndrome or ischemia, osteomyelitis, necrotizing fasciitis). C. Significance How important is this problem to the patient and his/her ability to maintain lifestyle and participate in activities of daily living (e. g., mobility or function). D. Motivation and ability of patient Determine whether the patient has the ability and is will-ing to follow the plan that is developed by the provider with the patient. IV. Goals of clinical management A. To appropriately evaluate and diagnose the type of wound and its severity. 1. D etermining the etiology will guide appropriate wound care management. 718 CHAPTER 71 | Wound Care

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2. C hronic wounds: Venous leg ulcers a. C leanse: At each dressing change, cleanse the ulcer with a neutral, nonirritating, nontoxic solu-tion performed with a minimum of chemical or mechanical trauma (O'Donnell et al., 2014). Water, normal saline, or a commercial wound cleanser may be used. b. D ebride: VLUs should receive thorough debride-ment at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. Serial wound assessment is important in determining the need for repeated debridement. A number of debridement methods are available including, sharp, enzymatic, autolytic, biologic (larval), and mechanical (O'Donnell et al., 2014). Mechanical debridement is nonselective and can be painful and therefore is not recommended. c. Dr essing: Apply a topical dressing that will man-age the ulcer exudate and maintain a moist, warm wound bed (O'Donnell et al., 2014). Dressings that absorb excess exudate include alginates, foams, cadexomer iodine, hydrocolloids, hydro-cellular dressings, hydropolymers, hypertonics, and medical honey (WOCN, 2011). d. Ad junctive therapy: Adjunctive wound therapy options may be considered for VLUs that fail to demonstrate improvement after a minimum of 4 to 6 weeks of standard therapy. Examples are cellular therapy with allogenic bilayer skin replacements or other skin substitutes (O'Donnell et al., 2014). e. P eriwound: Preventing periwound maceration and treating dermatitis are important measures. Skin lubricants or topical steroids may amelio-rate dermatitis (O'Donnell et al., 2014). f. C ompression: Compression therapy is the standard of care for VLUs and chronic venous insufficiency. Venous ulcers heal more quickly with compression than without compression. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain (Collins & Seraj, 2010). The amount of therapeutic compression is typ-ically 30-42 mm Hg at the ankle and can be pro-vided by elastic, multilayer compression dressings (e. g., Profore) or inelastic, paste-containing ban-dages (e. g., Unna's boot), stockings, and boots. Antiembolism hose are not designed to provide therapeutic compression (WOCN, 2011). Elastic compression therapy is more effective than inelastic therapy and high compression is more effective than low compression. Multilayer bandages are more effective than single layer but require specialized training to apply. Contraindications to compression therapy include clinically significant arterial disease and uncom-pensated heart failure. Once an ulcer has healed, lifelong maintenance of compression therapy may reduce recurrence (Collins & Seraj, 2010). g. Ele vation: Leg elevation is recommended and requires raising lower extremities above the level of the heart. The goal of elevation is to reduce edema, improve microcirculation and oxygen delivery, and hasten ulcer healing (Collins & Seraj, 2010). Leg elevation is most effective if performed for 30 minutes, three to four times per day (WOCN, 2011). h. M edications: For long-standing or large VLUs, treatment with pentoxifylline (T rental) is recom-mended when used in combination with com-pression therapy. Pentoxifylline has a powerful inhibitory effect on cytokine-mediated neutro-phil activation, white cell adhesion to endothe-lium, and oxidative stress (O'Donnell et al., 2014). Pentoxifylline (400 mg three times per day) has been shown to be an effective adjunctive treatment for VLUs when added to compression therapy (Collins & Seraj, 2010). i. P ain: Wound pain related to VLUs is very common and can become chronic without proper intervention. An individualized pain management plan should be developed to meet each patient's needs. Important components include compression, leg elevation, exercise, and analgesia (WOCN, 2011). Active exercise to improve muscle pump function and to reduce pain and edema is recommended (O'Donnell, et al., 2014). j. N utrition: A nutritional assessment should be performed on any patient with a VLU who has evidence of malnutrition (O'Donnell et al., 2014). Nutritional deficiencies are underdiag-nosed and underreported in patients with VLUs. Protein deficiency is prevalent and caloric intake is often suboptimal (WOCN, 2011). k. S urgery: The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recur-rence. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebec-tomy, stripping, sclerotherapy, or laser therapy (Collins & Seraj, 2010). 719 Plan

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3. C hronic wounds: Diabetic foot ulcer a. The pr imary management of diabetic foot ulcers is to gain closure as quickly as possible (Yazdanpanah et al., 2015). b. C leanse the wound at each dressing change with a neutral, nonirritating, nontoxic solution per-formed with a minimum of chemical or mechan-ical trauma (O'Donnell et al., 2014). Water, normal saline, or a commercial wound cleanser may be used. c. O ff-loading, taking pressure off the wound, is the mainstay of therapy in treatment of DFUs. Peripheral neuropathy may predispose the foot to ulceration due to loss of protective sensation and is the major component of nearly all DFUs (Chadwick et al., 2013). Off-loading is the reduction of focal pressure from a specific foot site with subsequent redistribution of that pres-sure over the larger foot surface thus decreasing repetitive stress and pressure from shoe wear. Abnormal pressure or stress to the foot may occur from limited joint mobility and/or struc-tural foot deformity. Unrelieved pressure impairs healing and increases the risk of complications such as infection or increased tissue damage (WOCN, 2012). Off-loading modalities include total contact cast (TCC), which is considered the “gold standard. ” However, TCC should not be used if patient has infection, poor arterial perfusion, unstable gait, fluctuating edema, or restless leg syndrome. Complete bed rest could be used to take pressure off an ulcer, however, it is not gen-erally recommended because it could lead to debilitation (WOCN, 2012). Other choices are crutches, walkers, wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotics, diabetic boots, and fore-foot and heel relief shoes. d. W ound debridement of nonviable tissue can be done by surgical/sharp, larval, autolytic, hydrodebridement, or ultrasonic debridement (Chadwick et al., 2013). The gold standard of debridement for DFUs is sharp debridement but should be carried out only by experienced prac-titioners (Chadwick et al., 2013). The nonviable tissue and callus surrounding the wound causes pressure and should be debrided at regular intervals (WOCN, 2012). e. A ssess for and treat infection, topically or sys-temically depending on the level of the infection. Although approximately 56% of DFUs become infected (Chadwick et al., 2013), poor glucose control has the potential to suppress the inflam-matory response thus decreasing response to infection (Yazdanpanah et al., 2015). Infection may be subtle in diabetic patients and clinical signs of infection, along with laboratory markers, may not be elevated in the presence of infection. However, antibiotic therapy should not be given as a preventive measure in the absence of signs of infection (Chadwick et al., 2013). Increase in drainage, swelling, necrotic tissue, abnormal granulation tissue, change in the color of the wound, purulent drainage, and increased friability can be signs of infection, along with erythema and increased warmth to the area (WOCN, 2012). For deep infected wounds, cel-lulitis, formation of necrotic tissue, gangrene, necrotizing fasciitis, or joint or bone involve-ment, intervention should be aggressive with systemic antibiotics and possible hospitalization. Culture swabs do not give an accurate account of wound bacteria and a biopsy can be done if needed (WOCN, 2012). f. I f osteomyelitis is suspected the initial imag-ing should be plain films of the area, which can detect osteomyelitis, osteolysis, fractures, dislo-cations, arterial calcifications, soft tissue gas, for-eign bodies, structural deformities, and arthritis. Magnetic resonance imaging can be done and has been called the gold standard for detection; however, tissue infection can interfere with an accurate diagnosis. A definitive diagnosis can be made through a bone biopsy with culture. Other imaging of computer tomography, or radionuclide scans can be used (Steed et al., 2006). Ideal treatment of acute osteomyelitis is surgical removal of the bone and infected tissue. If surgery is not possible, prolonged antibiotic therapy, usually for 6 weeks, is used with close follow-up and reevaluation of infection. g. W ound care should maintain a moist environ-ment, promote optimal cell migration, prolif-eration, differentiation, and neovascularization. Dressings should be chosen to either hold mois-ture in a wound that has minimal exudate or to collect drainage in wounds with heavier exudate. Periwound should be kept dry and protected to prevent maceration. Choice of wound dressings should be reassessed and may change based on the evolving characteristics of the wound. Other modalities include negative pressure wound ther-apy (NPWT) and biological wound coverings. Both of these should be placed over a clean wound bed without any slough, biofilm, or infection. 720 CHAPTER 71 | Wound Care

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h. H yperbaric oxygen has been shown to be of value in reducing the amputation rate in patients with ischemic DFU. i. O ptimal glycemic control contributes to heal-ing of the ulcer. All approaches that contribute to glycemic control should be considered. j. S ystemic evaluation and management of under-lying diseases is pivotal to the management of the lifelong risk of diabetic ulcers (e. g., diabetes control, prevention of neuropathy). The goal is to prevent loss of limb through amputation. C. Education Written instruction should be provided to the patient and family specific to wound management. Management of the underlying disease in the chronic conditions of venous disease and diabetes requires patient and family education for a lifetime. 1. V enous ulcer (WOCN, 2011): a. E ven after a VLU is healed, patients must commit to lifelong compression by wearing compression stockings. Not wearing stockings is associated with leg ulcer recurrence b. S tockings should be removed at night and applied upon rising in the morning c. C ompression stockings should be replaced every 3-6 months d. P atients should be encouraged to elevate their legs several times per day e. E ncourage optimal weight management, proper nutrition, and exercise f. E xercise includes brisk walking, ankle flexions, and resistance calf muscle exercises throughout the day 2. Di abetic foot ulcer Possibly 50% of DFUs can be prevented with effective education. Patients should be taught self-care, including (Yazdanpanah et al., 2015):a. Gly cemic control b. D aily foot inspection c. F oot hygiene d. R egular podiatry visits e. P roper shoe wear f. A voiding walking barefooted, which is discour-aged even in the home g. N eed to see primary practitioner or podiatrist immediately if foot problems occur Patients with diabetes require lifelong management of their chronic illness. Refer patients and their family for diabetic education. Referral should be made to a podiatrist for ongoing foot management and teaching. re Feren Ces American Diabetes Association. (2014). Statistics about diabetes. National diabetes statistics report, 2014. Retrieved from www. diabetes. org /diabetes-basics/statistics. Bryant, R. A., & Nix, D. P. (2012). Acute & chronic wounds: Current manage-ment concepts. St. Louis, MO: Mosby. Centers for Disease Control and Prevention. (2014). T rauma statistics. Retrieved from www. nationaltraumainstitute. org/home/trauma_statistics. html. Chadwick, P., Edmonds, M., Mc Cardle, J., & Armstrong, D. (2013). International best practice guidelines: Wound management in diabetic foot ulcers. Wounds International. Retrieved from www. woundsinternational. com. Cleveland Clinic. (2015). Lower extremity ulcers. Retrieved from http:// my. clevelandclinic. org/services/heart/disorders/pad/legfootulcer. Collins, L., & Seraj, S. (2010). Diagnosis and treatment of venous ulcers. American Family Physician, 81, 989-996. Franz, M. G., Robson, M. C., Steed, D. L., Barbul, A., Brem, H., Cooper, D. M., et al. (2008). Guidelines to aid healing of acute wounds by decreasing impediments of healing. Wound Repair and Regeneration, 16(6), 723-748. Kimmel, H., & Regler, J. (2011). An evidence based approach to treating diabetic foot ulcerations in a veteran population. Journal of Diabetic Foot Complications, 3(2), 50-54. Lazarus, G. S., Cooper, D. M., Knighton, D. R., Margolis, D. J., Pecoraro, R. E., Rodeheaver, G., et al. (1994). Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology, 130(4), 489-493. Mc Dermott, M. M., Applegate, W. B., Bonds, D. E., Bufore, T. W., Church, T. W., Espeland, M. A., et al. (2013). Ankle brachial index values, leg symptoms, and functional performance among community-dwelling older men and women in the lifestyle interventions and independence for elders study. Journal of the American Heart Association, 12, 1-10. O'Donnell, T. F., Passman, M. A., Martson, W. A., Ennis, W. J., Dalsing, M., Kistner, R. L., et al. (2014). Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery, 60, 3S-59S Rowe, V. L. (2014). Diabetic ulcers. Medscape. Retrieved from http:// emedicine. medscape. com/article/460282-overview. Wound Ostomy and Continence Nurses Society. (2011). Guideline for management of wounds in patients with lower-extremity venous disease. Mount Laurel, NJ: WOCN. Wound Ostomy and Continence Nurses Society. (2012). Guideline for man-agement of wounds in patients with lower-extremity neuropathic disease. Mount Laurel, NJ: WOCN. Wu, S. C., Driver, V. R., Wrobel, J. S., & Armstrong, D. G. (2007). Foot ulcers in the diabetic patient, prevention and treatment. Journal of Vascular Health Risk Management, 3(1), 65-76. Yazdanpanah, L, Nasiri, M., & Adarvishi, S. (2015). Literature review on the management of diabetic foot ulcer. World Journal of Diabetes, 6(1), 37-53. 721 References

