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PAIN WITHOUT A CAUSE: REPETITIVE STRAIN INJURY

admin — Sat, 11 Jun 2011 10:33:39 +0000

This is another example of a painful condition which is epidemic in its increase and yet appears to be without cause. It occurs particularly in office workers who use typewriter keyboards or computer mice. It has not suddenly appeared but used to be given names, such as writers’ cramp and tennis elbow. It appears first as a tingling or numbness in the fingers. As it develops, it becomes so painful that the hand cannot be used and long rests are needed before it dies down. The pain may spread up the arm and invade the shoulder and neck. Pain and tenderness may persist after very long periods of rest. The victim becomes unable to work. The standard medical examination reveals no cause.There is a very similar disease called carpal tunnel syndrome which has almost identical symptoms. However, in this case a test to measure the ability of nerves to conduct from the hand to the arm shows that they are conducting slowly and nerve entrapment is suspected. The two major nerves to the hand could become trapped where they pass under a band of fibrous tissue on the front of the wrist. This band of tissue holds the nerves, tendons and blood vessels close to the bones of the wrist, and is called the carpal tunnel. It is believed that, with heavy continuous use, the band swell and straps the nerves. A simple operation cuts the band and liberates the nerves from the pressure on them, sometimes completely curing the condition.Repetitive strain injury (RSI) not only has no obvious signs of damage but seems to occur in outbreaks in particular workplaces. This tended to make industrial doctors, employers and insurance companies suspicious that they were dealing with some form of mass hysteria of the type we have described for low back pain. Attempts to solve the problem were made by calling in ergonomic specialists who adjusted the tilt of the keyboards, put backs on the chairs, tilted the seats and changed the lighting. Although temporary effects were achieved, the workforce returned to their old problems. In two large telephone companies in the United States, one had serious problems but the other had few complaints, despite the fact that the equipment and tasks were identical. This observation exaggerated the belief that the disease was in the mind rather than the body. The belief was further supported when a difference was noted between the two companies. The one with problems paid workers on commission for each call answered, while in the other the workers were on a weekly wage.The growing belief that it was ‘all in the head’ received a further boost when a large publishing company recognized that, unlike the so-called workshy, movement-intolerant workers of Boeing complaining of back pain, the workers who complained of RSI tended to be eager-beaver ambitious types, while their more happy-go-lucky, slobbish workmates had fewer complaints. All of this had led to angry confrontations in many countries between workers with the condition and compensation agencies who refused to recognize this as a ‘real’ disease because they believed it had no organic cause.Very recently, workers with RSI have been examined in London using an unusual but simple neurological test. The palm was tested for the ability to detect a carefully controlled vibration. To the great surprise of doctors and scientists, the ability of the RSI patients to detect vibration was greatly reduced on the palm of the hand but was completely normal on the back of the hand. Furthermore, when they tested workers from the same company with the same job who were not complaining of RSI, they found that many of them were beginning to lose their ability to detect vibration. These tests immediately put an entirely new interpretation on the disorder because they provide evidence for a subtle disorder of the peripheral nerves in the hands and arms or in the brain cells that detect vibration. If some of these nerve fibres or cells are not functioning properly, the disorder is reclassified as one of nerve damage rather than as a psycho-social disorder. It is well known that in some cases of overt single-nerve damage, the pain spreads far beyond the territory of the damaged nerve. This means that the widespread of pain on the body of these RSI patients joins a well-known category of pain, rather than being a bizarre distribution that had previously made unfriendly doctors suspicious that RSI was simply a form of hysteria.We are left with a question: if RSI is now to be awarded the honour of having a ‘real’ cause rather than a self-inflicted psycho-social cause, why has it become more common? It could be that, in the past, complainers were simply dismissed, particularly as the majority were women, but women have now learned to fight. The numbers of people who regularly type as part of their job has greatly increased with the appearance of computers and with the near disappearance of the specialist typist. And there has been a subtle change with computer keyboards. The carriage return of the old-fashioned typewriter, which gave the typist a brief rest at the end of every line, has disappeared. The use of the mouse forces the worker into very fast, detailed movements and puts them almost into the category of violinists. Musicians have been famously plagued with painful cramps similar to RSI. Finally, forced pace and the additional task of making running corrections may have increased the mechanical strain of muscles and nerves.There are important consequences of the transition of RSI to a disease with a cause other than the psychological inadequacy of the victim.*48\219\2*

ARTHRITIS AND RHEUMATISM TREATMENTS

admin — Tue, 21 Apr 2009 04:55:04 +0000

The pain can sometimes be helped by the wise use of antidepressant medication, which causes an increase in the body’s natural production of pain-killers — the endorphins.

The most common form of treatment is a combination of physical therapies and non-steroidal anti-inflammatory drugs such as Dolobrid, Indocid, Brufen, Naprosyn, Voltaren, Orudis, Clinoril and Feldene. Aspirin and Paracetamol are also useful as pain killers and as drugs controlling inflammation. Specially coated or slow-release forms of aspirin have been developed to reduce the gastric problems associated with long term aspirin usage. These include Ecotrin, a specially coated tablet which releases its aspirin into the small intestine and not the more sensitive and fragile stomach lining.

Other drugs used in the treatment of arthritis include the cor-tico-steroid or steroid drugs such as Prednisolone and Depo-Medrol. These can be taken by mouth or injected directly into the joints.

