Teach Yourself Medicine, the Autonomic Nervous System

Teach Yourself Medicine (TYM) is the medicine of the Autonomic Nervous System

Click here for further information about the effect of damage or "denervation" to the autonomic nervous system and how this causes Western diseases.

The Autonomic Nervous (ANS) is like the computer system that runs the body. The ANS is brain of the human body. Difficulties with the Autonomic Nervous System cause 90% of western diseases.

Symptoms of autonomic nervous system malfunction, such as dizziness, fatigue, headache, muscle aches and pain are at best called "medically unexplained symptoms". Only traditional Western Medicine ignores these vital early clues to disease "unexplained" .

Chinese Medicine, Aruveydic medicine, Galenic medicine and every major system of medicine acknowledges symptoms coming from the Autonomic Nervous,

Only Western Medicine waits until the human body is damaged so badly that it is all but irreversible. Western medicine waits until the organs at the ends of the nerves, until the computer system running the body malfunctions so badly that a person is effectively disabled.

Until that point is reached, until there is sufficient damage to show up on medical tests, doctors are taught to dismiss symptoms as "psychological".

Symptoms coming from the Autonomic Nervous System include

Pain.

Pain is the most important warning the ANS gives. In many ways it is a final warning before permanent damage begins. Too often, people take aspirin, paracetamol, ibuprofen, voltarol, codeine, tramadol and continue to do exactly what they did that caused the pain.

Muscle fatigue

Fatigue means tiredness, something is tiring the body out and making it fail. Yet we have been taught to take a stimulant such as coffee, alcohol, tea, antidepressants, and painkillers to mask the symptoms of tiredness that mean we need to rest

Dizziness

Dizziness comes either from the body failing to manage blood pressure as person moves around or from a problem in the ear. A person's ability to move freely, animals ability to move from one environment to another depend on their ability to keep their blood pressure steady. Dizziness suggests that the ANS is no longer coping

Palpitations

Palpitations indicate the heart is beating incorrectly, even Tony Blair had palpitations at the height of the Iraq crisis, because of the pressure he experienced from having lied to the nation.

Stomach pains, bloating, diarrhoea

Although this collection of symptoms is frequently called Irritable Bowel Syndrome, it represents a failure of the Autonomic Nervous System to manage the stomach and bowels in the face of severe psychological pressure, a processed unnatural diet and interfering with the natural process of digestion and bowel movements

In every area of medicine, the role of the autonomic nervous system has been neglected. This means that western medicine does not intervene until a person has a serious medical condition. It means that people reporting symptoms that show mild problems are ignored until their symptoms are severe and disabling.

The most obvious and dangerous areas where Modern Medicine neglects its patients in the worst ways are

Obstetrics and Gynaecology, where damage in labour leads to gynaecological problems that last the rest of a woman's reproductive life.

Psychiatry, where failure to understand people leads to the widespread use and abuse of drugs that directly damage the Autonomic Nervous System

and finally

Occupational Health which fails to recognise the intimate relationship between work, health and disease and repeatedly consigns people to unemployment or intolerable working conditions which directly damage peoples' health.

Gastroenterology
Here as with the specialties mentioned above, there are only crude investigations. Those "abnormalities" that are seen are misinterpreted. The last conference I attended on gastroenterology failed to mention diet or bowel movements. It is like investigating the water and sewer system of London without understanding what is meant to go through the pipes. Needless to say that kind of approach leads to a lot of unfortunate errors!

Teach Yourself Medicine unpicks medicine as it is now and offers a medical education to everyone who is interested in finding out a little more about how their body works!



Copyright (c) Dr. Liz Miller
http://www.lizmiller.info/



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Occupational Health - Second opinions or Glimpses of the Obvious

Last week I saw three patients in rapid succession whose NHS doctors had made the wrong diagnosis, missed the diagnosis and ignored the diagnosis.

Occupational Health is about getting the patient back to work, and if that involves sending the patient back to their NHS doctors, I do what it takes.