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INDEX Note: Page numbers followed by f or t represent figures or tables respectively. A AACAP (American Academy of Child and Adolescent Psychiatry), 83, 94, 98 AADE. See American Association of Diabetes Educators (AADE) A A P. See American Academy of Pediatrics (AAP) Abnormal cytology, 171 management of, 174-176, 174-182f Abnormal uterine bleeding (AUB), 140-154 assessment of, 146-147 clinical management goals, 147clinical presentations of, 140, 141t COEIN etiologies, 144-145databases used for, 145-146diagnostic testing for, 147, 148-150tetiologies of, 140, 142-143toverview of, 140, 141, 144-145PALM (structural) etiologies, 141, 144physical examination, 146self-management resources, 154treatment and management of, 147, 151-153 Abscesses, cutaneous, management of. See Cutaneous abscesses, management of Abuse. See Maltreatment of children; Physical abuse; Substance use and abuse ACA (Affordable Care Act), 48ACCP (American College of Chest Physicians), 415 Acetaminophen, 482Achenbach Child Behavior Checklist, 82Acid inhibitors, adverse effects of, 300ACOG. See American Congress of Obstetricians and Gynecologists (ACOG) Acquired Immune Deficiency Syndrome. See HIV (Human immunodeficiency virus); Postexposure prophylaxis (PEP), for HIV infection Active vs. passive immunizations, 46Activities of daily living (ADLs), 561Acupressure wrist bands, 296Acute bleeding, 147, 151Acute heart failure, 569Acute wounds, 713, 714-715, 718AD (Alzheimer's disease), 218, 504, 507ADA. See American Diabetes Association (ADA) Addiction. See Substance use and abuse Addiction specialist, 491Adenomyosis, 141ADHD. See Attention-deficit/hyperactivity disorder (ADHD) Adolescence, defined, 32Adult health maintenance and promotion. See also specific issues developmental disabilities and, 345-363postexposure prophylaxis for HIV infection, 375-384 transgendered individuals and, 365-372 Adult presentations. See also specific disorders anemia, 401-413anticoagulation therapy, oral, 415-426anxiety, 428-435asthma, 436-448benign prostatic hyperplasia, 449-454cancer survivorship, 458-466chronic nonmalignant pain (CNP), 477-492 chronic obstructive pulmonary disease (COPD), 468-475 cutaneous abscess management, 395-400dementia, 504-513depression, 514-527diabetes mellitus, 529-538epilepsy, 539-546, 541tgastroesophageal reflux disease, 547-553heart failure, 566-574herpes simplex infections, 575-581HIV-infected adults, primary care of, 649-669 hypertension, 583-593intimate partner violence, 594-602irritable bowel syndrome, 605-612lipid disorders, 613-618low back pain, 619-633obesity, 634-647smoking cessation, 672-680thyroid disorders, 682-690upper back and neck pain syndromes, 691-704 upper extremity tendinopathy, 705-711viral hepatitis, chronic, 494-503wound care, 713-721 Advanced practice nurses (APNs), 104, 107 Advisory Committee on Immunization Practices (ACIP) vaccination recommendations, 42, 44-45 AEDs (antiepileptic drugs), 539-540, 542-544t, 545 AF (atrial fibrillation), 416, 417t Affordable Care Act (ACA), 48, 458AGC (atypical glandular cells), 174Ages and Stages Questionnaire (Squires & Bricker), 57 Agoraphobia, 431Agreement, breaks in opiate therapy, 490AIDS. See HIV (Human immunodeficiency virus); Postexposure prophylaxis (PEP), for HIV infection Airway inflammation, 436Alcohol consumption. See also Substance use and abuse drug use screening and, 36effects on INR, 418hypertension and, 588 Allergens 12-21 years, 33asthma and, 65, 436, 441atopic dermatitis and, 71, 75, 76-77fatigue and, 82skin testing for, 65, 72 Allergic rhinitis, 70Allergy & Asthma Network Mothers of Asthmatics, 69 Allergy immunotherapy, 67α 2-Adrenergic agonists, 86 Alpha-hydroxy acid lotion, 75Alzheimer's Association, 512, 564Alzheimer's disease (AD), 218, 504, 507Alzheimer's Disease Education and Referral Center, 512 Amenorrhea assessment of, 161 722

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associated with pituitary dysfunction, 156-157 clinical management goals, 161 databased used for, 158, 161diagnosis of, 161diagnostic testing for, 161, 162, 163-164t, 165 etiologies of, 158, 159-160t, 161hypothalamic, 156outflow tract/uterus disorders and, 157overview of, 156-158PCOS and, 156-169physical examination findings, 161, 162tprimary ovarian insufficiency and, 157self-management resources and tools, 169treatment and management of, 166-168 American Academy of Allergy, Asthma and Immunology, 69, 446 American Academy of Child and Adolescent Psychiatry (AACAP), 83, 94, 98 American Academy of Family Physicians, 10, 282, 578 American Academy of HIV Medicine (AAHIVM), 669 American Academy of Pain Medicine, 483American Academy of Pediatrics (AAP) on developmental and behavioral problems, 48 on healthy babies, 7on parenting, 10on post-NICU patients, 12, 17on postpartum care, 268 American Association for the Study of Liver Diseases, 503 American Association of Clinical Endocrinologists, 226 American Association of Diabetes Educators (AADE), 310 lifestyle behaviors, 306, 308-309 American College of Cardiology Foundation, 566, 567 American College of Chest Physicians (ACCP), 415 American College of Nurse-Midwives, 252, 282 American College of Sports Medicine, 647American Congress of Obstetricians and Gynecologists (ACOG), 190, 252 on AUB, 153on carrier screening, 255-256, 255ton cervical screening, 171-172on gestational diabetes mellitus, 306on menopause transition, 226on postpartum care, 268on preeclampsia, 317on VBAC, 282 American Diabetes Association (ADA), 305, 310, 537-538 American Geriatrics Society, 564American Geriatrics Society Beer, 564American Heart Association (AHA), 416, 566, 567, 574, 618, 647 American Liver Foundation, 503American Lung Association, 69, 446American Pain Society, 483, 492American Psychiatric Association (APA), 674 American Society for Clinical Oncology (ASCO), 458, 463 survivorship care plan template, 464-465f American Society for Colposcopy and Cervical Pathology (ASCCP), 174 American Society for Reproductive Medicine, 154 American Society of Hematology, 413American Society of Hypertension (ASH), 584 American Thyroid Association, 690American Urological Association, 451, 456Ammonium lactate, 75Amniocentesis, 257, 258Amphetamine salts, 84Analgesic therapy, 397Androgen insensitivity, 157Anemia, 401-413 assessment of, 407, 408-410, 409tclassification of, 401, 402tclinical management goals for, 410, 411tdatabases used for, 405-407defined, 401differentiation of, 402themolytic, 404, 406-407, 410, 412macrocytic, 404-405, 407, 412-413megaloblastic, 404, 407, 410, 412-413microcytic, 402-406, 408-410normocytic, 404, 406-407, 410, 412overview of, 401patient education and, 413physical examinations for, 407, 408tscreening, 25self-management resources and tools, 413 sideroblastic, 403, 404, 406, 410, 412treatment of, 410, 411-413 Anemia of chronic disease (ACD), 404, 406, 410, 412 Aneuploidy, fetal, 253Anhedonia, 90Anorectal trauma, in children, 109Anterior shoulder pain, 705Anticipated early death, infants with, 15Anticoagulation therapy. See Oral anticoagulation (OAC) therapy Anticonvulsants, 482Antidepressants, 94, 95, 432, 482, 522-526t Antidepressant Skills Workbook, 527Antiepileptic drugs (AEDs), 539-540, 542-544t, 545 Antihistamines, 66, 77-78, 296Antimicrobial therapy, 397Antiretroviral therapy (ART) and HIV, 385, 651-652, 653t Anxiety, 428-435 ADHD and, 81 assessment of, 430-431children/adolescents and, 435database used for, 429-430overview of, 428-429during pregnancy, 290psychosocial treatment, 434special populations and, 434-435treatment of, 431-432, 433t, 434 Anxiety Disorders Association of America, 435 APA. See American Psychiatric Association (APA) Apgar scores, 8, 15, 100Aphasia syndromes, 505Apnea fatigue and, 82in infants, 13 APNs (advanced practice nurses), 104, 107Arousal disorders, 226Arthritis. See Osteoarthritis (OA) ASB (asymptomatic bacteriuria), 323-324ASCCP (American Society for Colposcopy and Cervical Pathology), 174 ASC-H (atypical squamous cells of undetermined significance cannot rule out high grade), 173, 180-181f ASC-US (atypical squamous cells of undetermined significance), 173, 177f, 178f Asherman syndrome, 157Association of Asthma Educators, 446Association of Nurses in AIDS Care (ANAC), 669 Association of Reproductive Health Professionals, 226 Association of Reproductive Health Professionals (ARHP), 236 Asthma, in adolescents/adults, 436-448 action plan for, 446, 447-448fassessment of, 438clinical management goals to control, 438 Index723

