LOGICAL ANALYSIS OF POSTURE: PROTECTION OF THE SPINE – THE MOST IMPORTANT FACTOR FOR BACK HEALTH

The anti-gravitational force created by posture-controlling muscles and general muscle tone is the most important factor for back health. Trauma, nutritional deficiencies, birth defects (like spina bifida), osteoarthritis, polymyalgia rheumatica etc appear in a relatively rare number of cases. Scientific medicine claims that the majority of backache cases originate from the discs and joints of the spine. Muscular and ligament sprains or inflammation form the second largest group of backache. If the anti-gravitational force in the living body is what determines the state of delicate spinal structures like joints, discs etc, the lack of it leading to backache and other related problems, then why haven’t we looked at this over the centuries? Why did medicine go in the direction of treating symptoms only (pain, inflammation, nerve damage, scoliosis etc)? A branch called ‘orthopaedics’ (which someone once suggested to me translated as ‘bone setting’) was created, aimed at treating bones, joints and related hard tissues, which actually have hardly any primary role to play in the genesis of back-related problems. The bones and nerves are the final sufferers or victims of the weakening of another system, namely the muscular system, part of which, in a conscious state, produces an upward thrust that maintains the erect posture. This part of the muscular system is less voluntary and more involuntary, like the diaphragm muscles. Therefore, exercising it requires special skills as these muscles are under dual control, unlike skeletal muscles which are controlled entirely by the conscious brain.
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PAIN TREATMENT: MEDICINES ACTING ON THE CENTRAL NERVOUS SYSTEM