Person 1 injured his hip four months ago and has been off work for four months.
He complained to me of hip pain, he complained to his physiotherapist of hip pain, he complained to his General Practitioner of hip pain, he complained to his Orthopaedic consultant of hip pain. As far as I could tell, I was the first person to examine his hip since his initial visit to Accident and Emergency, where he was Xrayed

He gave a story of a "dislocated hip". This is unlikely - First, dislocating a hip takes a massive amount of force (FTR - hip replacements dislocate easily). Second, it takes a full general anaesthetic and a lot of effort to put them back.

However! - he did this during a Rugby game - and the "other buggers were big" - and he was immediately treated by an experienced physiotherapist who manipulated his hip and it then felt a lot better. But he still couldn't walk. He has not walked properly since.

His back did not show much wrong when I examined it, but when I examined his hip by feeling in his groin, which is where the hip joint can be felt - he hit the roof with pain. And this guy is a tough cookie. I have sent him back to his GP with a letter, and not back to work.

Person 2 has had funny turns for the last four years. He has extensive investigations for heart disease even to the point of having a stent put in. However his "funny turns" persist and to his mind he is worse than he was when he first went to see his doctor.

He is short of breath, he can't comfortably lie flat, he has episodes largely at night of feeling strange, even as though he has been stabbed in the chest and is about to die. The last doctor he saw almost got the diagnosis. But they sent him for a scan, and four days later the scan was normal. He also goes on long coach trips.

This is a classic story of recurrent pulmonary emboli - and the cardiologist put in a stent because he is fat geezer with slightly narrowed arteries to his heart.
I put him off work and wrote a note to his doctor, asking him to arrange for him to be investigated for pulmonary emboli and raised blood pressure in his lungs.

Person 3 also had dizzy spells, but of a different type perhaps more related to long term night shifts. But a twenty four hour ECG has shown his pulse slowing to 33 beats per minute.

He was told by his consultant that this was normal for a fit person. He is over 50 and even Rebecca Adlington's pulse rate never gets that low. He needs a pacemaker.

The morale of these stories, is that the diagnosis comes from understanding the patient. All three had been seen by consultants in major teaching hospitals. A consultant appointment was once a gold standard.

The difference between consultants and an occupational health physician is not so much one of skill but of time. All three diagnoses were in the history. "Investigations" can be wrong, Person 2's scan was done too late and in any case would not show up small clots on the lung (pulmonary emboli). They look at the wrong part - Person 1's MRI scan looked at his back not his hip. "Investigations" can be right and be ignored, as was the case with Person 3.

I would like to think that even ten or twelve years ago, I would not have found so many diagnoses. Roughly one in ten of the people I see, have the wrong diagnosis. Nothing, even in this high tech world beats a good history and examination. People matter, and cannot not be fobbed off with a few high tech tests, when they need a proper medical opinion.

Once upon a time, I thought tests were better and more reliable than doctors. Whether a Masserati is a better car than a Ford depends on more than the technology under the bonnet. If a blind person is driving the Masserati, you are safer in the Ford driven by someone who first finds out where you want to go.


Copyright Dr Liz Miller, Well and Working Ltd

www.lizmiller.co.uk
www.moodmapping.com

Occupational Health, Why employ someone with a disability?

Why employ someone with a disability, who needs job modifications and adjustments, if you don’t have to?


Employers are concerned about –

Employees take time off for medical appointments
Making expensive adjustments to the workplace
Having to spend time on peoples’ problems that might be better spent getting on with the business
Employees calling in sick at the last moment
Other employees thinking that someone is taking advantage
Employees use sickness to cover up their poor performance

On the surface, it may look more expensive to employ someone with a "disability" .
Ask yourself

1) Which costs the business more – a stroppy employee or a disabled employee?

Who would you prefer?
a) someone who appreciates your flexibility and your human side or
b) someone stroppy who wants to take you for everything they can

Of course choices are rarely black and white but most people appreciate it when their boss goes out of his or her way to make life better for them.