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Asthma, in adolescents/adults (cont. ) database used for, 437-438 diagnostic screening and testing of, 439, 441, 441f etiology of, 436management of, 441, 442-443t, 444overview of, 436-437patient education and training in, 444-446, 445-446b severity/control/response to treatment, 438, 439t, 440t Asthma, in children, 61-69 assessment of, 62atopic dermatitis and, 70classifying severity/control of, 62, 63-64tclinical management goals in, 65databases used for, 61-62defined, 61medication for, 66-67, 66toverview of, 61prevalence and incidence, 61treatment and management of, 65 Asymptomatic bacteriuria (ASB), 323-324Atomoxetine, 86Atopic dermatitis (AD), 70-79 assessment of, 72clinical management goals in, 72, 73conditions and features associated with, 72, 74f databases used for, 70-72defined, 70diagnostic tests for, 72, 75tdifferential diagnoses, 72, 76fetiology, 70overview of, 70phases of, 71, 72fprevalence and incidence, 70psychosocial and emotional support and, 79 self-management of, 78signs/symptoms of, 72treatment and management of, 73, 74, 75, 76-78 triggering factors for, 71, 71f Atopic eczema. See Atopic dermatitis (AD) Atrial fibrillation (AF), 416, 417t Attention-deficit/hyperactivity disorder (ADHD), 80-88 assessment of, 84database used for, 81-83incidence and prevalence, 81long-term issues, 87medications for, 84, 85t, 86overview of, 80-81physical examination for, 83-84screening tools for, 82, 82ttransition to adulthood, 88treatment and management of, 84, 86-88 Attorney General opinions, 3Atypical glandular cells (AGC), 174Atypical squamous cells, 173 ASC-H, 173, 180-181f ASC-US, 173, 177f, 178f AUB. See Abnormal uterine bleeding (AUB) Autism. See also Developmental delay and autism, screening for screening for, 48-59 Autism spectrum disorders (ASD), 347-348 B Babies, healthy, 7-10Back pain. See Low back pain (LBP) Back Pain Support Group, 703Bariatric surgery, 121, 645-646Barrett 's esophagus, 547Barrier methods, contraception, 230-232, 234-235, 236 contraceptive sponge, 231diaphragm, 231-232female condoms, 231Fem Cap, 232male condoms, 230-231 Battering. See Intimate partner violence (IPV) BBD (bladder and bowel dysfunction), 124, 125 Beck Depression Inventory-Primary Care Version (U. S. Preventive Services T ask Force), 36 Bedwetting Store, 139Behavioral variant frontotemporal dementia (bv FTD), 505 Behavior Assessment System for Children (Reynolds & Kamphaus), 57 Behavior changes in adults. See Lifestyle changes Benign prostatic hyperplasia (BPH), 449-454 assessment of, 451clinical management goals for, 451database used for, 450-451defined, 449diagnostic screening and tests for, 451, 452b, 453f impact index, 457management and treatment of, 451-452, 454overview of, 449patient and family education on, 454physical examination findings, 451prevalence and incidence, 449-450self-management resources and tools, 454symptom index, 456 Benzodiazepines, 432β 2-Agonists, 441 Beta blockers, 572t Bethesda System Pap smear classification, 172-173t, 173-174 Beyond Blue, 527Bicipital tendinopathy, 705-706, 708Bioidentical hormone therapy, 222, 223Biomarkers, 509Bipolar affective disorder (BAD), 92, 678Birth control. See Hormonal contraception; Nonhormonal contraception Birth Control Method Explorer, 38Birth to 5: Watch Me Thrive! (U. S. Departments of Health and Human Services and Education), 48 Birth weight, 16, 16t BJI (Bone and Joint Initiative), 695“Black box” labeling, 94-95Bladder and bowel dysfunction (BBD), 124, 125 Bladder disorders. See Urinary incontinence (UI) Bladder training, 240, 241t Bladder wall muscle, 124Bleeding abnormal uterine bleeding. See Abnormal uterine bleeding (AUB) acute bleeding, 147, 151breakthrough bleeding, 201chronic bleeding, 151withdrawal bleeding, 201 Blindness, 554Blood pressure (BP), 583, 584, 584t. See also Hypertension (HTN) Blood pressure, accurate measurements, steps for, 316t Body mass index (BMI), 118, 634Bone and Joint Initiative (BJI), 695BPH. See Benign prostatic hyperplasia (BPH) Brain imaging, 509Breakthrough bleeding, 201Breastfeeding, bottle feeding vs., 8, 13, 101Brief Infant/T oddler Social Emotional Assessment (Briggs-Gowan, Carter, Irwin, Wachtel, & Cicchetti), 57 Brigance Screens II (Glascoe), 57Bright Futures: Guidelines for Health Supervision of Adolescents (American Academy of Pediatrics and the Maternal Child Health Bureau), 38 Bromocriptine, 166Bronchitis, chronic. See Chronic obstructive pulmonary disease (COPD) Bronchodilators, 471724 INDEX

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Bruises on children, 107 Bupropion, 86, 675, 678Burns on children, 108 C Cabergoline, 166Calcineurin inhibitors, topical, 77California Diabetes and Pregnancy Program, 310 Caloric intake and absorption, 99-100Canadian Centre for Occupational Health and Safety, 711 Cancer screening for cervical, vaginal, and vulvar cancers cervical cancer in adolescents, 36 Cancer survivorship, 458-466 assessment of, 461, 462, 462fclinical management goals, 462, 463consultations and referrals, 466database used for, 459-460defined, 458diagnostic testing and, 463epidemiology, 459overview of, 458patient education on, 463physical examination findings, 460, 461t Cardiovascular disease (CVD), 613. See also Heart failure HIV and, 654 Caregivers, 511, 512, 564-565Caregiver Strain Index (CSI), 512Carrier screening for recessive conditions, 255-256, 255t Cataracts, 450Catch-up growth, 103. See also Growth trends CBT (cognitive behavioral therapy), 95, 97, 434 CDC. See Centers for Disease Control and Prevention (CDC) Cell-free fetal DNA testing, 255Center for the Health Professions, 4Centering Pregnancy (prenatal care model), 260, 261t Centers for Disease Control and Prevention (CDC), 38, 574 on asthma in children, 69 Division of Diabetes, 310 on HIV/AIDS, 649-650on immunization schedules, 326, 327-329f on obesity, 634on postexposure prophylaxis for HIV, 375sex-specific BMI-for-age growth charts, 114on smoking, 672 Cephalosporins, 78Cerebral palsy (CP), 346-347Cervical spine diseases, 692. See also Upper back/neck pain Cervicothoracic myofascial pain syndrome, 692-693 Cesarean deliveries, 7, 282. See also Vaginal birth after cesarean (VBAC) CHA2DS 2-VASc score, 416, 417t CHADS2 score, 416, 417t Chamomile, 291Chart reviews, 5CHCs. See Combined hormonal contraceptives (CHCs) Chemoprophylaxis, USPSTF recommenda-tions for prevention, 336t Chest radiographs, 65Child abuse and neglect. See Maltreatment of children Child Abuse Prevention and T reatment Act, 104 Childbirth Connection, 252Child Development Inventories (Doig, Macias, Saylor, Craver, & Ingram), 57 Child Protective Services (CPS), 107Children. See Pediatric health maintenance and promotion Children Now, 38Children's National Medical Center, 103Child Welfare and Information Gateway, 112Chlamydia screening, 36Chorionic villus sampling (CVS), 257Chronic bleeding, 151Chronic kidney disease (CKD), HIV and, 654 Chronic lung disease (CLD), in infants, 12-13 Chronic neuropsychiatric conditions, 80Chronic nonmalignant pain (CNP), 477-492 assessment of, 480, 481clinical management goals, 481-482databases used for, 478-480, 479f, 481fdefined, 477-478, 478fdiagnostic screening and tests, 479f, 480management and treatment of, 482-491, 484-487f, 488-489t overview of, 477-478, 478fpatient education, 491physical examination findings, 480prevalence of, 478support resources and tools, 492 Chronic obstructive pulmonary disease (COPD), 468-475 clinical management goals, 471combined assessment of, 470, 470tdatabase used for, 469-471defined, 468management and treatment of, 471-475, 472t, 473-474t overview of, 468physical examination findings, 469, 469tprevalence and incidence, 468spirometric testing for, 469, 470t Chronic pain syndrome, 477, 478Chronic venous disease (CVD), 714Chronic viral hepatitis, 494-503 assessment of, 498clinical management goals, 498-499databases used for, 495-497diagnostic tests for, 496-498tmanagement and treatment of, 498-503, 501-502t overview of, 494-495patient education and resources on, 502-503, 502t physical exam findings, 496, 496t Chronic wounds, 713-714, 719-720Cirrhosis, 494CISA. See Clinical Immunization Safety Assessment (CISA) Citizens United for Research in Epilepsy (CURE), 546 Client education. See Patient and family education and resources Clinical depression, 92Clinical Immunization Safety Assessment (CISA), 46 CNP. See Chronic nonmalignant pain (CNP) Coagulopathy, 144COC (combined oral contraceptives) pills, 151, 192, 200-201, 205-206 COEIN etiologies (coagulopathy, ovulatory, endometrial, iatrogenic, not yet classified), 144-145 Cognitive behavioral therapy (CBT), 95, 97, 434 Cold sores. See Herpes simplex virus (HSV) infections Collaborative practices, 4-5Colposcopic evaluation, 174, 175Combination therapies, 222, 223t Combined hormonal contraceptives (CHCs) assessment for, 205 COC pills, 151, 192, 200-201, 205-206 contraindications to start, 192, 193-199toral contraceptives, comparison of, 209-214t transdermal patch, 201, 206vaginal contraceptive ring, 201-202, 206 Index725

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Combined oral contraceptives (COC) pills, 151, 192, 200-201 Common adult presentations. See Adult presentations Common obstetric presentation. See Obstetric presentations Common pediatric presentations. See Pediatric presentations Communication with developmentally disabled adults, 348-349 Comorbidities, effect on warfarin stability, 418 Complementary and alternative medicine methods, 434 Condoms, as barrier method of contraception female, 231 male, 230-231 Conduct disorder, 81Confusion Assessment Method (CAM), 558f, 560 Congenital hypothyroid screening of infants, 9 Congenital scoliosis, 695Consent, patient adolescents and, 32-33for birth choice, 285-287f Constipation, 610, 611t Contraception. See Hormonal contraception; Nonhormonal contraception Contraceptive sponge, 231Contraindications, for stimulants, 86-87Controlled substances. See Opiates Controller medications, 66, 441COPD. See Chronic obstructive pulmonary disease (COPD) Copper T 380-A intrauterine contraceptive, 232-235, 236 Cortical inhibitory pathway, 124Corticosteroids, 77, 471Counseling. See Patient and family education and resources CP (cerebral palsy), 346-347CPS (Child Protective Services), 107CRAFFT (mnemonic), 36CURE (Citizens United for Research in Epilepsy), 546 Current Procedural T erminology (CPT), 48Cushing's disease, 157Cutaneous abscesses, management of, 395-400 assessment of, 396clinical management goals for, 396database used for, 395-396overview of, 395 CVS (chorionic villus sampling), 257Cyclothymia, 92Cystitis, 323-324Cytology. See Abnormal cytology D Dating violence. See Intimate partner violence (IPV) Daytime urinary incontinence, 125DCM (dilated cardiomyopathy), 566Degenerative joint disease. See Osteoarthritis (OA) Degenerative scoliosis, 695Delirium, 555-557, 560, 561, 561t Dementia, 504-513 assessment of, 509caregiver support and resources, 512causes of, 504, 505tclinical management goals for, 509database used for, 505, 506t, 507-509diagnostic tests for, 508-509, 509tfrontotemporal, 504, 505, 507-508management and treatment of, 509-512, 510t mixed, 505overview of, 504-505, 505tvascular, 504, 507 Dementia with Lewy bodies (DLB), 504, 505, 507 Denver II Developmental Screening T est (Frankenburg, Camp, & Van Natta), 57 Depo-Provera®, 202Depression, adults, 514-527 assessment of, 518-519databases used for, 516-518, 517tdefinition of, 514diagnostic screening and tests, 515f, 517-519, 518t, 521 management and treatment of, 521, 522-525t medications causing, 518, 518toverview of, 514-516, 515f, 516fpatient and family education on, 521physical examination findings, 517in pregnancy, 290self-management resources and tools, 527 Depression, childhood, 90-98 ADHD and, 82 adolescent, 36assessment of, 94databases used for, 92-93medication for, 94-95, 96-97t, 97overview of, 90-91self-management resources in, 98treatment and management of, 94-95, 97 Depression and Bipolar Support Alliance, 527De Quervain's tenosynovitis, 706Dermatitis. See Atopic dermatitis (AD) Detrusor muscle, 124Developmental delay and autism, screening for, 48-59. See also Development and behavior appraisal clinician resources for, 58-59overview of, 48psychometrics, 57-58surveillance and screening algorithm for, 49-57, 50-51f, 52-56t tools for, 52-56t Developmental disabilities (DDs), adults with, health maintenance for, 345-363 assessment of, 351, 352databases used for, 348-351defined, 346diagnostic tests, 352, 354-361thealthcare maintenance guidelines for, 354-361t interdisciplinary healthcare teams and, 350, 351f overview of, 345-348physical examination considerations and, 350-351, 352f, 353f self-management resources and tools, 362, 363 treatment of, 353, 362 Developmental Disabilities Assistance and Civil Rights Act of 2000, 346 Developmental kyphosis, 695Developmental screening tools, 52-56t Developmental surveillance and screening algorithm, 49-57, 50-51f, 52-56t Development and behavior appraisal. See also Developmental delay and autism, screening for 0-3 years, 193-6 years, 23-246-11 years, 27infants and, 14screening tests and tools, 48-50 Dextroamphetamine, 84DFU (diabetic foot ulcer), 714, 715, 717-718, 720-721 Diabetes mellitus, 529-538. See also Gestational diabetes mellitus (GDM) assessment of, 531, 531tclinical management goals for, 532, 532tdatabase used for, 529-530diagnosis screening and tests for, 530, 531tfoot ulcers and, 714HIV and, 654management and treatment of, 532-537, 533t, 534f, 535-536t overview of, 529726 INDEX

