Health Matters

Post Traumatic Stress Disorder: Some Thoughts While the Kingsway Therapeutic Centre does not offer psychotherapy or the like, the events of September 11th in the United States and those thereafter have become part of our daily lives and our psyche and as such, may give cause for reflection. This article addresses some of the potentially relevant aspects of PTSD, drawing upon numerous psychological studies of experiences of adults and children in Northern Ireland, France, Gaza, Lebanon, Algeria, Ethiopia, Mozambique, Cambodia and the United States. In some instances, people were directly injured by an act of (at times ongoing) violence (by the State or paramilitary groups or terrorists acting abroad) or knew people who were, whether as co-workers, friends or family. Other times, participants in the studies were by-standers or part of the general population which was witness to but not directly part of the event(s). Whether the violence committed was incidental or part of a campaign, PTSD was frequently experienced by the survivors. “Terrorism necessitates a healing environment of social cohesion to prevent panic and social disintegration.” Tucker, P. et al. “Oklahoma City: Disaster challenges mental health and medical administrators.” Journal of Behavioral Health Services and Research 25(1):93-99. On September 11th Canadians saw images of two hijacked planes being flown into the tallest towers of the World Trade Centre as well as the aftermath of one downed plane in Pennsylvania and of a gaping hole in the Pentagon. Within an hour other reports of explosions in Washington and more images of the collapse of the WTC were broadcast. Over the course of the next couple of days, incessantly replayed video clips were supplemented with ones of new angles. Without reprieve we have since moved rapidly from President Bush’s address on September 14th to the American public in which his eyes were welling, from the days of tallying the number of missing people, to a declared state of war with persistent warnings of possible future attacks, of anthrax-laced mail and an unprecedented (yet ongoing) humanitarian catastrophe for 1.5 million internally displaced Afghan citizens according the UNHCR and UNICEF. (There are already 2.5 million refugees in Pakistan and 1.4 million in Iran.) That and more are presented without pause, every minute of every day. In all of the events Canadians have been facing, it is probably impossible to speak of a collective emotional/psychological experience of them. The notion of the “Canadian mosaic” combined with the fact that ours is a young nation means that any assessment of experience needs more so to consider our personal history. That includes a mixture of exposure to past trauma, the history of the nation/region from which we (or our families) came, the degree to which we identify with that, and so on. While, however, there may be a number of such interpretations of events, there may be common threads in our responses. reliving recent events in some form: distressing recollections; distressful dreams; a feeling that the event is recurring; or a sense of mental distress to cues that symbolise or resemble the event or physiological responses to them (increased heart rate or elevated blood pressure). avoidance behavior and a sense of numbing of general responsiveness (previously absent): avoidance about thoughts, feelings or conversations about the event; that of activities, people or places which recall the event; inability to recall an important feature of the event; lack of interest in activities of prior personal importance; feeling detached or isolated from other people; restricted ability to feel strong emotions such as love; or feeling life will be brief or unfulfilling. symptoms of hyperarousal: insomnia, irritability, poor concentration, hypervigilance, or increased startle response. According to the DSM-IV, a diagnosis of PTSD may be made if one has at least one characteristic of (1); at least three of (2); and did not have at least two listed in (3). (Partial PTSD can involve just one category.) Symptoms of acute PTSD last between 1 and 3 months while the chronic form lasted 3 months or longer. Children may also experience symptoms of aggression, withdrawal, anxiety (difficulty in focussing and concentrating), irritability, nervousness, depression, headaches and stomach-aches. Such responses have been documented as common in a number of cases: the Oklahoma bombing in 1995 the wave of bombings in France from 1982-1987 in Gaza generally and also during the Intifada of the 1980s in Cambodia in part as a consequence of carpet bombing and the subsequent policies of the Khmer Rouge in Lebanon during the civil war from 1975-76 and events thereafter in Algeria following the eruption of violence after the cancellation of elections in 1991 in Ethiopia up to and including the separation of Eritrea from it in 1991 in Northern Ireland Besides the above considerations on the multicultural nature of Canadian society, further complicating assessment of the relevance of the experience of people in the above countries is the fact that while the bombings of September 11th are past, news broadcasts are replete with reports of possible future attacks. For the most part, they have proved incorrect although the fear of anthrax exposure is ongoing. Additionally, the public is being told that this will be a long conflict of undisclosed proportions. Thus, we are