Opium is a herbal remedy with an even longer history than willow bark. Like aspirin, it has spawned hundreds of descendants, so aspirin and opium together are responsible for at least 95 per cent of the analgesic medicines used today. Unfortunately, unlike aspirin, opium has gathered a disgraceful public image since Victorian times. For three thousand years, opium was used to produce sleep and dreams, the origin of the phrase ‘pipe dreams’. Although opium and its derivatives, morphine and heroin, have become associated in the puritanical mind with misuse by social drop-outs, opium was used for centuries as a means of relaxation. Robert Clive, who conquered and organized India for the British, adopted the local custom and used opium regularly for the rest of his life. Where the harried New York businessman may drink his evening Martini to relax, his equally powerful Chinese rival in Singapore smokes his evening opium pipe for the same purpose.
By the nineteenth century, physicians had begun to realize that opium was not just a way of knocking out patients into a nearly unconscious state. By this century, it was finally realized that low doses had a purely analgesic action while leaving the patient thinking in a clear fashion. The advance can be attributed to Dame Cicely Saunders, who invented the hospice movement for the care of terminally ill patients. She and her colleague Robert Twycross decided to combine the best of modern medicine with age-old tender loving care to bring comfort to cancer patients who became dominated by their pains in the anxious shambles of their last weeks.
Doctors up to that time had joined the generally held opinion that narcotics were dangerous and that comfort was brought at the price of addiction to rapidly escalating doses, which led to killing the patient. A cool, calm analysis of the effect of narcotics demolished this view and showed that doses carefully titrated to bring down pain to a bearable level led instead to a patient in comfort with clear thinking. The success of carefully controlled and monitored narcotics for the benefit of cancer patients in pain spread to other problems, such as the control of postoperative pain and pain in childbirth.
The variable herbal mixture of opium was analyzed into its constituent components in the nineteenth century. The most powerful fraction was found to be morphine, which was synthesized, while a weaker component, codeine, was also found to be effective against less severe pains. This discovery set off the expected search for related compounds in the hope that one could be found which was a pure analgesic, which could not be misused as an addictive social toy, and which would not stop the patient breathing when high doses were given. The 150-year search for this pure analgesic has failed, but that has not stopped the drug companies from trying. If you enjoy black humour, you may be interested in the late nineteenth-century discovery by the Bayer Company of a morphine derivative which they named ‘heroine’ as a particularly powerful narcotic that they claimed was free of an addiction potential. How wrong can you be!
Work in the past century has generated hundreds of compounds with slightly varying properties but hugely varying potency. One, called etorphine, is 10,000 times more potent than morphine. This is the drug used in darts by wildlife experts to immobilize big game. I have made it a personal rule never to remember drug doses because it was always safest to look up the dose. However, I make an exception for etorphine, for which the dose for elephants is one milligram per ton. A large elephant gently lies down if shot with a syringe containing 3.5 milligrams of etorphine. Once the veterinarians have done their job, the same dose of an antagonist is injected and within minutes the elephant stands up and wanders off with a puzzled expression.
Not surprisingly, a drug effective as a narcotic always has unwanted effects even if it is used as an analgesic. Narcotics produce constipation, and opium has been used for centuries to control diarrhoea by taking advantage of this side effect of gut paralysis. High doses of narcotics depress respiration, so weak narcotics such as codeine are included in most cough mixtures. When pain fails to respond to one of the aspirin-like drugs, it is common to move the treatment to a mixture combining an aspirin-like component with a weak narcotic. The widely advertised strong painkillers which are available over the counter contain these mixtures. Much commercial and scientific ingenuity has gone into inventing mixtures that will optimize the desired effect and reduce the unwanted ones.
Only in the past twenty years has the rationale for the use of narcotics against pain become apparent. This was revealed in a series of very surprising steps. First, Tony Yaksh in the United States searched the brain by giving small, localized injections to discover where morphine was acting to reduce pain. He found two areas, one in the midbrain, the other in the spinal cord where sensory messages were arriving from the tissues. Next, Kosterlitz in Aberdeen, as described before, ended a fifty-year search by discovering that the brain was itself producing its own narcotic-like substances. These endorphins, as they are known, were made by nerve cells which were particularly concentrated in the two target areas discovered by Yaksh. Finally, Snyder found that the brain also made special protein receptors which snapped up narcotic molecules and changed the excitability of the nerve cells on which they resided.
With this series of discoveries, it was possible to put together a most curious story. In the first place, the brain contains its own system for controlling the arrival of pain-producing messages. One part of this system exists as a barrier zone in the spinal cord where the sensory nerve fibres enter. The other part exists in the midbrain, from which region control orders descend into the spinal cord and further reduce the incoming message. When narcotics are given as a medicine, they penetrate the brain and stimulate the very system which the brain uses to control its own sensory input. There was an immediate practical consequence of the discovery of the location of the pain control systems. Because the spinal cord was one site of action, and because it is simple to make a needle penetrate to the surface of the spinal cord, it was possible to apply morphine precisely to the site where it is carrying out its useful action. This has grown into the widespread use of epidural narcotics, where a strong analgesia can be produced in an area of the body with a dose ten times smaller than that needed if the whole body is treated by tablets or injections. Because this targeted dose is small, the side effects, produced by the effect of narcotics on distant parts of the body, do not occur.
Cannabis is another herbal remedy with a terrible social reputation. It is going through a surprising revival as a therapeutic analgesic, which repeats with a gap of twenty years the story just described of the emergence of narcotics from being drugs of social menace to ones of therapeutic value with rational understanding. Cannabis has been used for millennia as folk medicine for poorly defined problems and for social entertainment. Queen Victoria used tincture of cannabis for her period pains. In this century, patients began to report beneficial effects of low doses of cannabis in very specific conditions including nausea and pain in multiple sclerosis. In the hostile social atmosphere, where the use of cannabis and narcotics were equated with abuse by inadequate people, these reports were dismissed or ignored.
In the meantime, scientists were at work with the traditional series of investigations like those into opium. Cannabis was purified by Meshulam in Jerusalem and found to contain a series of active compounds called cannabinoids. It was found that the brain itself was normally producing cannabis-like compounds. Finally, to round off the progress which imitates the investigation of narcotics, special receptors tuned to react specifically to natural and synthetic cannabinoids were found to be widespread in the brain and body tissues. While cannabinoids are at present only used in legal practice to control certain types of vomiting, it seems highly likely that they will also emerge to control some pains.
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SLEEP AND PAIN: NON-MEDICATION CURES FOR INSOMNIA

Exercise Vigorous physical exercise in the afternoon or early evening (not too close to bedtime) has been shown to increase the portion of time spent in the deepest stages of sleep. You may not sleep more but you may well sleep better after exercise.

Schedule Set the same time for sleep each night and stick to it rigidly. It may help to prepare yourself for bed with a bed-time ritual, such as a bath, a glass of milk, etc., at the same time each night.

You should also set a wakeup time and stick to this, no matter how little you slept that previous night. It is very tempting to sleep in when you’ve been awake half the night, but this only increases the chances you won’t sleep the next night.

Naps These usually increase the problem of insomnia. They should generally be avoided by those with insomnia until their sleep has become regulated. On the other hand, a twenty minute period of napping, relaxation, meditation or yoga can help reduce the tensions, pain and discomfort of the day for many, and can enable them to resume tasks with renewed energy.