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patient and family education on, 537 self-management resources and tools, 537-538 Diabetic foot ulcer (DFU), 714, 715, 717-718, 720-721 Diagnostic and Statistical Manual for Mental Disorders (DSM) on anxiety, 430-431on autism spectrum disorders, 347on childhood depression, 91on depression, 514, 518on transgendered individuals, 365 Diagnostic screening and tests for 0-3 years, 20-21for 3-6 years, 24-25for 6-11 years, 29for 12-21 years, 36for abscesses, 397for ADHD, 82-83for amenorrhea and PCOS, 161, 162, 163-165t, 165 for anemia in adults, 408-410, 409t, 411t for asthma, 62, 65, 439, 441, 441ffor atopic dermatitis, 72, 75tfor AUB, 147, 148-150tfor benign prostatic hyperplasia, 451, 452b, 453f for cancer screening, 179and cancer survivorship, 463for chronic viral hepatitis, 496-498tfor CNP, 479f, 480for dementia, 508-509, 509tfor depression in adults, 515f, 517-519, 518t for diabetes in pregnancy, 306, 307tfor diabetes mellitus, 530, 531tfor epilepsy, 540, 545for FTT in infancy, 102for GERD, 550for heart failure, 568-569for HIV, 657, 660-661HIV infection and, 381, 382tfor hormonal contraception, 205for HSV infections, 578-579for hypertension, 586-587, 587tfor IBS, 607, 608-609tinfants and, 9for intimate partner violence, 601for lipid disorders, 615-616for low back pain, 624-625maltreatment of children and, 111for menopause transition, 221for nonhormonal contraception, 235for obesity, 117-118, 637for post-NICU patients, 16postpartum, 272for preeclampsia-eclampsia, 317for preexposure prophylaxis for HIV, 388pregnancy and, 248, 249b, 260, 262tprenatal genetic, 253-257for smoking, 677for thyroid disorders, 684, 686-687t, 687, 688-689 for transgendered individuals, 367, 368tfor upper back/neck pain, 698t, 700, 700t for upper extremity tendinopathy, 707, 708, 709 for urinary incontinence in children, 131, 132-133f, 134f for urinary incontinence in women, 238-239, 238t Diaphragm, 231-232Diarrhea, 610, 611t Diastolic heart failure, 566Diastolic HTN, 583Diet history and obesity, 636interventions and patient motivation, 638, 639-641f Differential diagnoses for abscesses, 396for anemia in adults, 408-410, 409tfor asthma, 62, 438for atopic dermatitis, 72, 76ffor heart failure, 568for preeclampsia-eclampsia, 317during pregnancy, 293, 295for urinary incontinence in women, 237, 237t Dilated cardiomyopathy (DCM), 566Diphtheria and tetanus toxoids and acellular pertussis vaccine (DT a P), 42 Discomforts, of pregnancy, 290-300 musculoskeletal pain, 291-294overview of, 290poor quality of sleep, 290-291 Diuretic therapy, 573t DLB (dementia with Lewy bodies), 504, 505, 507 Documentation, importance of, 1, 4-5Domestic violence. See Intimate partner violence (IPV) Dopamine agonists, 166Dopamine antagonists, 296, 297Down syndrome, 348DREAMS mnemonic, 429Drugs and alcohol use. See Substance use and abuse DT a P vaccine, 42Dysfunctional uterine bleeding (DUB). See Abnormal uterine bleeding (AUB) Dyslipidemia screening, 25, 29, 36Dysmorphic features, 101Dyspnea, 566Dysthymia, 92-93, 514 E Early and Periodic Screening, Diagnostic, and T reatment (EPSDT), 48 E-cigarettes, 673Economic abuse, 594ECP (emergency contraception pill), 203-204, 205, 207, 230, 233 Eczema. See Atopic dermatitis (AD) Education. See Patient and family education and resources Elbow tendinopathy, 706, 708Elderly. See Older adults Emergency contraception pill (ECP), 203-204, 205, 207, 230, 233. See also Hormonal contraception Emotional abuse, 594Emotional or psychologic abuse. See Maltreatment of children Emotional/psychologic abuse, 105Emphysema. See Chronic obstructive pulmonary disease (COPD) Endocervical sampling, 175End-of-life and palliative care, 512, 573Endometrial etiologies, 144Endometrial sampling, 175End-organ abnormalities, 157Enuresis risoria, 125Environmental history. See Family and social histories Environmental toxin exposures, 468Epilepsy, 348, 539-546, 541t assessment of, 540, 541clinical management goals for, 541, 545database used for, 539-540defined, 539diagnostic screening and tests for, 540, 545 overview of, 539physical examination for, 540referral guidelines, 545self-management resources, 546treatment and management of, 545, 545t Epilepsy Therapy Project, 546Equianalgesic tables, 488, 490Erythropoiesis, 401Escitalopram, 95Esophageal carcinoma, 547Estradiol, 218Estrogens, 192, 200, 218, 221Estrogen therapy, 222, 222t Ethical concerns, 1Ethinyl estradiol, 147 Index727

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Ethnicity-based health issues carrier screening and, 255-256, 255t chronic viral hepatitis and, 494 HIV and, 651 hypertension and, 588 PCOS and, 158 Exacerbations of COPD, 472, 474-475Executive Function Performance T est, 508Exercise. See Physical activity External sphincter muscle, 124 F Failure to thrive (FTT), 99-103Fallopian tubal patency, 188Falls, as geriatric syndromes, 555, 556, 557, 561 prevention of, 334-335f FAM (fertility awareness methods), 230, 233-234 Familial transmission of depression, 91Family and social histories 0-3 years, 183-6 years, 236-11 years, 2712-21 years, 33-34abscesses and, 395amenorrhea and, 158of anemia in adults, 405-407asthma and, 61, 437atopic dermatitis and, 71AUB and, 146benign prostatic hyperplasia and, 450cancer survivorship and, 460chronic viral hepatitis and, 495-496CNP and, 480COPD and, 469depression and, 90-93, 516of developmentally disabled adults, 350diabetes mellitus and, 530epilepsy and, 539FTT in children and, 100GERD and, 548heart failure and, 567hormonal contraception and, 204HSV and, 577hypertension and, 585IBS and, 606infants, 8lipid disorders and, 614low back pain and, 623maltreatment of children and, 106-107menopause transition and, 219nonhormonal contraceptives and, 234-235 obesity and, 115, 636PCOS and, 161of post-NICU patients, 15postpartum care and, 269preeclampsia-eclampsia and, 315pregnancy and, 247smoking and, 675thyroid disorders and, 683-684transgendered individuals and, 366upper back/neck pain and, 696upper extremity tendinopathy and, 707wound care and, 715 Family Caregiver Alliance, 513, 564Family education. See Patient and family education and resources Family Smoking Prevention and T obacco Control Act, 2009, 673 Fatigue. See Sleep FDA. See U. S. Food and Drug Administration (FDA) Female condoms, 231Female-to-male (FTM) identities, 366, 368, 371t Fem Cap, 232Feminizing hormone options, 369t Fertility awareness method (FAM), 230, 233-234 Fetal fibronectin (f FN), 321Fever blisters. See Herpes simplex virus (HSV) infections FHA (functional hypothalamic amenorrhea), 156 First well-baby visits, 7-10Fluoxetine, 95Fluvoxamine, 95Folate (folic acid) deficiency, 405, 407, 410, 413 Food and Drug Administration. See U. S. Food and Drug Administration (FDA) Forced expiratory volume (FEV), 439, 469Forced vital capacity (FVC), 439, 469Formal developmental assessments, infant, 14Fractures, in children, 108-109Frailty, 554, 556, 557, 561-562Frontotemporal dementia (FTD), 504, 505, 507-508 FTT. See Failure to thrive (FTT) Functional Activities Questionnaire, 508Functional bowel disorder. See Irritable bowel syndrome (IBS) Functional hypothalamic amenorrhea (FHA), 156 G Gastroesophageal reflux disease (GERD), 547-553 assessment of, 549clinical management goals, 550databases used for, 548-549defined, 547diagnostic screening and tests for, 550in infants, 13management and treatment of, 550-551, 552t, 553 overview of, 547-548, 548tpatient education and resources on, 553pregnancy and, 298-300, 299t Gastrointestinal tract during pregnancy, 294-295, 295t, 296, 297-298, 297t GCT (glucose challenge test), 306GDM (Gestational diabetes mellitus) in pregnancy, 304-310 Geisinger's Health Library, 690Gender identity disorder. See T ransgendered individuals, health maintenance for General Anxiety Disorder-7 screening tool (GAD-7), 429, 430f Generalized anxiety disorder, 428, 431Genetics disorders, 348prenatal diagnosis. See Prenatal genetic diagnosis prenatal screening. See Prenatal genetic screening transmission of depression, 91 Genital HSV, 575, 576f Genitourinary syndrome of menopause (GSM), 217-218 GERD. See Gastroesophageal reflux disease (GERD) Geriatric Depression Scale, 508, 512, 516Geriatrics. See Older adults Geriatric syndromes, 554-565 assessment of, 560-561clinical management goals, 562database used for, 556-557, 560defined, 554delirium, 555-557diagnostic tests for, 562-564, 563tfalls, 555, 556frailty, 554, 556online resources for clinicians/patients/ caregivers, 564-565 physical examinations for, 557, 558-559f, 560t sensory impairment, 554-555, 556treatment and management of, 562-564urinary incontinence, 555, 556 Gerontological Advanced Practice Nurses Association, 564 Gestational diabetes mellitus (GDM), in pregnancy, 304-310, 529. See also Diabetes mellitus728 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

clinical management goals for, 306 defined, 305 GDM A1/A2, postpartum management of, 309-310 methods to diagnose, 306, 307toverview of, 305prevalence and incidence, 305women with, resources for, 310 Giggle incontinence (enuresis risoria), 125Global Consensus Statement on Menopausal Hormone Therapy, 221 Global Initiative for Chronic Obstructive Lung Disease (GOLD), 469, 471, 475 Glucose challenge test (GCT), 306Goiter. See Thyroid disorders Gonadal dysgenesis, 157Gonadotropin-releasing hormone agonists, 152 Gonorrhea screening, 36Group and family therapies, 434Growth trends catch-up growth, 103FTT and, 101infants and, 8post-NICU patients and, 16 GSM (genitourinary syndrome of menopause), 217-218 Gynecology. See also specific issues abnormal uterine bleeding. See Abnormal uterine bleeding (AUB) amenorrhea and PCOS, 156-169hormonal contraception, 192-207lower genital tract, cancer screening for, 171-186 menopause transition, 217-227nonhormonal contraception, 230-236oral contraceptives, comparison of, 209-214t sterilization, 188-190urinary incontinence, 237-244 H H2RA (histamine-2 receptor antagonists), 298, 300 Haemophilus influenzae Type B (Hib) vaccine, 42, 45 Hartford Institute for Geriatric Nursing, 565HBV (hepatitis B virus). See Chronic viral hepatitis HCV (hepatitis C virus). See Chronic viral hepatitis HDL. See High-density lipoprotein (HDL) Head trauma, in children, 109Healia Health Communities and Support Groups, 703Health assessment form, 349Healthcare disparity, 345Healthcare for Adults with Intellectual and Developmental Disabilities, 362 Health education. See Patient and family education and resources Health histories 0-3 years, 183-6 years, 236-11 years, 2712-21 years, 33abscesses and, 395ADHD in children and, 84of adults with developmental disabilities, 349-350 amenorrhea and, 158anemia and, 405-407asthma and, 61, 437atopic dermatitis and, 70-71AUB and, 145-146benign prostatic hyperplasia and, 450cancer survivorship and, 459-460chronic viral hepatitis and, 495-496CNP and, 480COPD and, 469depression and, 518diabetes mellitus and, 529-530epilepsy and, 539FTT in children and, 100heart failure and, 567HIV infection and, 380-381hormonal contraception and, 204HSV and, 577hypertension and, 585IBS and, 606of infants, 8lipid disorders and, 614low back pain and, 623lower genital tract cancer and, 176menopause transition and, 219obesity and, 115, 636PCOS and, 161of post-NICU patients, 15preeclampsia-eclampsia and, 315Pr EP and, 386, 387PTB risk and, 320-321smoking and, 675sterilization and, 190thyroid disorders and, 683-684of transgendered individuals, 366transgendered individuals and, 366upper back/neck pain and, 695-696upper extremity tendinopathy and, 706-707 urinary incontinence in children, 126, 128urinary tract infection and, 323wound care and, 714-715 Health maintenance and promotion, adult, 326-343 assessment of, 333, 335-336bclinical management goals for, 333database used for, 331, 332t, 333overview of, 326 Healthy People 2010 (U. S. Department of Health & Human Services), 634 Healthy People 2020 (U. S. Department of Health & Human Services), 33, 634-635 Hearing impairment, 554-555, 556, 561Hearing screening 0-3 years, 9, 13-14, 203-6 years, 256-11 years, 29 Heartburn. See Gastroesophageal reflux disease (GERD) Heart failure, 566-574 assessment of, 568clinical management goals, 568database used for, 567-568defined, 566diagnostic tests for, 568-569overview of, 566-567physical examinations for, 568treatment and management for, 569, 570f, 571, 571b, 573-574 HEEADSSS (mnemonic), 34HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, 295, 313 Hemiplegic cerebral palsy, 347Hemoglobin, and hematocrit screening, 36Hemolytic anemia, 404, 406-407, 410, 412Hepatitis A (Hep A) vaccine, 43, 45Hepatitis B vaccine, 42Hepatitis B virus (HBV), 494Hepatitis C virus (HCV), 494-495Hepatocytes, 494Hepcidin, 404Herbal alternatives, for menopause transition, 224 Herpes Resource Center, 581Herpes simplex virus (HSV) infections, 78, 575-581 assessment of, 577-578clinical management goals, 578database used for, 577diagnostic screening and tests for, 578-579 overview of, 575treatment and management of, 579-580, 579-580t types of, 575-576 Index 729