living in a state of hypervigilance. One off-setting factor may be the sense of solidarity within communities and with those who have or are suffering a loss. The ability to view personal trauma as honourable by children in Gaza seemed to have helped reinforce their sense of self-esteem while PTSD developed. Whether it was adults donating blood or children organising fund-raising events with people contributing (etc.), a certain segment of Canadian society has been proactive which may have reduced feelings of isolation/vulnerability. Nevertheless, should the reader find that s/he is concerned about their or their children’s response to the current political climate, then s/he may wish to speak with a qualified mental-health-care practitioner or their general practitioner. Should it not be serious, then our clients and readers are very welcome to drop by for a cup of tea. As has been also found in studies, maintaining our sense of community is of great importance. Arthritic Pain, Part Two As the second installment in the series, this article is dedicated to examining the most prevalent form of arthritis — osteoarthritis (OA) — which is characterised largely by a degeneration of cartilage in weight-bearing joints such as the hip and knee. Estimated to affect 20-30% of Canadians aged 65-74 and 80% over the age of 75, osteoarthritis is the principal form of arthritis. While age is the greatest risk factor in developing the condition, other factors include repetitive strain; accidents (such as to the AC ligament of the knee); genetic predisposition; and one’s weight. A decrease of 5 kg in people with obesity reduces the probability of developing OA by 50%. Finally, women are twice as likely to develop it as men. Initially symptoms include pain in the joint with activity which subsides with rest. Over time, however, less and less activity is required to induce pain which may not be relieved with rest and may develop into night pain. Inflammation may be present but not acutely. Lastly, crepitus (that grinding sound and sensation) is also experienced with movement. While the destruction of cartilage is the source of pain, it is not the cause because it does not have a nerve supply (or vascular). Rather, it is the surrounding tissues which become irritated such as muscles, tendons, ligaments and the membrane which helps encapsulate the joint. The muscles start to contract and hypercontract to prevent painful movements. Treatments for OA have two basic aims: to decrease pain and increase the functioning of affected joints. The former may involve the use of ‘pain-killers’ (analgesics and non-steriodal anti-inflammatories (NSAIDs) in addition to cortisone injections). Exercise and physiotherapy are also indicated to reduce excess weight and to help proper functioning of associated muscles. Another treatment may be surgery. Acupuncture has also been shown to reduce pain and possibly increase functioning. For instance, one controlled study found 29 participants receiving 2 treatments semiweekly for 8 weeks had a 34% reduction in pain at 4 weeks; 44% at 8 weeks; and 42% a month after treatments concluded with no side effects (Berman et al. (1999) “A randomised trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee.” Rheumatology 38:346-354). Similar results were found by Christensen et al. ((1992) “Acupuncture treatment of severe knee osteoarthritis: a long-term study.” Acta Anaesthesiol Scand 36: 519-25) along with significantly reduced NSAID use. To speak with one of our Doctors of Acupuncture about how we may be able to help you, please call the Centre

Migraine and Acupuncture: The Point of Treatment Lasting hours to days, migraines are a debilitating condition which can impair or prevent a sufferer from performing normal, daily activities. Also known as “primary headache,” they are to be differentiated from both tension-type and cluster headaches by their signs and symptoms, suspected causes and pathophysiology — the mechanisms which generate and sustain them. Moreover, there are various sub-types, the broadest being those that occur with and those without an aura (to be described later). In 1988 the International Headache Society established diagnostic criteria for migraines, which is summarised in the following table: Migraines without Auras A. at least 5 attacks fulfilling B-D B. headaches lasting 4 to 72 hours (untreated or unsuccessfully treated) C. headache has at least two of the following characteristics: one-sided pulsating sensation moderate or severe intensity (reduces or stops daily activity) worsened by walking stairs or similar routine physical activity D. during the headache, at least one of the following is present: nausea, vomiting, or both aversion to light and sound E. exclusion of a secondary condition by history, physical examination and diagnostic tests Atypical migraines lack one of the above criteria while status migrainosus is one which lasts more than 3 days. The development of a migraine occurs over three phases: (1) The Premonitory Phase For a period of hours to a couple of days prior to the onset of a headache, a person may find s/he is experiencing one or more of the following symptoms: being depressed or euphoric; being drowsy or quite alert; difficulty concentrating; feeling sluggish or very energetic, or unusually calm or nervous. Sometimes, yawning, loss of appetite, hunger (including for particular foods), thirst may also occur. (2) The Headache Phase