Stimulants No coffee or tea after the evening meal. You should also avoid chocolate or caffeine containing soft drinks until you have assessed their role in keeping you awake. Proprietary soft drinks such as CocaCola and TAB contain amounts of caffeine sufficient to interfere with sleep in those with insomnia.

Don’t fight it Many people drive themselves into an absolute frenzy — rolling and tossing all night in a largely futile attempt to force themselves into sleep. It may help to make a rule for yourself that if you are not asleep within 15 minutes, leave the room and do something restful.

Reading, knitting, doing jigsaw puzzles or listening to quiet music are all useful but, should always be done outside the bedroom. Loud music, exciting television programmes or suspenseful books should be avoided because they increase the level of mental arousal and consequent adrenaline production. They may also be hard to leave.

When you feel the slightest amount of drowsiness return to your bed. If you are not asleep within 15 minutes get up and leave the bedroom again.

Bedroom* are for sleeping And loving. Nothing else. Using the room for paying bills, doing homework or arguing can prevent the room from being a comfortable refuge in which you automatically relax.

Avoid habituating drugs Wherever possible avoid those drugs which are potentially addictive. This is more difficult for those with chronic pain who are offered barbiturates containing medications such as Nembudeine by doctors who still believe that they are safe. Nembudeine is one of the few drugs containing barbiturates available in Australia.

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SOME POINTS OF SPECIFIC PAIN CONTROL TECHNIQUES

• You can be asked under the hypnotic state to imagine going backward in time ‘to a time long ago, before any pain or discomfort, when you were full of energy and had a sense of complete well-being — and, when you return to the normal waking state, you will feel again that same sense of well-being. ‘ Hypnotic distortion of time can be used either to lengthen periods of discomfort or to apparently shorten periods of intense pain: ‘As a result of your new capacity to relax, time will now seem to fly whenever you experience periods of intense pain. On the other hand, time will move very slowly indeed with every second stretching out so that you can enjoy those periods when discomfort is at a minimum and so use them as positively as possible.’

• Other techniques involve asking you to transform your pain into a visual image that can be manipulated in the imagination. ‘Now see your pain. What shape is it? A triangle? A circle? Perhaps a pyramid or a cube? See its colour? Is it red? Yellow? Purple? Perhaps another colour? Now change the shape and colour. The new shape and colour are definitely not compatible with your pain.

Or the red balloon image: ‘Imagine you’re out in an open green field somewhere. It’s a beautiful day. The sky is a brilliant blue. Wisps of fleecy clouds drift lazily by. Near you, tethered by a rope attached to a peg on the ground, is a large red, helium-filled balloon. There’s a large wicker basket hanging beneath it. Now, imagine that you’re loading into the basket all of your pain and discomfort. You now free the balloon from its peg, allowing it to float into the air. See how vivid the rising red balloon looks against the blue sky.

The balloon is disappearing with all of your pain and discomfort.’

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NEUROSURGERY: UNNECESSARY PROCEDURES

The implantation of spinal stimulators and even deep brain stimulators are examples of the merging of technology and that most sophisticated of neurochemical devices — the human brain and nervous system.

However, all too often patients are subjected to unnecessary and sometimes harmful procedures because pain is still thought of in a very simplistic way. In some cases the operation is done technically with brilliance but still fails to resolve the suffering. It must always be remembered that surgery once performed is difficult to reverse.

Neurosurgeons may be involved in the treatment of such difficult pain conditions as phantom limb pain, trigeminal neuralgia and central pain following strokes.

The major involvement of neurosurgeons together with anaesthetists at pain clinics is to perform nerve blocks — or to cut nerve pathways when there is no other choice. In many cases, patients obtain temporary pain relief. With the onset or recurrence of pain six months later, the problem is again posed as what to do to help such patients.

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MEDICATION IN USE OF PAIN TREATMENT: ANTI-EPILEPTIC MEDICATIONS

Anti-epileptic drugs have been consistently used over the past twenty years, particularly for the treatment of facial pain.

The most severe cause of facial pain is trigeminal neuralgia. The more commonly used anti-epileptic medications such as Dilantin and Tegretol have been found to be useful in treating this painful condition and also the pain associated with shingles.

Rivotril, which was included in the minor tranquilliser group, is more commonly used as an anti-epileptic drug.

These medications have been used successfully in many of the painful states associated with nerve damage, such as RSI and the central pain that sometimes follows ‘strokes’ (cerebrovascular accidents). Central pain is thought to be due to the damage to the normal pain control centres in the brain and the brainstem.

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