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

HG (hyperemesis gravidarum), 294 Hib vaccine, 42High-density lipoprotein (HDL), 613High-grade squamous intraepithelial lesion (HSIL), 174, 181f Histamine-2 receptor antagonists (H2RA), 298, 300 HIV (Human immunodeficiency virus), 649-669. See also Postexposure prophylaxis (PEP), for HIV infection assessment of, 663care continuum, 652, 653-654, 653f, 657clinical management goals, 663database used for, 661-663diagnostic screening and tests, 657, 660-661 epidemiology, 649-651, 650timmunizations for, 657, 658-660tinfectious fluids, 375, 376tpathogenesis, 651-652, 653fpatient education on, 668preexposure prophylaxis for. See Preexposure prophylaxis (Pr EP), for HIV routes of exposure to, 375, 376tscreening for, 36status, documenting, 387ftreatment and management of, 663, 666t, 667-668 Hormonal contraception, 192-207 alternatives to oral contraception, 215-216t assessment of, 205clinical management goals in, 205COC pills, 200-201, 205-206combined hormonal contraception, 192, 200-202 contraindications to, 192, 193-199tdatabases used for, 204-205emergency contraception pill, 203-204oral contraceptives, comparison of, 209-214t overview of, 192patient adherence, 206-208physical examinations for, 204-205progestin-only contraception, 202-203transdermal patch, 201treatment and management of, 206-208vaginal contraceptive ring, 201-202 Hormonal gender reassignment therapy, 367Hormone therapy (HT), 221-223Hospital Elder Life Program, 565Hospital for Sick Children, 294HPV (human papillomavirus), 171HPV DNA testing, 174HSDD (hypoactive sexual desire disorder), 225 HSG (hysterosalpingography), 189HSIL (high-grade squamous intraepithelial lesion), 174, 181f HSV infections, 78. See Herpes simplex virus (HSV) infections HT (hormone therapy), 221-223HTN. See Hypertension (HTN) Human papillomavirus (HPV), 44, 45, 171Hydration, during pregnancy, 2965-Hydroxytryptamine 3-receptor antagonists, 297 Hyperemesis gravidarum (HG), 294Hyperglycemia and Adverse Pregnancy Outcomes (HAPO), 305 Hyperkyphosis, 695Hyperprolactinemia, 157, 167Hypertension (HTN), 583-593 assessment of, 587classification of, 583clinical management goals, 587database used for, 584-587defined, 583diagnostic screening and tests for, 586-587, 587t management and treatment of, 587-588, 589f, 590-591t, 592 patient education on, 592in pregnancy. See Preeclampsia-eclampsia prevalence of, 583substances associated with, 585, 586t Hyperthyroidism, 682-683, 689Hypertriglyceridemia, 613Hypoactive sexual desire disorder (HSDD), 225 Hypoglycemia, 530. See also Diabetes mellitus Hypothalamic amenorrhea, 156, 166. See also Amenorrhea; Polycystic ovarian syndrome (PCOS) Hypothalamic-pituitary-ovarian (HPO) axis, 140, 156 Hypothyroidism, 156Hysterectomy, 153, 188, 283Hysterosalpingography (HSG), 189Hysteroscopy, 189 I IASP (International Association for the Study of Pain), 477 Iatrogenic etiologies, 144-145IBS. See Irritable bowel syndrome (IBS) Ibuprofen, 151ID (intellectual disability), 346Idiopathic scoliosis, 695IFIS (intraoperative floppy iris syndrome), 450 Ig E sensitization, 65, 70, 436, 441ILAE (International League Against Epilepsy), 539 Immunizations 0-3 years, 213-6 years, 256-11 years, 2912-21 years, 33, 37active vs. passive, 46infants, 9lag in, 37modalities, 45-46pediatric schedule, 42-44schedules, 42 Implanon®, 202Implants, contraceptive, 202-203, 207IN (intraepithelial neoplasia), 171Inactivated poliovirus vaccine (IPV), 43Incision and drainage procedure, 397, 398-400 Independent practices, 4Independent reports on maltreatment of children, 110, 110t Individuals with Disabilities Education Improvement Act (IDEA), 48 Infants, healthy, 7-10Infectious Disease Society of America (IDSA), 649 Influenza vaccine, 43, 44Inhaled corticosteroids (ICS), 66Inhalers, 444-445b, 445 nicotine, 678 Injectable progestin, 202, 206-207Injuries, 106INR. See International Normalized Ratio (INR) Insomnia, during pregnancy, 291Institute of Medicine (IOM), 458Instrumental activities of daily living (IADLs), 561 Instrumental Activities of Daily Living Scale, 508 Insulins, 535, 536t Intellectual disability (ID), 346Interdisciplinary healthcare teams, 350, 351f Intermenstrual bleeding, 219International Association for Study of Pain (IASP), 477, 492 International Association of Diabetes and Pregnancy Study Groups (IADPSG), 305-306730 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

International Children's Continence Society, 139 International Classification of Diseases-10 codes, 480 International League Against Epilepsy (ILAE), 539 International Normalized Ratio (INR) managing variations in, 419, 420-421t variables in warfarin response, 416-419, 417-418t, 419t warfarin therapy, monitoring of, 415, 416t International Premature Ovarian Failure Support Group, 169 International Society for Hypertension (ISH), 584 Intimate partner violence (IPV), 594-602 assessment of, 600-601, 600tcategories of, 594client/patient education, 601clinical management goals for, 601consequences of, 595, 596database used for, 598, 599tdefined, 594diagnostic testing for, 601overview of, 594physical examination for, 599, 599tprevalence and incidence, 595self-management resources and tools, 601-602 special risk populations, 596-598ttreatment and management of, 601victimization by race/ethnicity, 595, 595t Intraepithelial neoplasia (IN), 171Intraoperative floppy iris syndrome (IFIS), 450 Intrauterine contraceptive (IUC), 230, 232-233 Intravenous fluid therapy, 296Iodine deficiency, and thyroid disorder, 682I P V. See Intimate partner violence (IPV) IPV (inactivated poliovirus) vaccine, 43Iron deficiency, 20 anemia, 402, 403, 405-406, 408-409, 409t, 410, 411-412 Irritable bowel syndrome (IBS), 605-612 assessment of, 607clinical management goals, 607database used for, 606defined, 605diagnostic testing for, 607, 608-609tepidemiology, 605-606overview of, 605-606pathophysiology of, 606patient and family education on, 611physical examination for, 606symptoms of, 605treatment and management of, 607, 609-611, 611t Irritable Bowel Syndrome Association, 612 Irritants, asthma and, 66, 436IUC (intrauterine contraceptive), 230, 232-233 J John A. Hartford Foundation, 565Johns Hopkins Medical School, 454Joint National Committee on Prevention, Detection, Evaluation, and T reatment of High Blood Pressure ( JNC 7), 583-584 Joslin Diabetes Center, 538Juvenile Diabetes Research Foundation International, 538 K Kaiser Family Foundation, 38Kaiser Permanente Chronic Pain Program and Support Group, 492 Kyphosis, 695 L Labor management, preterm, 320-322Lactational amenorrhea method (LAM), 230, 234 LAM (lactational amenorrhea method), 230, 234 LARC (long-acting reversible contraception), 192, 232 Lateral epicondylitis, 706, 708Laughter Y oga International, 492LBP. See Low back pain (LBP) Lead screening 0-3 years, 203-6 years, 256-11 years, 29 Learning disabilities, screening for, 83Left ventricular heart failure, 566Legal issues implications of reporting child maltreatment, 110t scope of practice, 1-5 Legislative updates, 4Leiomyomas, 142, 144, 153LES (lower esophageal sphincter), 547Levonorgestrel, 192Levonorgestrel intrauterine system (LNG-IUS), 203, 207 Life expectancy, adults with developmental disabilities, 345Lifestyle changes for hypertension, 587-588and menopause transition, 224for obesity and weight loss, 118, 120-121, 120f, 642, 643-644f, 644-645 for smoking cessation, 679 Lipid disorders, 613-618 assessment of, 615classifications of, 613-614clinical management goals, 615database used for, 614-615defined, 613diagnostics tests for, 615-616overview of, 613patient education, 618prevalence of, 613treatment and management of, 616, 617t Lipid profile, 0-3 years, 21Liver diseases, 494LNG-IUS (levonorgestrel intrauterine system), 203, 207 Long-acting reversible contraception (LARC), 192, 232 Low back pain (LBP), 619-633 assessment of, 625causes of, 619, 619tdatabase used for, 619, 621t, 622-625, 622t diagnostic screening and tests for, 624-625 management and treatment of, 626-627, 631-633 overview of, 619patient education on, 627, 627f, 628-631f, 631-633 physical examinations for, 621t, 623-624 pregnancy and, 291-294 Lower esophageal sphincter (LES), 547Lower genital tract, cancer screening for, 171-186 abnormal cytology, management of, 174-176, 174-182f assessment of, 177, 178 Bethesda System Pap smear classification, 172-173t, 173-174 clinical management goals, 178, 179database used for, 176, 177diagnostic tests for, 179overview of, 171-172treatment and management of, 179, 183, 184-186f Lower urinary tract symptoms (LUTS), 449, 450 Low-grade squamous intraepithelial lesion (LSIL), 174, 178f, 179f, 180f Index731

