an autodidact meets a dilettante…

‘Rise above yourself and grasp the world’ Archimedes – attribution

Posts Tagged ‘pain

My current health condition 3: nerves

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I’ve been to see a physiotherapist/sports medicine specialist, on the advice of a couple of people, and I’m happy with the result. It won’t mean an immediate cure, but the session has provided me with hope and a pathway to recovery.

Today and yesterday, the pain has been fairly minimal, after an excess of pain the day before. It seems to be about managing the medication.
So, to the physio. I described my situation in minute detail, describing as best I could the type of pain I felt, its sudden onset, how it responds to head movements and so forth. He very quickly conjectured that it was a nerve problem, which in fact had been my first intuition before I began researching the problem. He described the ‘queerness’ of nerve injury, or nerve impingement as it’s often termed – how damage in one place can be felt in another seemingly unrelated region. Interestingly, it was my description of how, since this condition has struck me, I’ve had difficulty moving my head back (this causing my shoulder pain to increase), and so not being able to gargle with mouthwash – which I do because of my bronchiectasis – it was this description which made him feel more certain that it was a nerve problem. He could be wrong but I think he’s right.

He did a lot of physical manipulation of the shoulder region and gave me advice. Keep up the medication, maintain activity of the shoulder and arm regions – not too much but not too little – and keep the area warm. He gave me some shoulder exercises to do, and assured me things would come good in time. I’ll revisit him next week.
Now, on this concept of impingement. It’s a term that comes up in the literature, and it was used by the physiotherapist today, so I asked him about it. He obliged by giving an explanation that was complex and difficult to follow, much like the material I’ve been reading online about the subject. So I’ll have a go at explaining it to myself.
Nerve impingement is one term among many (e.g pinched nerve, nerve compression, nerve entrapment), which indicates the trickiness of the condition and its description. In my case the suprascapular nerve is probably involved. As Wikipedia puts it ‘the nerve passes across the posterior triangle of the neck parallel to the inferior belly of the omohyoid muscle and deep to the trapezius muscle.’ I don’t know exactly what this means, but it seems to explain the pain at the back of my neck, left side, when I throw my head back.

The posterior triangle of the neck is a technical term with its own Wikipedia page. Here’s an image of it. As can be seen, it connects the omohyoid muscle and the massive trapezius which goes well down the back.
So nerve impingement/compression/entrapment is what it implies – something is impinging on the nerve, entrapping it, compressing it, pinching it. It could be bones, muscles, tendons, ligaments, cartilege, and that just about exhausts the possibilities. Carpal tunnel syndrome, for example, generally involves a pinched nerve in the wrist. The causes of course, are various. It could be a particular injury – but I can’t trace my own sudden onset to a particular injury (which doesn’t mean that no injury occurred) – or physical stress from repetitive work or sports activity, or some rheumatoid problem (which presumably would’ve shown up as some sign of inflammation, and I’ve never shown any signs of rheumatism) – or obesity.

The possibility that this was caused by lawn bowling remains real, if remote. Fascinatingly, when I told the physiotherapist that the only sports activity I’d taken up in recent times was lawn bowling, he asked me if I played at Walkerville – it turns out that he recognised me as he played in the competitions there too – out team had thrashed his only a few weeks ago! He agreed that bowling as a cause seemed unlikely – but being a bowler himself, he would say that, wouldn’t he?

But whatever the cause – and I won’t be bowling again for a while, if ever – the diagnosis and cure are the things, and it’s amazing what a seemingly effective diagnosis can do to calm the – nerves! I feel I can cope much better now, and I’ve had the humbling experience of knowing what severe pain is like. This is important as I’ve tended to be dismissive of the pain of others, with thoughts of ‘low pain threshold’ and ‘get over it’. So, it’s a lesson.

I’ll be returning to the physiotherapist next week, hopefully for the last time. His feeling was that just one more session would be enough, that if I simply followed the light exercise regime he suggested, things would come good. The pain has risen and fallen since then, but there’s been no relapse into anything agonising. I worked at Eynesbury yesterday, a relief day, but hopefully there won’t be any work for a while. In any case Covid-19 means we probably won’t be getting many, if any, students coming in from overseas over the next few months.

Of course, it’s not all back to normal, though I’ll try to get back to regular reading, writing and the like. Here’s a final quote from the Mayo Clinic on my situation:

If a nerve is pinched for only a short time, there’s usually no permanent damage. Once the pressure is relieved, nerve function returns to normal. However, if the pressure continues, chronic pain and permanent nerve damage can occur.

We’ll have to wait and see.

References

https://www.mayoclinic.org/diseases-conditions/pinched-nerve/symptoms-causes/syc-20354746

https://www.healthline.com/health/nerve-compression-syndrome

https://orthoinfo.aaos.org/en/diseases–conditions/cervical-radiculopathy-pinched-nerve/

https://en.wikipedia.org/wiki/Suprascapular_nerve

Written by stewart henderson

March 18, 2020 at 2:02 pm

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