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Painful Inspiration

After seven years of pain, hygienist Carol Coady found relief by re-educating herself through neuromuscular and postural habit retraining. Her experiences prompted her to develop the Hygienists` Pain Network, which aids other hygienists suffering from work-related chronic pain.

Frances Dean Wolfe

Imagine suffering from chronic pain, seeking help from one practitioner after another only to obtain no permanent relief. Such was the plight of veteran California hygienist, Carol Coady. Her pain began in 1985, long before micro-ultrasonics became available to the hygiene profession. Her case load involved a high number of periodontal patients who required intensive hand instrumentation in addition to traditional ultrasonic instrumentation.

One Friday evening, after a typically taxing week, her dominant hand, wrist, and forearm began to throb. She purchased a wrist splint and took over-the-counter NSAIDs. On the following Monday, Carol was in the office of a hand specialist. He diagnosed her as having tendinitis, and he recommended that she wear the hand splint while not at work. He also advised her to reduce her workload by 25 percent. He wrote a prescription for a course of physical therapy, which primarily consisted of heat therapy followed by massage of her affected hand, wrist, and forearm. Despite following all of the physician`s instructions, Carol`s pain persisted.

Unfortunately, thousands of workers suffer from a wide variety of occupational pain and/or injuries. A vast number of Americans work in jobs that place them at risk for developing cumulative trauma disorders and repetitive motion injuries. The American Academy of Orthopedic Surgeons reports the costs in medical bills and lost work days as a result of these disorders to approximate $27 billion annually.

By 1991, Carol`s pain had spread to her other arm. "It felt as though there were tight rubber bands around both wrists," she said, "and my arms throbbed."

Carol underwent testing for carpal tunnel syndrome, which turned out negative. Subsequently, she felt stabbing pains in her neck and between her shoulder blades. "I had developed persistent knots in my upper back muscles (myofascial pain syndrome)," she said, "that constantly recurred despite upper back massage, chiropractic treatment, and trigger-point injections."

Upper body movement became difficult. "My arms felt painfully heavy, as though filled with concrete," she says. She rearranged her supplies at the office so she wouldn`t have to lift her arms to reach for them in the cupboards above shoulder height.

"My head felt as though it was the weight of an exceptionally heavy bowling ball. I was constantly working to balance my head on top of my spine," she recalls. "The weight of my head was inadequately supported due to my weakened neck muscles, which caused my head to continually pull to one side.

"By this time, I had consulted with two orthopedic surgeons, a doctor of physical medicine, and was under the care of a neurologist. My pain had become generalized throughout my body."

Carol developed a sleep disturbance with accompanying constant generalized fatigue. Her neurologist diagnosed the condition as fibromyalgia. An MRI also indicated degeneration of the discs and osteoarthritis of the vertebrae in her neck. Cervical traction, back-strengthening exercises, biofeedback, various medications, and transcutaneous electrical nerve stimulation were employed - but to no avail.

"The pain and exhaustion were constant and overwhelming," she recalls.

As a last-ditch effort, Carol`s neurologist suggested she take lessons in the Alexander Technique. "Starting in June 1992," she recalls, "I took 20 lessons over six months. By the end of the third week, I started to notice improvement.

"By the end of the six months, I was no longer in pain, and my energy rebounded."

She recalls her seven-year pain ordeal as "a very long, arduous journey." She also feels she was fortunate to have had family and employer support. Carol points out that not all hygienists who experience such ordeals are so lucky. "Some have expressed [to her] that chronic pain has played a substantial role in family breakups and in previously amicable employer/employee relationships turning sour."

Carol laments that her seven-year ordeal of pain could have been avoided. "It could have been stopped with appropriate intervention," she says. "Unfortunately, until my introduction to the Alexander Technique, no one in my health care circle knew how to help me." She says that what they didn`t know at the time was that the therapeutic intervention she needed most was education.