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Low transverse cesarean sections (LTCS), 282 Lozenge, 677-678 LSIL (low-grade squamous intraepithelial lesion), 174, 178f, 179f, 180f LTCS (low transverse cesarean sections), 282 Lucile Packard Children's Hospital, 103Lung disease. See Asthma; Chronic obstructive pulmonary disease (COPD) LUTS (lower urinary tract symptoms), 449, 450 Lymphadenopathy, 72 M Mac Arthur Initiative on Depression and Primary Care, 527 Macrocytic anemia, 404-405, 407, 412-413Magnetic resonance imaging (MRI), 293Major depressive disorders (MDD), 91, 92Male condom, 230-231Male-to-female (MTF) identities, 366, 368, 370t Malignancy, 144Maltreatment of children, 104-112. See also specific types of abuse; specific types of abuses assessment of, 110-111databases used for, 106-110independent report triggers for, 110, 110toverview of, 104physical examination findings in, 107-110, 108t safety, 110, 111treatment and management of, 112 Mandatory reporting, on maltreatment of children, 110-111, 110t March of Dimes, 17, 252Masculinizing hormone options, 370t Mayo Clinic, 169, 553MCV (mean cell volume), 404, 410MDD (major depressive disorder), 91, 92Mean cell volume (MCV), 404, 410Measles, 40-41Measles, mumps, rubella (MMR) vaccine, 43, 45 Medical history. See Health histories Medical Nutrition Therapy (MNT), 533Medications. See also Pharmacotherapy/ psychotherapy; specific medications 12-21 years, 33asthma and, 61causing depression, 518, 518tmonitoring, 95prescribing, supervision for, 4for urinary infections in pregnancy, 324tweight gain and, 636 Medroxyprogesterone acetate (MPA), 152, 202 Medscape e Medicine, 103Mefenamic acid, 152Megaloblastic anemias, 404, 407, 410, 412-413Mended Hearts, 574Meningococcal vaccine, 44, 45Menometrorrhagia, 219Menopause hormone therapy (MHT), 221Menopause transition, 217-227 assessment of, 220clinical management goals in, 220clinical practice guidelines for, 226-227database used for, 219-220overview of, 217physical examination findings, 220self-management resources and tools, 226symptoms, 217-219treatment and management of, 221-226types of, 217 Menorrhagia, 140, 219Menstrual cycle. See also Amenorrhea; Polycystic ovarian syndrome (PCOS) disturbances in, 219, 220phases of, 140 Mental status examination (MSE), 93Men who have sex with men (MSM), 385 behavioral risk assessment, 391screening tool for, 392 Merck Medicus Resource Library, 454Methicillin-resistant Staphylococcus aureus (MRSA), 395 MHT (menopause hormone therapy), 221Microcytic anemias, 402-404, 408-410, 411-412 Mirena®, 203Mixed dementia, 505MMR vaccine. See Measles, mumps, rubella (MMR) vaccine MNT (Medical Nutrition Therapy), 533Modified British Medical Research Council Questionnaire for Assessing the Severity of Breathlessness (m MRC), 470, 470t Monophasic COC, 152Monosymptomatic enuresis, 126Montreal Cognitive Assessment (MOCA), 559f, 560 Mood and cognition, menopause transition and, 218, 220, 225 Mortality/morbidity maternal, 283neonatal, 283from preeclampsia, 314 Motherisk, 294MPA (medroxyprogesterone acetate), 152 MRSA (methicillin-resistant Staphylococcus aureus), 395 MSE (mental status examination), 93Müllerian abnormalities, 157Multidisciplinary treatment teams. See Interdisciplinary healthcare teams Multi-infarct dementia, 504Musculoskeletal neck pain, acute, 692Musculoskeletal pain, in pregnancy, 291-294 differential diagnosis and management of, 291, 292t “red flag” symptoms, 292, 292ttypes of, 291 Musculoskeletal strains/sprains, 694Myofascial pain syndrome, 692-693 N NAFC (National Association for Continence), 244 NAMS (North American Menopause Society), 223, 226, 227 Naproxen sodium, 151-152Nasal spray, nicotine, 678National Alliance for the Mentally Ill (NAMI), 435, 527 National Association for Continence (NAFC), 244 National Association of Pediatric Nurse Practitioners, 25 National Cancer Institute (NCI), 458National Center for Health Care T echnology, 282 National Center for PTSD, 435National Center for T ransgender Equality, 372 National Center for Victims of Crime's Stalking Resource Center, 602 National Child Abuse and Neglect Data System (NCANDS), 104 National Childhood Vaccine Injury Act (NCVIA), 46 National Coalition for Cancer Survivorship (NCCS), 458 National Coalition of Anti-Violence Programs, 602 National Comprehensive Cancer Network (NCCN), 462 survivorship baseline assessment guideline, 462f National Diabetes Education Program, 537732 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

National Eczema Association Support Network, 79 National Eczema Society (UK), 79 National Health and Nutrition Examination Survey (NHANES), 583, 634 National Heart, Lung, and Blood Institute, 69, 402, 446, 618 National HIV/AIDS Clinicians' Consulting Center, 384 National Institute for Diabetes, Digestive and Kidney Diseases (NIDDK), 244 National Institute for Health and Clinical Excellence (NICE), 79 National Institute of Allergy and Infectious Disease, 581 National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 703 National Institute of Child and Human Development, 282 National Institute of Diabetes and Digestive and Kidney Diseases, 503 National Institute on Aging, 565National Institutes of Health (NIH), 10, 413, 454 on BMI categories, 634-635on e-cigarettes, 673on GDM, 306on GERD, 553on IBS, 612on VBAC, 282 National Intimate Partner and Sexual Violence Survey (NISVS), 595 National Jewish Medical and Research Center, 69, 77, 79 National Online Resource Center on Violence Against Women, 602 National Sexual Violence Resource Center, 601 National Women's Health Information Center, 252 National Y outh T obacco Survey (NYTS), 673Natural family planning (NFP), 230, 233-234, 235, 236 Nausea and vomiting of pregnancy (NVP), 294-298 pharmacotherapy for, 297 NCANDS (National Child Abuse and Neglect Data System), 104 NCVIA. See National Childhood Vaccine Injury Act (NCVIA) Neck pain. See Upper back/neck pain Neglect, child, 105-106. See also Maltreatment of children physical examination for, 110Nemours Children's Health Systems, 38Neonatal intensive care unit (NICU), 12-17 Nerve impingement, 622, 622t Neural tube defects (NTD), 253, 254-255Neurobehavioral and sensory deficits, 13-14 Neurologic examinations, 624Neuromuscular scoliosis, 695Neuropsychiatric conditions, and ADHD, 83-84 Newborns, 7-10New Y ork Heart Association (NYHA), 566New Y ork State Department of Health (NYSDOH), 375, 376-377t Nexplanon, 202NFP (natural family planning), 230, 233-234, 235, 236 NICE (National Institute for Health and Clinical Excellence), 79 Nicotine addictive nature of, 673replacement product, 674-675, 677-678 Nicotine patch, 677NICU patients, 12-17NIDDK (National Institute for Diabetes, Digestive and Kidney Diseases), 244 Nighttime intermittent incontinence, 125-126 NIPT (noninvasive prenatal testing), 255Nocturnal enuresis, 125-126Nonhormonal contraception, 230-236 assessment of, 235barrier method of contraception. See Barrier methods, contraception clinical management goals in, 235databases used for, 234-235overview, 230self-management resources and tools, 236 treatment and management of, 235-236 Nonhormonal drugs, and menopause transition, 223-224 Noninvasive prenatal testing (NIPT), 255Nonmalignant pain, chronic (CNP). See Chronic nonmalignant pain (CNP) Nonmonosymptomatic enuresis, 126Nonoccupational postexposure prophylaxis (n PEP), 377, 379f. See also Postexposure prophylaxis (PEP), for HIV infection risks and benefits of, 380 Nonsteroidal anti-inflammatory drugs (NSAIDs), 151-152, 482Nonstimulant medications, and ADHD, 86Normocytic anemia, 404, 406-407, 410, 412 North American Menopause Society (NAMS), 223, 226, 227 Not yet classified etiologies, 145Novel antipsychotic medications and weight gain, 636 NSAIDs (nonsteroidal anti-inflammatory drugs), 151-152, 482 Nuchal line, 691Nuchal translucency (NT), 253, 254Nutrition 0-3 years, 193-6 years, 236-11 years, 28FTT and, 99-103infants and, 8, 14menopause transition and, 226post NICU infants and, 15postpartum care, 270pregnancy and, 247, 263, 263t, 296and preterm labor risk, 321supplements use, 419 NVP. See Nausea and vomiting of pregnancy (NVP) O OAB (overactive bladder), 238, 238t, 240, 242t OAC therapy. See Oral anticoagulation (OAC) therapy Obesity, 634-647 in adolescents, 35, 114-115in adults, 635assessment of, 118, 638in children, 635consequences of, 635databases used for, 115, 116f, 117-118, 636-637 diagnostic testing for, 117-118, 637diet interventions and, 638, 639-641fin early childhood, 114etiology of, 635in infancy, 114mental illness and, 635-636overview of, 634patient and family education and resources on, 646-647 in school-age children, 114in special populations, 115treatment and management of, 118, 119t, 120-121, 120f, 642, 643-644f, 644-646 in women, 158 Index733