2) If you just pick winners are you likely to win?
Thirty years ago Belbin showed that a team of winners does not win. The best teams are mixed groups. When everyone is highly competitive, that is a winner, employees spend their competing against each other instead of outwitting the competition.

3) Is it better, for example, to adjust a rota or treat the workforce as automatons?
Rotating shift systems are bad for circadian rythms. How can a diabetic manage his blood sugar well when his sleep wake cycle keeps changing and what about the insomniac who can’t sleep at night? If your manager doesn’t like helping people work for you, may you have the wrong manager.

One thing is certain, if you want motivated employees, someone who has struggled with life is likely to go further than someone who has had it easy. One thing is certain, if disabled people are not highly motivated, they go nowhere, apart from outpatients.


Employers concerns

1) Yes, an employee with a disability or medical condition will need to go to the doctor more often than someone who does not. And yes, they are entitled to attend their medical appointments. However, you do not have to pay them to visit the doctor. Your employee can either make up the time or to forego the money.

2) Yes you have to make reasonable adjustments but not expensive adjustments that are beyond the reach of your business. For example, you do not have to employ someone to help a blind person read scripts but there is speaking software for computers and it may be reasonable to make the appropriate modifications, it may not. It depends on the job.

3) It may take more time to get someone with a disability set up but these people are used to coping with adversity and with the coming crisis, are you better off with employees who expect everything served up to them on a tray, or with people who are able to sort problems out?

Employees calling in sick at the last moment Other employees thinking that someone is taking advantage


Finally,

Yes, you do have to employ someone with a Disability because that is what the law says. You do have to make reasonable adjustments but that is all. Occupational Health helps you decide what, from a medical perspective, reasonable adjustments might be. It is up to you to decide whether or not you can comply and whether the adjustments are reasonable.

If for example, you think the adjustments are unreasonable and can show that. For example, you are a haulage company, with no light duties where everyone is expected to help out, it is unreasonable to expect you to employ someone who cannot lift more than 10kg and who has no office skills.

But if you have jobs in the warehouse, and that same employee is capable of doing them and wants the job, then you do have an obligation to help them. The spirit of the law is about being reasonable. And if you are reasonable, and can show that, you will not have problems employing the best person for the job.


Copyright Dr Liz Miller, Well and Working Ltd

Work Related Upper Limb Disorder, WRULD, Repetitive Strain Injury, Carpal Tunnel Syndrome

Work Related Upper Limb Disorder

Carpal Tunnel syndrome is often just another form of Repetitive Strain Injury (RSI). Other names include De Quervains synovitis when it is so bad the tendon "crackles", golfer's elbow, tennis elbow, sometimes frozen shoulder, dystonia (Awkward movements), writers' cramp, and good old myalgia (Pain in the muscles). In truth all these conditions have the same underlying cause. The results are stiff, painful, swollen and tender muscles in the hands, arms, shoulders and neck. The swollen muscles put pressure on the nerves. The Carpal Tunnel is literally a tunnel at the wrist, through which the nerves and tendons to go through on their way to the hand. As this is a narrow point, it is not surprising it becomes painful.

Upper Limb Disorder (WRULD) .

The pain from WRULD can be horrific, it can keep a person up at night, it can prevent them doing everything and anything physical. However the good news is that, with the right treatment, it gets better.

Similar problems can happen in the lower limbs, - runners used to call it "Shin Splints".

Work Related Upper Limb Disorder can cause pain at any point - from the wrists, to the elbows, shoulders and neck. However although the pain may be intense at one point in the Upper Limb "girdle", it is always possible to find evidence of this condition elsewhere in the shoulders, neck and arms.

How can you tell if someone has WRULD?

Diagnosis - depends on finding a characteristic pattern of pain and physical changes. (Medical term - "signs and symptoms")

The problem (Medical term - Presenting complaint) is pain and discomfort in the wrists, arms, shoulders and or neck.

The pain of WRULD gets worse with work or the activity and better when a person rests

WRULD is often set off by a relatively minor injury that does not get better. The body naturally heals, almost regardless of what we do to it. If pain or a minor injury is not healing, something else is happening, and one reason may be that the person has underlying Work Related Upper Limb Disorder.

