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My current health condition 2: searching for a diagnosis

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It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.

Julius Caesar (and I’m willing to volunteer)

I haven’t been much in the mood for writing. You could say I’m feeing sorry for myself, or indulging in the pain I’m experiencing, but truth to tell, my current condition doesn’t make it so easy to ‘rise above myself and grasp the world’. I’m hoping at least to rise above my own pain and grasp the world of pain in general! But before I look at the ‘philosophy of pain’ I should update my situation.
The pain – shooting down from the left shoulder – first became acute on February 29. On that Saturday I arrived in an ambulance at Royal Adelaide Hospital, was examined, questioned and released without a diagnosis. Panadol, administered by the paramedic in the ambulance, had relieved the worst of the pain. I bought over the counter medication, ibuprofen and paracetamol, and using them at the upper limit of, and perhaps beyond, what was recommended, I was able to work at Eynesbury College on the following Monday and Tuesday. On Wednesday I visited my GP. I was referred to St Andrews Hospital for an ultrasound and an x-ray. The GP told me that if the pain subsisted or worsened the hospital could give me a corticosteroid injection in the shoulder, which he thought would do the trick, painwise.

Meanwhile I was doing my own research. It seemed that bicipital or biceps tendinitis was the best fit. There was also bursitis and some kind of rotator cuff damage. I couldn’t think of an obvious cause, the only ‘different’ activity I’d been engaging in was lawn bowling, generally associated with geriatrics and hardly recognised as strenuous activity. However, when Sarah, who was also doing some research, noted that one line of enquiry led to ‘dangers and injuries from lawn bowling’, I felt less dismissive.

My appointment at St Andrews was for Friday (March 6), but on Thursday a felt increase in pain had me asking Sarah to ring the GP for stronger medication. I was prescribed ibuprofen plus codeine, which I started taking, again pushing beyond the recommended limits. However, my subjective sense told me that paracetamol was more effective than ibuprofen. Yet ibuprofen was an anti-inflammatory, paracetamol was not. It was all very confusing. Did I have pain without inflammation? How could this be?

I was driven to St Andrews hospital next morning, where I was given, first an X-ray, then an ultrasound test. This was a first for me, and I was able to watch the screen as the young woman administering the test slowly moved the scanner across my shoulder region. From her silent response and my own observation of a kind of softly rolling ocean of muscle disappearing into the distance, I got the strong impression that there was nothing untoward, no sign of damage or dysfunction.

Meanwhile, the pain continued, together with difficulty sleeping, and a general lethargy, which might just be a sort of depression at the sense of restricted movement. I noted that I felt physically at my best when lying still, on the sofa or my bed. Just getting up resulted in shooting pains. Reading, holding a book, was a pain. All of this was on my left side, and I’m very left-handed.

And so it went, until something dramatic happened, I think it was on Sunday (March 8). I experienced severe constipation, certainly unlike anything I’d ever experienced before, and I won’t go into the shitty details, though it did make me think of my mortality (as has this experience of pain in general). How many people have died on the toilet seat? A dirty little secret, no doubt. In any case, I recovered, and, upon further desperate research (and noting that, before this bout, I hadn’t done a ‘number two’ for days – how had I missed that?), I dropped the ibuprofen plus codeine medication and went back to paracetamol.
I work part-time at Eynesbury College, currently two days a week (Monday and Tuesday), barely enough to live on, as a teacher of academic English to foreign students. It’s the most poorly paid job in the teaching profession. I’m paid as a casual, and work from five-week contract to five-week contract. It’s anything but ideal. For example during this current contract, which ends tomorrow (Friday), there were two public holiday Mondays, for which I wasn’t paid. I was offered another five-week contract starting next week, but I’ve made a decision to decline the offer, hoping to get on top of this pain situation once and for all.

I won’t go into my parlous financial situation, but it’s important due to my status vis a vis subsidised health care. More about that anon.

So I worked on Tuesday, and it was something of a struggle. Yesterday (Wednesday March 11) I returned to my GP and received the report from St Andrews Hospital. So I’ll now present the findings together with my comments.