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Obstetric health maintenance and promotion. See also specific issues medical consultation/interprofessional collaboration/transfer of care during, 277-281 postpartum visits, 268-274prenatal genetic screening and diagnosis, 253-259 prenatal visits, initial, 246-252prenatal visits, return, 260-266 Obstetric presentations. See also specific issues discomforts of pregnancy, 290-300gestational diabetes mellitus in pregnancy, 304-310 preterm labor management, 320-322trial of labor vs. vaginal birth after cesarean, 282-287 urinary tract infection in pregnancy, 323-325 Obstetrics and Gynaecology of Canada Guidelines, 227 Obstructive pulmonary disease, chronic. See Chronic obstructive pulmonary disease (COPD) Occupational and environmental history, asthma and, 61 Occupational exposures (PEP). See Postexposure prophylaxis (PEP), for HIV infection Office of Developmental Primary Care, University of California, 362 OGTT (oral glucose tolerance test), 305Older adults. See also Dementia anxiety disorders and, 434-435individualizing screening decisions, 326, 330-331, 331f prevention of falls in, 334-335f Omalizumab (Xolair), 67Opiates long-acting, 488, 489tpolicies and protocols for, 483, 484-487f, 487, 488-489t, 490-491 risk assessment, 480, 481fshort-acting, 488, 488t Oppositional defiant disorder, 81Oral anticoagulation (OAC) therapy, 415-426 associated risk, 416dosing and follow-up in, 419, 420tmanaging variations in INR, 419, 420-421t overview of, 415patient education and safety, 421, 422-424t target-specific anticoagulants, 424-425, 426ttreatment duration, 416, 416tvariables in warfarin response, 416-419, 417-418t, 419t Oral contraceptives comparison of, 209-214thormonal alternatives to, 215-216t Oral glucose tolerance test (OGTT), 305Oral health 0-3 years, 19, 216-11 years, 2912-21 years, 33 Oral systemic corticosteroids, 66Order serum testing, 317Osteoarthritis (OA), 694Outflow tract/uterus disorders, and amenorrhea, 157, 167 Ovarian disorders, 167. See also Amenorrhea; Polycystic ovarian syndrome (PCOS) Overactive bladder (OAB), 238, 238t, 240, 242t Overweight. See Obesity Ovulatory disorders, 144 P Palliative care, 512, 573PALM (polyps, adenomyosis, leiomyomas, malignancy), 141, 144 Palo Alto Medical Foundation, 38Panic disorder, 428, 430Pap smears Bethesda System classification, 172-173t, 173-174 evaluation techniques for, 174, 175screening guidelines for, 171-172 Parent-child interactions 0-3 years, 18, 213-6 years, 236-11 years, 27, 30-3112-21 years, 32, 37infants, 8post-NICU patients and, 16 Parent education. See Patient and family education and resources Parents' Evaluation of Developmental Status (Glascoe), 57 Passive vs. active immunizations, 46. See also Immunizations Pathologic reflux, 13Pathophysiology, theories for ADHD, 81Patient and family education and resources 0-3 years, 213-6 years, 256-11 years, 29-30, 30f12-21 years, 37on abscess infections, 400on ADHD, 84, 87, 88bon adults with developmental disabilities, 362, 362f on amenorrhea and PCOS, 168-169on anemia, 413on anticoagulation therapy (oral), 421, 422-424t on asthma, 67-68on atopic dermatitis in children, 78on AUB, 153-154on benign prostatic hyperplasia, 454on cancer, 183on cancer survivorship, 463on chronic nonmalignant pain, 491on chronic viral hepatitis, 502-503, 502ton COPD, 475on depression, 521on diabetes mellitus, 537on epilepsy, 545on FTT, 103on GDM, 306on GERD, 553on geriatric syndromes, 564-565on heart failure, 573-574on HIV, 668on HIV infection, 383on hormonal contraception, 205-207on HSV infections, 580-581f, 581on hypertension, 592on IBS, 611on infants, 10for intimate partner violence, 601on lipid disorders, 618on maltreatment in children, 112on menopause transition, 226for nonhormonal contraception, 236on obesity, 646-647on post-NICU patients, 17on postpartum care, 273-274on preeclampsia-eclampsia, 318on pregnancy, 248, 249, 250-251f, 263, 264-265f, 294, 296 on prenatal genetic diagnosis, 259on Pr EP, 389on sterilization, 190on tendinopathy, 711on thyroid disorders, 689-690on transgendered individuals, 372on upper back/neck pain, 700, 703-704urinary incontinence in children, 139on urinary incontinence in women, 244on wound care, 721 Patient consent. See Consent, patient Patient Health Questionnaire (PHQ)-2, 516 Patient Health Questionnaire-9 (PHQ-9), 515f734 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Patient Health Questionnaire for Adolescents, 36 Patient Health Questionnaires (PHQ), 508, 512 PCOS. See Polycystic ovarian syndrome (PCOS) PCV13 vaccine, 42-43, 44 PDE-4 inhibitor, 471Peak Expiratory Flow Rate Monitoring, 444b, 445 Pediatric health maintenance and promotion 0-3 years, 18-213-6 years, 23-266-11 years, 27-3112-21 years, 32-38developmental delay and autism, screening for, 48-59 first well-baby visits, 7-10post-neonatal intensive care unit (NICU) patients, 12-17 Pediatric presentations asthma, 61-69attention-deficit/hyperactivity disorder (ADHD), 80-88 depression, 90-98failure to thrive (FTT), 99-103maltreatment, 104-112urinary incontinence, 124-139 Pediatrics Symptom Checklist ( Jellinek et al. ), 57 Pelvic girdle pain (PGP), 291-294Penile trauma, in children, 109PEP. See Postexposure prophylaxis (PEP), for HIV infection Percutaneous tibial nerve stimulation (PTNS), 243 Perimenopause transition, 219Persistent abnormal vaginal bleeding, 219Persistent depressive disorder (dysthymia), 91-92 Personal habits 0-3 years, 193-6 years, 256-11 years, 2812-21 years, 34adults with developmental disabilities, 350 and preterm birth, 320 Pertussis, 41Pervasive Developmental Disorders Screening T est, 57 Pessaries, 243PGP (pelvic girdle pain), 291-294Pharmacotherapy/psychotherapy for anxiety disorders, 431-432, 433t, 434for dementia, 510, 510tfor heart failure, 571, 572b, 573for hypertension, 588, 590-591tfor smoking cessation, 674 Phenothiazines, 297Phenylketonuria (PKU) screening, 9Phototherapy, 78PHQ (Patient Health Questionnaires), 508Physical abuse, 105. See also Intimate partner violence (IPV); Maltreatment of children defined, 594physical examination for, 107-109, 108t Physical activity 3-6 years, 256-11 years, 2812-21 years, 37asthma and, 67diabetes and, 533, 533tdiabetes in pregnancy and, 308hypertension and, 588obesity and, 636-637pregnancy and, 293 Physical examinations 0-3 years, 18-203-6 years, 246-11 years, 28-2912-21 years, 35for abscess assessment, 396for ADHD, 83-84of adults with developmental disabilities, 350-351, 352f, 353f amenorrhea and PCOS, 161, 162tfor anemia, 407, 408tfor anxiety, 429for asthma, 62, 437-438for atopic dermatitis, 72for AUB, 146for benign prostatic hyperplasia, 451for bicipital tendinopathy, 707, 708tcancer survivorship and, 460, 461tfor chronic nonmalignant pain, 480for chronic viral hepatitis, 496, 496tfor COPD, 469, 469tfor depression, 517for epilepsy, 540for FTT in children, 101for GERD, 549for geriatric syndromes, 557, 558-559f, 560t for heart failure, 568for herpes simplex infections, 577for hormonal contraception, 204-205for hypertension, 585infants and, 8-9for intimate partner violence, 599, 599tfor irritable bowel syndrome, 606for lipid disorders, 614-615for low back pain, 621t, 623-624for maltreatment in children, 107-110, 108t for menopause transition, 220for obesity, 117for postexposure prophylaxis for HIV infection, 381 for post-NICU patients, 16for preeclampsia-eclampsia, 315-316 for preexposure prophylaxis for HIV, 388 for pregnancy discomforts, 293for prenatal visits, 248for smoking cessation, 676for thyroid disorders, 684, 685tfor transgendered individuals, 367for upper back/neck pain, 696-699turinary incontinence in children, 128, 129-130t for wound care, 716 Physiologic reflux, 13Pituitary amenorrhea, 156-157, 166. See also Amenorrhea; Polycystic ovarian syndrome (PCOS) Placenta accreta, 283Placental growth, 294Placental hormones, 304, 304t Placenta previa, 283Planned Parenthood, 190, 236Plasma glucose concentrations, clinical interpretations of, 531t Pneumococcal vaccine scheduling, 44, 330f PNFA (progressive nonfluent aphasia), 505POI (primary ovarian insufficiency), 157Polio, 40Polycystic ovarian syndrome (PCOS), 145, 156. See also Amenorrhea assessment of, 161databased used for, 158, 161defined, 157-158diagnostic testing for, 161, 162, 165, 165t overview, 157-158physical examination findings, 161, 162tself-management resources and tools, 169 treatment and management of, 167-168 Polyps, 141, 144, 153POP (progestin-only pill), 202, 206Positive predictive value (PPV), of screening tests, 58 Posterior pelvic pain provocation test, 293 Index 735

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Postexposure prophylaxis (PEP), for HIV infection, 375-384. See also HIV (Human immunodeficiency virus) assessment of, 383 clinician and patient resources, 383-384databases used for, 380-381diagnostic testing, 381, 382tmanagement of, 383, 383toverview of, 375physical examination for, 381risks and recommendations, 375, 376-378t Postnatal growth restriction, 13Postnatal infection, 14Post-neonatal intensive care unit (NICU) patients, 12-17 Postpartum care, 268-274 assessment of, 271clinical management goals for, 271-272database used for, 269-271overview, 268-269 Posttraumatic stress disorder (PTSD), 428, 429, 431, 432, 433t Postural kyphosis, 695PPIs (proton pump inhibitors), 298, 300, 550 PPV (Positive predictive value), of screening tests, 58 Preeclampsia-eclampsia, 313-319 assessment of, 316, 317clinical management goals for, 317clinical risk assessment for, 313, 315tconsultation and referral, 318-319database used for, 315-316diagnostic tests, 317etiology of, 313overview of, 313-315, 314tphysical examination for, 315-316treatment/follow-up of, 317-318 Preexposure prophylaxis (Pr EP), for HIV, 385-389 assessment of, 388clinical management goals for, 388database used for, 386, 387-388diagnostic screening and tests for, 388evidence for, 385-386guidance for usage, 393indications for, 386overview of, 385patient education and resources, 389treatment and management of, 388-389 Pregnancy abuse during, 260, 262tanxiety disorders and, 434complications, 277-278consultation and referral during, 257dating of, 246, 247bdepression during, 290diagnostic testing during, 260, 262tdiscomforts. See Discomforts, of pregnancy fetal evaluation, 265, 266tgestational diabetes mellitus in, 304-310healthcare visits, 246-252hypertension in. See Preeclampsia-eclampsia medical consultation and referral during, 278-281, 279f, 280t medical consultation/interprofessional collaboration/transfer of care during, 277-281 nutrition and, 263, 263tpatient education and counseling, 263, 264-265f PEP drugs during, 380, 380tpostterm, 265, 266turinary tract infection in, 323-325 Preimplantation genetic diagnosis, 258Premature and late premature infants, 7, 320-322 Premature births (PTB), 320-322Premature Ovarian Failure Support group, 169 Prenatal genetic diagnosis, 257-259 assessment of, 258clinical management goals for, 258database used for, 258overview, 257 Prenatal genetic screening, 253-257 assessment for, 256clinical management goals for, 256database used for, 256overview of, 253for trisomies/NTD/SLOS, 253-255, 254t Prenatal health care visits, 246-252, 260-266 Pr EP, for HIV. See Preexposure prophylaxis (Pr EP), for HIV Preschool and Kindergarten Behavior Scales (Allin), 57 Preschoolers. See Pediatric health maintenance and promotion Prescribing medications, supervision for, 4Preterm labor management, 320-322Primary care setting, anxiety disorders and, 428 Primary hypothyroidism, 682, 689Primary ovarian insufficiency (POI), 157Professional and ethical responsibilities, 1Professional organizations, 3-4Progesterone, during pregnancy, 294Progestin, 192, 200Progestin-only contraception, 202-203. See also Hormonal contraception assessment for, 205implants, 202-203, 207injectable, 202, 206-207levonorgestrel intrauterine system, 203, 207 POP pills, 202, 206 Progestogen therapy, 222, 222t Progressive nonfluent aphasia (PNFA), 505Project Health, 372Prolactin-secreting tumors, 156-157Prothrombin time (PT), 415Proton pump inhibitors (PPIs), 298, 300, 550 Pruritus, 72, 78Psychoeducation, and ADHD, 84Psychological abuse, 594Psychologic/emotional abuse, 105Psychometrics, 57-58Psychosocial and emotional support, atopic dermatitis and, 79 Psychosocial assessment and support 12-21 years, 33-36atopic dermatitis in children and, 79interventions, 434 Psychotherapy. See Pharmacotherapy/ psychotherapy PT (prothrombin time), 415PTB (premature births), 320-322PTNS (percutaneous tibial nerve stimulation), 243 PTSD (posttraumatic stress disorder), 428, 429, 431, 432, 433t Puberty, 27, 436Pulmonary edema, 566PUQE (pregnancy-unique quantification of emesis/nausea) index, 295, 295t Purulent exudate, 395Pyelonephritis, 293, 323-325 Q Quadruple (quad) marker serum examination, 254-255 Questionnaires, written, 106 R Race. See Ethnicity-based health issues RADAR mnemonic, 601Rape, Abuse, and Incest National Network, 602 Recommended Adult Immunization Schedule, 2015, 326, 327-329f Refeeding syndrome, 103Referrals for anxiety disorders, 434736 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