WRULD leaves clues. Before WRULD was recognised and understood, employees complaining of pain while they worked were seen as "sciving". In truth, people with WRULD are not scivers, these are the hard working employees. The subtle changes that indicate (Medical term - sign) are readily seen, once you know what to look for.

The Symptoms:
Pain - the pain may be any where in the mechanism, just as a bridge will tend to crack at its weakest point, so the pain will tend to be felt at the "weakest" point, perhaps where there has been an injury. Nonetheless, the whole bridge is under pressure, and it has cracked at its weakest point. In order to repair the bridge, it is necessary not just to work on the crack but also to look at what it putting the bridge under pressure.

The cause:

Repetitive limited movement under pressure. Most often this is work related, typically typing although I have seen WRULD associated with many different occupations, from driving and train driving to ticket sales - especially the turntables beloved of railway ticket offices, packing, counting and any kind of keyboard work.

Anyone who is not a traditional shape or size is at particular risk - for example, if someone is more than 5' 9" or less than 5' 4"

Over the last ten years, employers, Human Resources and employees generally have become more aware of the problem. Work station assessments, which make sure people are in the correct ergonomic position and as a result WRULD is less common than it was perhaps five years ago. Nonetheless, this also means that those people who do have WRULD can be more difficult to diagnose than in the past.

Work Related Upper Limb Disorder is the result of overusing one set of muscles whilst working under pressure.

Signs of WRULD

Tender muscles:

Firmly touching the muscles of arms, especially around the elbows, even the biceps, especially around the shoulders and neck, causes if not pain, definite discomfort. Muscles should not be tender!!! they should be soft, pliable and flexible. If muscles are stiff and painful, something is not right! - they have been overused or abused in some way. Typing, driving, playing tennis, sitting in an office are not natural activities and they have a cost, even though they may be fun and even good for you when done properly!

Stiff muscles:

Almost everyone can pinch their shoulder blades together at the back. However if someone has WRULD, their muscles are stiff and they find it difficult to "roll" their shoulders and cannot pinch their shoulder blades together. When I test for this, I put my finger on the person's spine and ask that person to squeeze my finger. This sign is always present - almost to the point that if a person has sufficient flexibilty to squeeze my finger they cannot have WRULD and if they are too stiff, then they are at risk of WRULD.

Squeezing your shoulder blades together at the back could be useful part of every work station assessment!

This is the One Minute Doctors's approach to RSI

1) RSI is caused by repeating one action or activity or a limited range of activities. Any activity done often enough, can cause RSI. From counting tickets, running on running machines (yes any limb, any activity - it used to be called "shin splints"), writing, data entry, to good old typing.

2) Hard working types get RSI. People going for the Word Speed Record, or Ticket Counting Tally. It is not a condition for idlers or the faintheartedly. Their enthusiasm means they ignore the first warning signs of pain and stiffness and wait until it becomes seriously painful.

3) RSI causes pain and stiffness in all of the muscles of the arms, shoulders and neck. The person is usually tense and rigid, and highly focused on work, and they do not notice the pain that this causes. This may be the only exercise they get. Wrists, hands and shoulders are stiff, often on both side and he or she can never pinch their shoulder blades together at the back.

Shoulder stiffness might almost be seen as diagnostic, and where you find shoulder stiffness you will also find neck stiffness as well as arm stiffness.

Treatment is three fold


1) Stop it - whatever it is that is causing the problem, whether typing, driving or an obscure hobby

Stop or reduce the activity - that is complete rest until pain goes and then start from scratch gradually increasing the activity with frequent breaks. This may be every ten minutes to at the beginning

a) Voice recognition software, but it can be difficlt to train a computer and you have to speak to it slowly
b) Dictate the reports and get them back from India four hours later, ready for editing - for example, http://www.indraftsolutions.com/

2) Do the it differently -

a) work station assessments to make sure the person's posture is correct,
b) wrist rests and other aids, to make sure the person keeps their joints in a neutral position. For example, Track Balls instead of mice, big pens that are easier to grip and so on.
c) change your typing position - most of learn to type in a hit or miss sort of a way. A proper old fashioned typing coure can help someone unlearn bad habits and learn to type better and more effectively

The neutral position is the most efficient way to work a muscle and joint. Extending or stretchig to work at a distance from the body means that the muscles do not work efficiently. This causes pain quicker than if the joint or limb is held in a comfortable neutral position.