"My pain problems became worse over time because I was increasingly exacerbating problems of muscle tension, muscle imbalance, and postural imbalance. At the same time, I was generating complex pain feedback, which `trained` my central nervous system to hold onto and spread the pain."

She continues, "There was no way out but for me to learn how to use my body differently. I needed to learn how to release the tension throughout my body so that my muscles were not chronically tight. I needed to learn how to regain my innate neuromuscular and postural balance."

Carol describes what happened to her during her painful ordeal. "My skeletal muscles were chronically deprived of oxygen because they were chronically tensed. This chronic oxygen deficit resulted in the inability of these muscles to function efficiently," she says. "Instead of experiencing good muscle metabolism, I experienced painful, toxic by-product buildup in the muscles, which was a constant source of pain."

The chronic tension-spasm-pain cycle made it difficult for these pain-generating chemicals to be cleared from Carol`s muscles and returned to the circulatory system. Massage and chiropractic treatment gave her temporary relief from symptoms, but, within a day or two of practicing clinical hygiene, the tension-spasm-pain cycle recurred. "I had to learn how to practice dental hygiene without irritating the tension-spasm-pain cycle," Carol says.

A learning experience

She learned a "multidimensional, educational approach to resolving my pain" during the first 20 lessons of the Alexander Technique. Carol said she "carried far too much tension in my body." Eight biofeedback lessons helped Carol become aware of the tension she unknowingly held in her body. The Alexander Technique, she said, expanded on her awareness of her neuromuscular and postural habits. It also provided a broader base of understanding of how to release tension on a long-term basis.

Carol learned that she had damaged the vertebrae and discs in her neck from postural habits at the office. The habits involved working in positions where her head was frequently forward of her center of gravity. "Instead of sitting upright, I persistently dropped my head to better see into the mouth," she says. "Over the years, this poor postural habit created chronic neuromuscular and postural imbalance. It resulted in my constantly holding too much tension in my neck, shoulders, and upper back."

These muscles rotated her head into a back-and-down position on her spine, which chronically compressed her cervical vertebrae and discs. The spinal nerves that exit from between these vertebrae and feed the entire length of the arms were impeded from providing their optimal function.

"My years of leaning forward in my clinical work caused my shoulders to become rounded and my chest muscles to become chronically shortened. These postural alterations in combination with excessive neck-shoulder-arm tension compressed the nerves as they proceed down the length of my arms," she says.

The compressed nerves, deprived of their capability to function optimally, made her elbows and wrists more vulnerable to painful symptoms of aching and feeling like "pins and needles" in Carol`s hands. Carol learned that her initial tendinitis and the resulting spread of pain were due to these neuromuscular and postural alterations.

"The years spent in physical therapy focused on treating my hand, wrist, and forearm," says Carol, "but did nothing to target the true problem. My Alexander teacher spent time evaluating and teaching me to undo my dysfunctional neuromuscular habits," says Carol. "I learned how to stand, walk, sit, move, work, and tend to the activities of daily living without generating pain. This one-on-one teaching method using observation, education, demonstration, and guidance was ideal for focusing on my unique dysfunctional neuromuscular patterns."

Her teacher also focused on Carol`s emotions that were tied into the dysfunctional habits. She learned that every emotion has a correspondingly physiological effect. She also learned it was normal to eventually experience negative consequences as a result of battling the pain.

Chronic pain had taken its toll on Carol emotionally, socially, professionally, and spiritually. She reveals, "By carrying around suppressed negative feelings including frustration, fear, isolation, anger, hostility, bitterness, and depression, I was unknowingly exacerbating my problems by generating additional muscle tension and pain."

She learned to address all of the elements that contributed to her symptoms. Unraveling the physical, emotional, and behavioral aspects of her pain became an enlightening and refreshing experience for Carol. She elaborates, "After spending so much time feeling as though I had so little control over my pain, I found I was beginning to understand the work I needed to do to regain my total health."