Frequently over the course of 30 minutes to several hours, a headache will developed which is a one-sided and throbbing, located usually at the temple although any part of the face, head and neck may be affected. In addition to pain, a sufferer may have an aversion to light, sound or certain smells. Nausea is almost always present and should the headache become severe, vomiting may also develop. Blurred vision in both eyes, congestion, diarrhea, abdominal cramps, hot or cold sensations, sweating, and stiffness are common as well as is tenderness in the scalp and muscles and/or skin of the face, neck, shoulder and upper extremities. The latter can be experienced as difficulty in brushing one’s hair or shaving. (3) The Resolution Phase While all signs and symptoms may be gone, one may feel exhausted, weak or fatigued. In 20% of migraine sufferers, attacks are accompanied by an aura which precedes the second but follows the first phase. Generally, one may think of this as the classic scintillating lights but it can be much more than that including physical weakness, uncoordination, difficulty finding words or understanding conversation. Treatments While treatments can be effective, it is their timing in relation to the onset of a migraine’s signs and symptoms and to some migraine triggers which is of critical importance. That is true not only because certain treatments may aggravate the headache phase if conducted during it but also for the benefits to be had. In that sense, reducing head/neck/shoulder muscular tightness/trigger-point activity prior to attacks can have a preventative or mitigating effect. The reason for that is partially revealed by the way in which the headache phase develops. Initially it begins with throbbing. Next a progressive pattern of increasing sensitivity is experienced: to types of mechanical pressure and to cold on the side of the head with the headache after one hour; to these sensations on the opposite side of the head and in the forearm of the same side after 2 hours; and to heat after 4 hours. In each of these instances, pain is now perceived from previously non-painful stimuli in addition to more pain from painful stimuli, reflecting conditions of allodynia and hyperalgesia, respectively. The associated process of central sensitisation seems similar to that which develops with a site of inflammation in the skin or muscle; however, the initiating cause(s) is different in the case of migraines. One possible source could be specific pain receptors of arteries located in the dura mater — a tissue between the brain and the skull. Stimuli is signaled to the brainstem via the trigeminal nerve which also sends information back to the arteries thus creating a sort of a information loop. For whichever reason, the nerve may be stimulated to secrete a neurotransmitter called CGRP which causes the smooth muscle of arteries to dilate and become wider. That in turn may activate pain receptors which respond to increased mechanical pressure and send those signals back the brainstem.A vicious cycle may ensue. Parenthetically, this may explain the mode of action of certain classes of drugs such as triptans (i.e., Sumatriptan) and ergots which may selectively bind to specific serotonin-receptors (5-HT1B/1D) and prevent CGRP release. Over time the constant signaling may sensitise other neurons (i.e., in laminae IV-V) that receive convergent information from the arteries just mentioned, the skin in the vicinity of the eye and from areas of skin and muscles of the neck... These neurons convey information to centres of the brain involved in processing pain and have been found under similar experimental conditions to become overactive. In essence, they become ‘jumpy’ and ‘shout’ rather than ‘whisper.’ Some speculate that the process of sensitisation continues to cortical neurons of the brain; however, it should be remembered that pain is not just what one feels. The experience also includes one’s emotional response and interpretation of it as well as the evaluation of its impact upon oneself. These different aspects reflect to a degree different circuits in pain pathways: sensory, more spinal; cognitive-emotional and evaluative, more higher-brain functions. As Dr. Cathy Chen (China) has demonstrated, acupuncture is an effective tool depending upon the needling protocol used. One-third of participants in her study suffered from 1-2 attacks/week while for the others, the frequency was less. (a copy of the study methodology which included a control group is available upon request.) Ten percent did not have a recurrence of attack within the 6-month period following the study while 76.7% experienced significantly reduced frequency during the same period. Acupuncture can be performed even during an attack. Shiatsu and registered massage therapy can also be beneficial but typically not during an attack. As the reader can imagine, the process of sensitisation described above would make both treatments potentially unbearable. Additionally, inactivating muscular trigger-points during a migraine may further dilate arteries within the pain reference zone of the muscle harbouring it. Instead treatments between attacks both may reduce trigger-point activity in muscles and a source of pain during the headache phase. In so doing, they may alter the process of sensitisation by reducing or eliminating a contributing factor. * * * * * * * *

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