3) Loosen up !

a) Physiotherapists are best at managing RSI. They intuitively understand that all parts, wrists, arms, shoulders and neck need treating. Physio is essential if you want to solve the problem and prevent it coming back
b) learn to fidget rather than sit still - stretch and shake yourself out every few minutes, change positions, shrug your shoulders, keep moving!
c) do different physical activities - like dance, yoga, pilates, Alexander technique, different sports, gardening and other outdoor pursuits, rather than just the gym. Do a different type of exercise every day.
d) learn to relax and enjoy the day, rather than keep trying to chase your tail faster and faster - the harder you chase your tail, the faster it moves. Do things differently!
e) Quick exercise = Roll your shoulders forwards, Roll your shoulder backwards and shake your arms out! 10 of each every twenty minutes as required.

What not to do!!

1) Take painkillers in order to continue working without sorting out the problem

2) Have an operation

Surgeons are tempted to relieve the pain by operating on the Carpal Tunnel.
However
a) no one knows what happens in the long term when a youngster has this surgery. It reminds me of the enthusiasm with which cartilages were removed from knees in the 1970s an 1980s and the knee pain and osteoarthritis which inevitably followed in the 1990s and 2000s .
b) It does not treat the cause, just one symptom.

Patients should always be wary of having surgery, especially on "soft tissues", that is muscles, ligaments and tendons. Operating on something that has taken millions of years to evolve and was fine until the turn of the century is rash. Especially as the cause relates to our unnatural lifestyles, poor typing posture, intensive work and too few breaks. At best surgery relieves the symptom, at worst it is storing up problems for the future.

I wrote this post because this morning, I saw a young girl heading for surgery for her "Carpal Tunnel Syndrome". I was left wondering why after millions of years of evolution, and some of the finest biological design work imagineable, does a person suddenly need their wrists cut open in order to lead a normal life?

Copyright (c) Dr. Liz Miller

http://www.drlizmiller.co.uk

www.lizmiller.co.uk
www.moodmapping.com

Occupational Health - more second opinions - Tragic and Trivial

Occupational health is a window on the world, I cannot prescribe drugs, nor order any tests but from my crow's nest I see life. Sometimes what I see in Occupational health goes beyond description for a twentieth first century civilised nation



45 year man blind from an avoidable and treatable complications of cataract surgery.

Refuse Collector - Essential manual worker



Aged 45, rapidly progressive cataracts and hypertension. Waits eighteen months for surgery "to get his blood pressure under control". Operations 4 and 6 months ago. Not back at work, sent for Occupational Health referral.



On examination, Light and Dark perception only.



Likely diagnosis - Bilateral detached retinas, occuring a few days after surgery.



Complications - no post operative check, not when the man goes for surgery on his second eye



Prognosis - Grim



The trivial.



Technician (aka Mechanic) for top car manufacturere

Non essential Manual worker



Pains in wrist, not severe, just aches occasionally.



Third visit to private specialists - and private physiotherapists, following checks for Hand and Arm Vibration Syndrome and Carpal Tunnel Surgery



Unknown fact - this employee races 1,000 cc bikes at the weekend, which puts his wrists into extension and this, combined with the vibration and weight of the bike, is hurting his wrist.



Complications - at risk of private surgery for Carpal Tunnel Syndrome



Prognosis - excellent if he changes the bars on his bike
www.lizmiller.co.uk
www.moodmapping.com

Occupational Health - more second opinions - Glimpses of the Obvious

Occupational health is an unlikely place to make a diagnosis. On the other hand, there are a lot of people not working because they have not had proper treatment

I have seen two people recently who have been treated for the wrong diagnosis.