X-ray and ultrasound left shoulder with subacromial bursal injection

subacromial bursitis has to do with inflammation of the bursa that separates the upper surface of the supraspinatus tendon (one of the rotator cuff set of tendons) from the overlying coraco-acromial ligament, the acromion, and the coracoid. To be explored further. A bursa, or synovial bursa, is a fluid-filled sac which cushions connections between bones, tendons, ligaments etc in joints.

X-ray – no bony injury. Alignment is normal. Subacromial space is preserved. No subacromial calcification.

Nothing to see here.

ultrasound- biceps tendon intact. No fluid in the sheath. The tendon does not sublux during internal/external rotation

Nothing again. Subluxation is a partial or incomplete dislocation of a joint or organ.

supraspinatus and other rotator cuff tendons are intact. No tear or tendinopathy. The subacromial bursa does not appear thickened and no bursal drag with abduction is identified.

So there are four rotator cuff tendons or muscles (not too sure of the difference); supraspinatus, infraspinatus, teres minor and subscapularis. The subacromial bursa is as described above.

The AC joint is normal in appearance and remained stable during forward flexion.

This is the acromioclavicular joint, at the top of the shoulder. It feels to me that the pain comes from ‘inside’ and lower than the shoulder, but it’s actually difficult to locate precisely. It may be a problem with the acromion, however. Or the Glenoid cavity or labrum. It may be a SLAP lesion (symptoms include ‘trouble localising a specific point of pain’. SLAP stands for ‘superior labrum, anterior to posterior’.

I’ll no doubt have to see a specialist, and the worry now is money

Written by stewart henderson

March 12, 2020 at 1:59 pm

My current health condition 1: it’s bizarre

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I can bear any pain as long as it has meaning

Haruki Murakami

stuff to learn about

I haven’t written for a while because I have a new health problem which flared up last Saturday, February 29, 2020. I had been feeling mild pain in my shoulder and I was lying on my bed reading when I tried to get up. Shooting pain from my shoulder down my left arm was so excruciating that I fell back on the bed and and lay down for a while before trying to get up again. Again I couldn’t get up because of the pain. I called for help but even with two of us it was difficult. I may have had a panic attack and exaggerated the pain of rising – I was gasping a lot. To cut a long story short Sarah called an ambulance (and the paramedic got me into a sitting position easily enough). I spent the next few hours in emergency at the Royal Adelaide Hospital.

Due to being given Panadol in the ambulance, and a long wait in reception while the painkiller took effect, by the time the friendly, efficient and strikingly beautiful (oh dear) young intern saw me, the pain, my only symptom, had much reduced. She found that, yes, I could move my arm above my shoulder, flex my elbow and my wrist, and no, I couldn’t precisely describe the nature or location of the pain. She checked my arm for swelling or redness (none), and asked about any recent history of injury to the region (none). I was beginning to feel like a fraud, a malingerer, a milquetoast.

So after some more prodding and questioning and advice from higher authorities, I was released with a report for my local doctor.

I’m very left-handed, so this left arm pain is quite a problem for me. I was due to work on the Monday and I needed some pain relief. It would have to be over the counter at first. The report’s only solid conclusion was ‘skeletal-muscular pain’. Since I needed to work on Monday and Tuesday I could only get to the GP on Wednesday. So on Sunday I started doing what research I could. I’ve never taken regular medication for anything, and I’ve never experienced regular pain like this. The only over-the-counter treatments for pain are ibuprofen and paracetamol as far as I know. Only ibuprofens is an anti-inflammatory. Paracetamol works on pain centres in the brain. Which one would work best? Was it all in my mind? But don’t we always feel pain via the brain? Isn’t that how the nervous system works?

I obtained both medicines. Over the next day or so I experimented with both, singly and in combination, and I got through Monday and Tuesday’s work. The pain never went completely away, though the teaching days, when I had to concentrate on and interact with my students and other teachers, helped to distract me from it, which gave me that guilty ‘it’s all in the mind’ feeling.