Physiotherapy has a major place in the treatment of pain associated with arthritic conditions. Gentle mobilisation of affected joints together with the application of heat and cold to the joints will help keep those with advanced arthritis mobile.

Water-based exercise in the form of hydrotherapy and the more vigorous aqua-aerobics takes the strain of gravity from the painful and stiffened joints.

In the later stages, when joints are burnt out, surgical procedures are carried out to help those with artificial joints or to fuse joints which are too painful to move.

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PAIN GAMES

admin — Tue, 21 Apr 2009 04:52:30 +0000

What is a ‘pain game’? It is often an expensive and emotionally exhausting experience for the patient and family and a long-standing disappointment for the medical profession. The term ‘game’ to doctors specialising in pain relief refers to the patient’s ways of behaving and reacting, as well as the family — and even the doctor. All have developed in reaction to the pain itself. When patients allow their suffering to control their behaviour, they are playing a ‘game’. There is thus little chance of relief. And there are no winners. Pain is more than just a hurt. Strangely, for many, it is a way of life. It may begin as a short game but sometimes it takes over and patients can find themselves trapped in the role they have unwittingly created for themselves. The symptoms can become a habit and this can then slide into a lifestyle. From the patient’s point of view, the therapy and treatment have usually been ineffective, sometimes destructive and often very costly.

Some build their lifestyle around their pain. They actually enjoy their poor health. While every day and night is an ordeal ranging from discomfort to downright agony, they at the same time find it as comfortable as putting on an old pair of slippers. Their pain has the comforting ring of normality. Relieving the pain actually disrupts their attitude-behaviour system. At the very least, pain behaviour is a mindless bad habit. It can be broken, but, it can also become an addiction.

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DEPRESSION AND CHRONIC PAIN

admin — Tue, 21 Apr 2009 04:49:34 +0000

Pain is also common in patients suffering from depression. Psychological testing shows depression in up to 80 percent of chronic pain patients. Patients should be aware that they may be suffering from masked depression. Treatment of the depression frequently greatly reduces pain. In turn, a decrease in pain may also cause a decrease in depression.

Recent research confirms that dietary manipulation may be possible. Certain natural substances appear to be the forerunners of brain chemicals important in pain control. For example, the amino acid L-Tryptophan is a substance that is converted to Serotonin (also called 5HT), a brain transmitter substance involved in pain perception. When taken orally, it may help to modify the experience of pain and to encourage natural sleep. Some caution in the administration of L-Tryptophan may be necessary.

At the time this book was written disturbing reports of abnormally increased number of eosinophils (white blood cells) due to L-Tryptophan have been received in the United States and in Europe. This has led to the withdrawal of L-Tryptophan containing preparations in America and Australia. Another amino acid, D-L Phenylalanine, blocks the destruction of the natural opiates — endorphins — produced by the brain.

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COSTS OF CHRONIC PAIN

admin — Tue, 21 Apr 2009 04:46:35 +0000

Chronic pain is that which is persistent or recurrent and lasts longer than the usual expected time after illness or injury. Low back pain is by far the most common form of chronic pain, comprising about

80 per cent of cases. Millions more suffer other chronic pain conditions such as the excruciating facial pain of trigeminal neuralgia,TMJ (temporo-mandibular joint dysfunction syndrome) affecting the jaw joint, post-herpetic neuralgia and phantom limb pain. Many cope with headaches, arthritis and other musculo-skeletal problems without excessive invalidism, medication, or health care. Unfortunately, a significant number of chronic pain sufferers have a complex variety of feelings, thinking and behaviourial symptoms.The financial costs of chronic pain may well be the highest of any health problem.

It includes the costs of social security payments, treatment, workers compensation and the loss of productivity. In New South Wales, 1984-85 figures showed that ‘sprains and strains’ accounted for 49.5% of claims for workers compensation, a total of 48,751 cases. The NSW compensation payout had risen from $286 million in 1980 to $666 in 1984-85. Australian Bureau of Statistics (ABS) figures quoted in a leading article on pain in The Bulletin magazine showed that over 20% of compensation claims in Australia were for the condition of Repetitive Strain Injury (RSI) consisting of work related synovitis, bursitis and myofascial pain disorders. A further 20% had other problems of the musculoskeletal system and connective tissues. Apart from industrial deafness at 42% of claims, no other condition exceeded more than 4% of the total.

The ABS survey showed that headache due to unspecified or trivial causes was the most common Australian complaint. Some 10% said they had suffered one in the two week survey period. According to the Arthritis Foundation of Australia, one person in 12 in this country suffers from arthritis. This means that 1.3 million Australians have pain as a major disability. Arthritis accounts for more lost work days (over 7.5 million man hours) than any other medical condition and exceeds those lost due to industrial strikes.

The social costs of chronic pain are even more tragic, with so many young sufferers incapacitated for life, and the subsequent disruption to the family, the individual and society as a whole. Rather than brand sufferers as ‘neurotic and hysterical’, a more enlightened approach is called for, with early treatment, research and ultimately prevention.

Chronic pain in Australia is also a major issue in law suits and disability-benefit decisions. Whether or not a pain sufferer is typical of a hospital’pain clinic, or of a private practice population, the behaviour of pain patients gradually becomes less consistent with organic pathology.

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