The first was a woman on a large number of painkillers, and had recently started antidepressants, for piercing chest pain. Every orifice had been penetrated by medical instruments. However what made her different, was her habit of drinking a cup of scalding tea every hour. Was there a connection between pouring near boiling liquid down your throat and severe pain? Almost certainly! We negotiated a deal - she would carry on drinking tea, but cool it down first.

The second had injured his finger. His work involved typing and the pain he still had, three months after the injury prevented him working. A quick examination showed that he had also injured his nerve. In the hand and fingers, tendon and nerve injuries often occur together - the nerves and tendons are close together. When I was a medical student, our teachers drilled us to look for a nerve injury where there is a tendon injury, and to look for a tendon injury, where there is a nerve injury. This young man had a partially severed nerve, that had not been treated, was causing severe pain, and making it impossible for him to do his job.

I probably see one case a month where poor medical treatment of minor injuries leads to a person losing their job. A woman who does not have an X-ray to check their fracture has healed, until the fracture has past the point of healing. Nowadays no one seems to get physiotherapy after a knee replacement. The result is that he cannot climb stairs, not because the operation was not a success but because no one showed him how to climb stairs after surgery.

These injuries and omissions are not audited. No one checks that a doctor has asked about hot tea drinking or that someone can climb stairs after a knee replacement. Yet they reflect the underlying quality of a service. The everyday touches that make up good care.

What is the remedy? Nothing short of personal vigilance. If it does not feel right, it probably is not. Learn to be your own doctor, and save up and get private medical care.

Private doctors tend to care more about their patients. Private patients are valuable, because they pay directly for their treatment. Private doctors depend on their reputations for referrals. State doctors do a job, with too few resources and as long as they get their targets, tick the bureaucratic boxes, no one is the wiser as to whether they include the everyday touches of good medical care.

www.lizmiller.co.uk
www.moodmapping.com

Diagnosis - find out everything about the problem

Just as you expect your garage mechanic to fix your car, people expect the doctor to fix them

And in many ways the process is similar!

I saw a young lad in the clinic two days ago. a 24 year old security guard, with a pain in the knee. He had been off work for a month and he could barely walk. He had seen his GP, been referred to a specialist and was seeing a physiotherapist with a diagnosis of "Patellar misalignment"

Except it didn't add up. I don't like the diagnosis "Patellar misalignment". The patella is a bone that sits in the quadruceps tendon. It is not a bone like the femur or thigh bone, it is a "sesamoid" bone. The patella sits in the quadruceps or thigh muscle where the muscle crosses the knee joint. If the patella is "misaligned", the muscle not the patella has a problem. Nonetheless, surgeons get so excited by the diagnosis of "patella misalignment that they even remove the patella.

The typical patient with patella misalignment is a teenage girl, not a fit young man

I looked at his knee, not swollen and full movement but he had an acutely painful spot where the muscle joined the top of the patella. Nonetheless, his legs did not look right and he did not look right. He was zipped up in a jacket even though he was in the clinic. My attennae were burning.

The penny finally dropped. "Do you do weight training?" "Yes" "Take your top off"

Once the jacket was off, there was the incredible hulk. Massive pects, and taut abdominals and tiny spindly legs. I got the full story. He weight trained in the gym but he only did his torso because that was the bit people saw first. Until May of last year, he had trained as a boxer but he had stopped the boxing training and within a month the pain had started in his knee.

I know I was the not the first person to tell him about the dangers of concentrating on a few muscle groups in the gym rather than whole body training. He had a boxing trainer but he did the weights on his own

The diagnosis - "patellar misalignment" - but anyone who builds up part of their body and neglects the rest is building a maching with a lever partly made of reinforced steel - the massive pects and taut abdominals and partly twigs - the puny legs and knees.

The lad's twig legs were having trouble holding up the steel girder, causing Pain in his knees.

The remedy - weight training with a professional trainer and all round training such as boxing. This would help his body to come back into balance and help him lose the hulk on matchsticks profile.