Even so, on Wednesday (March 4), the pain came roaring back. My subjective sense told me that the paracetamol was much more effective than the ibuprofen, another surprise. I visited my GP, who smiled at the hospital report, saying, ‘yes, they wanted you out of there as soon as possible – they’re there for acute, intensive care stuff, it’s understandable – a GP can refer you to a specialist, and we can go from there’. So he filled out a referral form for St Andrews Hospital, for an x-ray and an ultrascan. I rang them and organised an appointment, for Friday, March 6 at 11am.

I was still in pain, though. The OTC medication had reduced the pain to more bearable levels, but I still hadn’t worked out which worked best. Unlike me, Sarah was on many medications, for pain and other problems, including Prodeine (paracetamol plus codeine) and a set of tablets which combined paracetamol and caffeine. I was taking the tabs at the upper level of what was recommended, and beyond. I was trying to monitor the pain, what it felt like. It was always a low-level throbbing, which increased and became a shooting pain if I used the arm too much. It was a strange delayed pain – I would engage in a flurry of physical activity, such as preparing a quick meal, and then lie down, knowing that the pain would rise up as a result of the activity, then slowly subside. I had difficulty sleeping, and I dreaded dressing myself in the morning. Typing this is giving me an ache, and I’m experimenting with dictation – I find the Apple dictation system a pain (mentally speaking). I have to learn more about how to use it effectively.

Stupidly, I hadn’t asked my GP about stronger prescription medication. The day after the consult (Thursday, March 5) I had Sarah ring the surgery – I was experiencing bouts of serious pain, and was finding it hard to track what medication was working, or not. The doctor wrote a prescription, which Sarah collected and had made out at the pharmacy around the corner. It was for ibuprofen (200mg) and codeine phosphate hemihydrate (12.8mg). I was skeptical about the efficacy of ibuprofen, and I had been researching anti-inflammatories, and inflammation generally.

What, exactly, is inflammation? There are, supposedly, five signs of it, remembered under the acronym PRISH – pain, redness, immobility, swelling and heat. My only symptom was pain. There was certainly no redness or swelling. Immobility wasn’t a real problem either. I could move my arm above the shoulder, I could flex my elbow, etc, but some pain would come afterwards. Heat wasn’t something I could measure, but it didn’t seem an issue. Only pain. And I hadn’t pinpointed any cause of all this. I remembered what I’d said, quite often (or at least I thought I did – maybe I was mostly saying it to myself) to the intern at emergency: ‘It’s bizarre!’

Anyway, I’ll wind up this piece, and start on a new one, dealing with my time at St Andrews Hospital, the x-ray and the ultrasound.

Written by stewart henderson

March 8, 2020 at 12:43 pm

On cramp, sensation and pain

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hard to find a non-athletic-looking image of leg cramp

In recent times I’ve been suffering from cramp, usually in bed in the early mornings, almost always in the calf but sometimes in the foot, around the toes but sometimes at the back of the foot, and invariably on the left leg. So all of this leads to a great variety of thoughts and anxieties. What is cramp? What causes it? Can it be cured or prevented? Why only on the left side? Why now and not in the past? Will it keep getting worse? How to describe the sensation? What’s the difference between a description of a sensation and the sensation itself?  Can pain be measured? Can it be distinguished from pain response?

The cramps I suffer from are clearly not the same thing as those experienced by footballers near the end of a go-for-broke cup final, when they crumple in a heap of agony and have to be massaged back to life by a team-mate, an exercise which also seems to involve a stretching of the afflicted muscle. I’ve heard this has to do with a lack of oxygen getting to the muscle when it’s being strenuously exercised. I don’t know if I’ve ever experienced that kind of cramp (does it feel different?) but I do recall getting a sharp pain in the abdominal region, referred to by others as ‘the stitch’, when, either during a football game or a school run, I exercised myself beyond my level of fitness – which was very easily done. That pain, however, was qualitatively different from the cramps of today. It didn’t feel muscular.