for cancer survivorship, 466 for diabetes, 537for epilepsy, 545for postpartum care, 274for preeclampsia-eclampsia, 318-319during pregnancy, 278-281, 279f, 280tfor pregnancy, 249, 251b, 257for tendinopathy, 710-711 Referred neck pain, 691-692Regional pain syndrome, 692-693Regulations and statutes, 1-3Regulatory agencies, 3Reliability, of screening tests, 58Reporting, mandatory on maltreatment of children, 110-111, 110t Representative samples, of screening tests, 58 Rescue medications, 66, 441Respiratory diseases. See Asthma; Chronic obstructive pulmonary disease (COPD) Respiratory syncytial virus (RSV), 14RICE (rest, ice, compression, elevation), 709-710 Rome III criteria, for IBS diagnosis, 605Rotavirus vaccine (RV), 42Rotterdam PCOS Consensus Workshop Group (2004), 158 Roux-en-Y gastric bypass, 645-646RSV (respiratory syncytial virus), 14Rubella, 41RV vaccine, 42 S SAD PERSONS mnemonic, 515, 516t Safety 0-3 years, 213-6 years, 256-11 years, 27-29, 30-31, 30f12-21 years, 34, 37infants, 10maltreatment of children and, 110, 111 Scalene-myofascial pain syndrome, 693Scheuermann's kyphosis, 695Schools 3-6 years, 256-11 years, 2812-21 years, 34asthma medications and, 68-69outcomes for FTT children, 103 Sciatica, 624Scoliosis, 694-695SCORAD (clinical tool), 72Screening tests. See also specific type accurate, characteristics of, 57-58standardized, 48-49 Seizures. See Epilepsy Seizure T racker, 546Selective serotonin reuptake inhibitors (SSRIs), 95, 96-97t, 223-224, 432 Self-injurious behavior, 93Self-management resources, 38Senior citizens. See Older adults Sensitivity, of screening tests, 57-58Sensory impairments, 554-555, 556, 557, 561 Sequential integrated screening, 255Serotonin-norepinephrine reuptake inhibitors (SNRIs), 432, 482 Sertraline, 95Serum integrated screening, 255Sexual abuse, 105, 594. See also Maltreatment of children physical examination for, 109 Sexual acting out, 106Sexual debut, 93Sexual dysfunction, 218, 220, 225-226Sexual functioning, 218Sexually transmitted infections (STIs), 109, 230-231 Sexual pain disorder, 226Sexual reassignment surgeries, 366. See also T ransgendered individuals, health maintenance for Short-acting β-agonists (SABA), 66Sickle cell screening, 9Side effects, of stimulant medications, 84Sideroblastic anemia, 403, 404, 406, 410, 412 SIDS (Sudden Infant Death Syndrome), 674 Simon Foundation for Continence, 244SIRS (systemic inflammatory response syndrome), 396, 396t Skin and soft tissue infections (SSTIs), 395Skin disorders. See Atopic dermatitis (AD) Skyla®, 203Sleep 0-3 years, 196-11 years, 28fatigue and, 82FTT and, 101medications and, 84menopause transition and, 218-219poor quality, during pregnancy, 290-291 Smith-Lemli-Opitz syndrome (SLOS), 253, 254-255 Smoking. See also T obacco and asthma, 437benefits of quitting, 674-675cessation, 672-680and COPD, 469, 471, 475health effects of, 672and hypertension, 588incidence/prevalence, 672 SNRIs (serotonin-norepinephrine reuptake inhibitors), 432, 482 Social and environmental risks 6-11 years, 2912-21 years, 33, 34-35for asthma in children, 67for childhood maltreatment, 106-107for post-NICU patients, 14-15for urinary incontinence in children, 124 Social anxiety disorder, 428, 431Social history. See Family and social histories Society for the Study of Behavioural Phenotypes, 362 Spastic diplegia, 347Specific Ig E immunoassay (in vitro), 65Specificity, of screening tests, 58Spermicides, 232, 234, 235Spinal deformities, 694-695Spirometry, 65, 439, 441, 441f, 469, 470t Spondylosis, 694SSHADESS (mnemonic), 34SSRIs (selective serotonin reuptake inhibitors), 95, 96-97t, 223-224, 432 SSTIs (skin and soft tissue infections), 395Stages of Reproductive Aging Workshop (STRAW), 217 Standardized screening tests, 48-49State of California Regional Center System, 363 State regulation of professional practice, 1-3 Statin therapy, 616, 617t Statutes and regulations, 1-3Sterilization, 188-190 assessment of, 190database used for, 190overview of, 188-190self-management resources, 190 Stimulant medications, and ADHD, 84, 85t, 86 STIs (sexually transmitted infections), 109, 230-231 Stomach acid, 298Strains/sprains, 694STRAW (Stages of Reproductive Aging Workshop), 217 Stress incontinence, 125Stress UI (SUI), 237Substance use and abuse, 34, 93, 477, 478f Sudden changes in behavior, 106 Index 737

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

Sudden death, and stimulants, 83 Sudden Infant Death Syndrome (SIDS), 674Suicide 12-21 years, 34depression and, 94 Supervision requirements, physician, 5Supine active straight leg raise (SLR) test, 293Surveillance, Epidemiology, and End Results (S EE R) database, 459 Syphilis screening, 36Systemic inflammatory response syndrome (SIRS), 396, 396t Systolic heart failure, 566Systolic HTN, 583 T TADS (T reatment for Adolescents with Depression Study), 95 T arget specific oral anticoagulants (TSOACs), 415, 424-425, 426t T d/T dap vaccine. See T etanus, diphtheria, and acellular pertussis (T d/T dap) vaccine TE (thromboembolism), 415T eenagers. See Pediatric health maintenance and promotion T endinopathy, 706. See Upper extremity tendinopathy T etanus, diphtheria, and acellular pertussis (T d/T dap) vaccine, 44 T etanus prophylaxis, 397T exas Functional Living Scale, 508Th1 and Th2 cytokines, 436Thalassemia, 403, 403t, 406, 409, 412Thoracic outlet syndrome, 693, 694Thoracoabdominal trauma, in children, 109Thromboembolism (TE), 415Thyroid disorders, 682-690 assessment of, 687, 688tclinical management goals for, 687databases used for, 683-684diagnostic screening and tests for, 684, 686-687t, 687, 688-689 management and treatment of, 689overview of, 682-683patient and family education and resources on, 689-690 Thyroid nodules, 683, 689Thyroid-stimulating hormone (TSH), 682Tic disorders, 83-84Title V, Social Security Act, 48T obacco. See also Smoking and asthma, 61history of, 672-673and hypertension, 588mental health disorders and, 674T obacco Control Act, 2009, 672T oddlers. See Pediatric health maintenance and promotion T opical analgesic creams and patches, 482T racheal shaving, 366T racking medication effects, 87T ranscervical tubal occlusion, 189T ransdermal patch, 201, 206T ransgendered individuals, health maintenance for, 365-372 assessment for, 367database used for, 366-367overview of, 365-366, 366fphysical examinations, 367self-management resources and tools, 372surgical options for, 371-372, 371ttreatment for, 367, 368-372, 369-370t, 371t T ransgender Law Center, 372T ranssexual individuals. See T ransgendered individuals, health maintenance for T ransvaginal ultrasound (TVUS), 153Transvestites. See T ransgendered individuals, health maintenance for T raumatic kyphosis, 695T raumatic wounds, 713T reatment for Adolescents with Depression Study (TADS), 95 T rial of labor (TOL) contraindications for, 284, 285t VBAC vs., 282-287 T ricyclic antidepressants, 86, 482T risomies, 253, 254-255TSOACs (target specific oral anticoagulants), 415, 424-425, 426t Tubal ligation, 188-189Tuberculosis screening 0-3 years, 213-6 years, 256-11 years, 2912-21 years, 36 TVUS (transvaginal ultrasound), 153Type 1 diabetes (T1D), 529. See also Diabetes mellitus Type 2 diabetes (T2D), 529. See also Diabetes mellitus risk factors for, 306, 306t U UCSF Women's Continence Center, 244UI. See Urinary incontinence (UI), in children; Urinary incontinence (UI), in women Ulcers. See Wound care Ulipristal acetate, 192Underactive bladder, 125United States Public Health Service (USPHS), 375, 376-377t, 385 University of California, San Francisco, 103Upper back/neck pain, 691-704 assessment of, 699, 699tcauses of, 691clinical management goals for, 700databases used for, 695-696diagnostic screening and tests for, 698t, 700, 700t mechanical spine disease, acute, 692musculoskeletal strains and sprains, 694myofascial pain syndrome, 692-693osteoarthritis, 694overview of, 691-692patient education and resources on, 700, 703-704 physical examination findings, 696-699tscalene muscle pain/thoracic outlet syndrome, 693-694 treatment and management of, 701-703t Upper extremity tendinopathy, 705-711 assessment of, 708clinical management goals for, 709databased used for, 706-708, 708tdiagnostic tests for, 707, 708, 709overview of, 705treatment and management of, 709-711 Upper GI (UGI) tract, 547, 548Urge incontinence (UUI), 238, 238t, 240, 242t Urinalysis, 25Urinary diary, 239, 239t Urinary incontinence (UI), in children, 124-139 assessment of, 128, 130clinical management goals, 130-131databases used in, 126, 128daytime, 125defined, 124diagnostic tests for, 131, 132-133f, 134fnight, 125-126overview of, 124-126physical examination findings and, 128, 129-130t treatment and management of, 131, 132-133f, 133, 134, 134f, 135-138t voiding and elimination history and, 127, 127t Urinary incontinence (UI), in women, 237-244 assessment of, 239-240clinical management goals for, 240initial evaluation of, 238, 238t, 239nonpharmacologic treatment for, 240, 241t, 242t738 INDEX

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf

overview of, 237 pharmacologic treatment for, 240, 241t, 242t prevalence of, 238self-management resources and tools, 244 treatment and management of, 240-244types of, 237-238, 237turinary diary, 239, 239t Urinary tract infections (UTIs), 124, 323-325 Urogenital atrophy, 220, 224U. S. Collaborative Review of Sterilization (CREST), 188 U. S. Department of Health and Human Services (USDHHS), 649 U. S. Environmental Protection Agency, 446U. S. Food and Drug Administration (FDA), 94, 95, 189, 203, 223, 231, 405, 415, 673 U. S. Preventive Services T ask Force (USPSTF), 326, 515, 516, 565, 578 screening/counseling recommendations, 332t, 337t-340t on screening for lipid disorders, 615 Uterine bleeding. See Abnormal uterine bleeding (AUB) Uterine ruptures, 282-283UTIs (urinary tract infections), 124, 323-325 UUI (urge incontinence), 238, 238t, 240, 242t V Vaccinations. See Immunizations Vaccine Adverse Events Reporting System (VAERS), 44, 46 Vaccine Injury Compensation Program (VICP), 46, 47 Vaccine-preventable diseases measles, 40-41pertussis, 41polio, 40rubella, 41varicella, 41-42 VAERS. See Vaccine Adverse Events Reporting System (VAERS)Vaginal birth after cesarean (VBAC), 282-287 client information and consent, 285-287f overview, 282success factors, 284, 284tsuccess rates, 284, 284ttrial of labor vs., 282-287 Vaginal contraceptive ring, 201-202, 206Vaginal deliveries, 7Vaginal/rectal electrical stimulation, 243Vaginal reflux and postvoid dribbling, 125Vaginal trauma, in children, 109Validity, of screening tests, 58Vancouver Coastal Health Clinic, 372Varenicline, 675Varicella vaccine, 41-42, 43, 44-45Vascular dementia, 504, 507Vasectomy, 188, 189-190Vasomotor symptoms, 217, 220VBAC. See Vaginal birth after cesarean (VBAC) Venous leg ulcer (VLU), 714, 715Venous thrombosis (VTE), 200, 201VICP. See Vaccine Injury Compensation Program (VICP) Viral hepatitis, chronic. See Chronic viral hepatitis Vision screening 0-3 years, 203-6 years, 246-11 years, 29infants and, 14 Visual impairment, 554-555, 556, 561Vitamin B12 deficiency, 404-405, 407, 410, 412-413 Vitamin K antagonists (VKA), 415. See also Oral anticoagulation (OAC) therapy associated risk of, 416 VKA. See Vitamin K antagonists (VKA) VLU (venous leg ulcer), 714, 715Voiding and elimination history, 126, 127tpostponement, 125process of, 124von Willebrand disease (VWD), 145 VTE (venous thrombosis), 200, 201Vulnerable child syndrome, 14VWD (von Willebrand disease), 145 W Warfarin therapy. See also Oral anticoagulation (OAC) therapy drug and nutritional supplement interactions with, 418-419, 418t, 419t management of, 419, 420tmonitoring of, 415, 416tpatient education and safety with, 421, 422 variables affecting stability of, 420Weight losshypertension and, 588urinary incontinence in women and, 240 Weight-to-height ratio, 101Well babies visits, 7-10Wet-wrap dressings, 77Whiplash, 693Withdrawal bleeding, 201Women. See also Pregnancy obesity in, 158urinary incontinence. See Urinary incontinence (UI) in women Women's Health Initiative (WHI), 218, 221Workplace modification during pregnancy, 293 World Federation of Societies of Biological Psychiatry (WFSBP), 521 World Health Organization (WHO), 118, 200, 306, 401, 583, 672 World Professional Association for T ransgender Health, 372 Wound care, 713-721 assessment of, 718clinical management goals for, 718database used for, 714-715, 717-718diagnostic screening and tests for, 717toverview of, 713 Z Zoster vaccine, 45 Index739

Clinical Guidelines for Advanced Practice Nursing-1 1.pdf