Linda, a 32-year-old public hospital cleaner slipped on a wet floor and struck her knee. Although she was able to get up with some difficulty and continue working for the rest of the day, she slowly developed more severe pain in her knee. After several months, and having experienced a number of occasions when the knee gave way beneath her, she was referred to an orthopaedic surgeon.
He performed an arthroscopy — passing a thin fibre-optic instrument into the knee — and removed some cartilage and damaged tissue from the back of the kneecap.
It was thought that this procedure would probably alleviate the condition but some months after the operation Linda’s knee was extremely painful. She had also developed a burning sensation in the skin above the knee and had noted that the pain was now present whether she was walking or at rest.
More X-rays were taken and it was decided to do a further arthroscopy. On this occasion it was noted that the back of the patella, or kneecap, showed an erosion, or damage, of the cartilage which normally exists to ensure smooth passage of the kneecap over the thigh bone.
Linda’s damaged cartilage was removed during the arthroscopy and an assurance was given that she would have no more pain. But by then the knee had swollen to several times its normal size and she was only able to walk short distances, with great difficulty.
Meanwhile, she was finding it difficult to look after herself, let alone her family and she had not worked for six months. Linda was then referred to a pain clinic for assessment and treatment. Upon examination it was noted that the affected knee was several degrees cooler than the normal knee. She was also unable to flex or bend the knee in any normal way. It was decided to perform thermography. This confirmed the presence of a reflex sympathetic dystrophy affecting her knee.
Linda was initially treated as an out-patient with an antidepressant medication and TENS therapy. But the depression was so severe that it was eventually decided to admit her to the in-patient program for further treatment and assessment. In the meantime, she was also referred to an orthopaedic surgeon who was an expert in the assessment and treatment of reflex sympathetic dystrophy. He agreed that the treatment Linda was receiving was probably the most appropriate under the circumstances.
During her stay of four weeks in the in-patient program, Linda was taught relaxation techniques and was encouraged to become more active. As part of her rehabilitation, she was to swim regularly and to walk as often as possible.
Meanwhile, her depression was controlled by appropriate medication, the antidepressant Surmontil and also Rivotril. She was seen by an occupational therapist who showed her how to maximise the use of her limb without pain or disability.
By the time she left the in-patient program, Linda was coping extremely well with her pain. She had accepted the fact that there was probably no further surgical intervention that would help her. She had accepted that surgical procedures might even worsen her condition.
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How do you know if you have chronic pain? What are the conditions that cause chronic pain and prompt someone to seek help?
Descriptions of pain vary greatly: ‘A river of ice in the arm,’ said a patient with a brachial plexus injury. ‘The pain is excruciating — just like having a tight metal cap over my entire scalp. I even dread combing my hair,’ said Jill who had suffered chronic headaches for 10 years. ‘All vertebrae feel as though they’re moving on one another as if there’s no gristle between them,’ said Max with a three year history of low back pain.
Chronic pain is a disease that is complex both in its causes and the symptoms it produces. It can originate in the muscles, the ligaments and the supporting tissues of the joints, or in the arterial or the nervous systems.
Pain can be triggered in different ways. There could be an initial trauma (an injury) which in turn leads to emotional problems and then to the awareness of pain. Some chronic pain sufferers may well worsen their problems with the treatments they seek. Often, pain is increased by the development of adhesions formed as a result of scar tissue attached to healthy tissue after one or more surgical operations.
Further problems occur when excessive dosages of multiple inappropriate medications, sometimes prescribed by more than one physician are taken. (Some see up to six different practitioners and are found to be taking as many as three different antidepressants and several tranquillisers as well as anti-convulsant medication. No wonder they feel sick!)
Pain can sometimes result from the adverse reactions these drugs have on one another and on the body’s system and can sometimes be completely eliminated by rationalising the medication.
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Since Selye’s research, scientists have found that stress provokes a number of even subtler chemical changes in the body which may have profound physical and mental health effects. For example, medical researchers are now certain that stress triggers chemical changes in the brain. Particularly sensitive to such emotional strains are the concentrations of potent chemicals called neurotransmitters. These act as messengers between nerve cells. They include: serotonin, epinephrine (adrenaline), norepinephrine (noradrenaline), acetylcholine and dopamine. In a Stanford University study, rats were forced to swim in 4 degree C water for three minutes. Later examination of their brain tissue showed that levels of norepinephrine had fallen 20 per cent and epinephrine between 30 and 40 per cent. Scientists have also discovered that the body produces its own painkillers, morphine-like chemicals called endorphins. Stress boosts the production of these analgesics, thus raising the pain threshold.
Because stress alters the body’s chemical balance, it seems to influence the development of many diseases,including psychiatric disorders. Depression has also been associated with low levels of two neurotransmitters — serotonin and norepinephrine.
Stress has been found to severely affect the body’s immune system. Researchers have also discovered that chronic stress inhibits the body’s production of its own cancer-fighting cells, including natural killer cells, T-lymphocytes and macrophages. A remarkable chemical triggers the body’s stress reactions — corticotropin releasing factor (RTF), which is produced in the hypothalamus, a powerful but tiny structure sometimes called the brain’s ‘brain’.
Research with animals has shown that.stressful stimuli can be less damaging when regulated. Being in control of the situation seems to make all the difference.
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Pharmacopoeias, which were comprehensive lists of drugs compiled during the Renaissance period included practically every known organic and inorganic substance. One fourteenth-century recipe for relieving dental pain, for example, recommended combining gall of a cow, heart of a magpie, mouse fat, cow dung, lice and oil of cloves (the only active ingredient recognised in our time).
Patients have chewed, imbibed, sucked, or suffered treatment with crocodile dung, teeth of swine, hooves of asses, spermatic fluid of frogs, unicorn fat, fly specks, lozenges of dried vipers, powder of precious stones, oils derived from ants, earthworms and spiders, bricks,feathers, hair, human perspiration and moss scraped from the victim of a violent death. George Washington is a good example of the treatment lavished on the wealthy in the eighteenth century. When he had a throat infection, complicated by pneumonia, it was said that he was fortunate ‘he could afford the best medical care available’. This wonderful treatment consisted of a mixture of molasses, vinegar and butter. Vomiting and diarrhoea were induced. But still he lapsed. In desperation, his physicians applied irritating poultices to blister his feet and throat while draining several pints of blood. Then, mercifully, he died.
Also pity the British monarch, Charles II. He was treated by the best physicians of the day, using the multiple treatment methods then believed appropriate for treating pain. Many are now known to have little therapeutic value and some may have actually done more harm than good. The treatment given to Charles II as he lay dying in 1685 was:
‘A pint of blood was extracted from his right arm and a half pint from his left shoulder. This was followed by an emetic, sneezing powder, bleedings, soothing potions, a plaster of pitch, and pigeon dung was smeared on his feet. Potions containing 10 different substances, chiefly herbs, as well as 40 drops of extract of human skull, were swallowed. Finally, application of the bezoar stone (gallstones from sheep or goats) was prescribed. Following extensive treatment, the king died.’
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