 So now to what the pundits say. First, on ‘stitch’, this BBC health and fitness website has it that ‘most scientists believe the pain is caused by a reduction of blood supply to the diaphragm, causing it to cramp’. It’s certainly common in long-distance runners, but as I recall – and it’s been a long time since I’ve been silly enough to bring on that particular pain – it felt very different from the leg cramps, more like an organ pain, of the stomach perhaps, or the duodenum (I’ve no idea). If it is a muscular cramp, it’s an indication that these cramps can feel very different from each other.

It hasn’t taken me long to realise that the science of cramps isn’t particularly well-developed. Though perhaps that’s a bit unfair – better to say that it’s not settled, due largely to its complexity. Some cramps, though surely not mine, are caused by muscle fatigue, while others are caused by a lack of electrolytes, or it could be a combo.

So what are these electrolytes? Salts, acids and bases mostly, which become ionised in solution when an electric current passes through it. The major electrolytes in our body are calcium, sodium, magnesium, potassium, phosphate and chloride.

Okay, I’ve got it slightly wrong. These electrolytes, or ‘lytes’ as the pundits call them, dissolve in any ‘polar solvent’, such as water, and separate into cations and anions. I learned a bit about this at school but I’ve forgotten. Basically the dissolved lytes become ionised, I don’t know why, becoming either positively charged (having fewer electrons than protons, making them cations), or negatively charged anions (with more electrons than protons). These anions and cations disperse more or less uniformly through the fluid, making it electrically neutral. But when an electric potential (something very complicated, but I think it basically means an electric charge) is applied to the fluid, the cations gravitate (surely the wrong word!) to the electron-rich electrode, the anions to the … other one.

What does this mean for cramp sufferers? Fuck knows, but I think it means that if you don’t have enough of these lytes, for whatever reason, you don’t get this ionisation happening and that’s bad for your body. Anyway, we’ve all presumably heard of these probably bogus electrolyte-bearing drinks that are advertised as a salvation for athletes, of which I’m very obviously not one, but it does seem possible that I’m a bit light on my lytes. What I’m doing here is engaging in a bit of deductive reasoning a la Sherlock Holmes. If you eliminate all the impossibles, whatever’s left, however improbable, is probably true, or something like that.

So… my cramps are definitely not caused by hyperflexion (flexing of a muscle beyond normal limits), or by hypoxia (deprivation of oxygen at the tissue level). Nor is it likely to be a complication of pregnancy (I wish). I don’t want to think about it being symptomatic of kidney or thyroid disease (I feel otherwise healthy), but they’re extreme improbabilities that might need to be looked at later. Three other conditions are highlighted on the fabulous Wikipedia: hypokalemia, hypomagnesemia and hypocalcaemia. Careful inspection from the astute reader should render these terms intelligible. They refer, bien entendu, to a, presumably chronic, lack of potassium, magnesium and calcium, respectively (the aforementioned lytes). A quick glance at the symptoms of these three conditions suggests to me that they can be relegated to the bottom section of the list of probable causes. Often they result from the use or overuse of prescription medication. I don’t take any.

Now I’m starting to run out of possible causes, and I don’t want to complicate the problem too much. Actually the best advice I’ve read so far on the Wikipedia website is this: Stretching, massage and drinking plenty of fluid, such as water, may be helpful in treating simple muscle cramps. Obviously they don’t include wine as a useful fluid in these circs. That may be my downfall – alcohol tends to dehydrate, which is negative in itself but also seems implicated in cramping. It narrows the blood vessels (hypoxia enfin? the blood vessels oxygenate the muscles don’t they?), which is probably what gives that headachey hungover feeling I sometimes have in the morning. It also causes a build-up of lactic acid, another probable cause of cramping. I’m beginning to feel that a few small adjustments, such as drinking some water before bed-time, avoiding excessive alcohol intake, and keeping the muscles of the lower leg warm (cramping always seems more excruciating in winter) might be enough to solve my problems, which are only minor after all.

So that’ll do me, all that philosophical stuff about the nature of pain will have to wait for another day. I need to hydrate and keep warm, firstly, and I’ll see how that helps as winter is coming.

Written by stewart henderson

April 29, 2017 at 5:53 pm

Posted in fitness, health, pain

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