As her lessons progressed, Carol`s movement patterns become more fluid as her range of motion improved. She no longer felt weighed down as she felt her body improve. "I could once again vacuum, clean house, write, type, drive, and hold a telephone receiver up to my ear without pain, tingling, and numbness in my back, neck, arms, wrists, and hands.

"I knew I had made great strides when I was able to resume treating root planing patients."

"Joyfully," she adds.

She said distance walking became a pleasure when she no longer experienced burning in her ankles and lower legs from oxygen debt. "The soles of my feet recovered so I could walk barefoot in my home."

Several years later, Carol had healed to the point that she could swim again and circuit train with weight machines at the local health club. "These were activities that were not possible when I experienced generalized, whole-body pain," she remembers.

After six months of Alexander lessons, Carol felt light, energized, and comfortable. "As my physical health improved, so did my mental outlook. I no longer feared that pain would again overtake me. I had learned what caused my pain and what I must do to remain comfortable," she says. "I came close to losing my career and feel very fortunate to have regained my health and my ability to continue practicing clinical dental hygiene."

Relief turns into a crusade

"My seven year pain ordeal was the most difficult experience I have ever had to face," Carol recalls. "In the seven years since, it has been my personal crusade to help others in similar circumstances." Many hygienists have written to her over the years, and she has learned that her situation was not as unique as she had originally thought.

"My greatest satisfaction," says Carol, "comes from knowing that I can reach out to others who need help." Carol has since focused her attention on reconnecting with her family, staying well, and continuing her work in clinical hygiene, as well as sharing her experiences with others.

"I have found that by presenting continuing education courses and by increasing my involvement with the ADHA, I am able to share my message about occupational health with a greater number of hygienists needing information." She continues, "Helping others is a powerful reward. It has served me well in healing my emotional hurts incurred from experiencing seven prime years in pain."

Carol believes the micro-ultrasonic instruments are a tremendous asset to our current armamentarium. "Our potential to stay well on the job will continue to improve as innovative products, instruments, and equipment are introduced into practice," she says. "Our opportunities for prevention and early intervention of musculoskeletal pain disorders will also continue to improve as the knowledge base broadens in the educational, medical, and complementary-medicine disciplines."

Since her recovery in 1992, Carol continues to incorporate movement before work, between patients, and after work. "When I go out for a walk, I incorporate more than the usual amount of movement," she explains. "I work on my range of motion, mobilizing my shoulders, while loosening muscle tightness in my neck and upper back."

Carol also works on creating movements that counteract static postural contractions. "I also incorporate movement into my morning shower while the warm water streams over my upper back and neck." Carol`s focus is on maintaining the resiliency and suppleness of her muscles to relax and nourish them and to allow for proper elimination of toxic metabolic wastes. "I find that stretching, certain yoga postures, and circuit weight training are particularly helpful in minimizing excess muscle tension," she says.

At the office, Carol makes a deliberate effort to stay relaxed and in a peaceful state. "I am conscious of good ergonomic habits and pay close attention to `using` myself well as I treat my patients," she says.

Although she works in a busy office, Carol feels fortunate that the work pace is moderate. "I don`t feel pushed to work faster than feels comfortable," she says. "We pride ourselves in delivering quality patient care and in maintaining amiable, long-term relationships with one another in the office and with our patients. We recognize the role that our workload and relationships play in our health."

"My immediate project," says Carol, "is to make as much of the resource information as I can available for easy access over the Internet." Responding to requests by e-mail saves photocopying and postage costs. OMy workload is reduced considerably,O she says, Oand hygienists can access the material quickly, easily and at no additional expense.O

Carol is the sole manager of the Hygienists? Pain Network. Since its initiation in 1992, Carol has responded to more than 400 requests for educational support and information. The resources available through the Hygienists? Pain Network continue to evolve as she constantly sources current information helpful for hygienists.

Frances Dean Wolfe is a pseudonym for a frequent contributor to RDH. She is based in Phoenix, Arizona.

References

Y Coady, Carol D. The Alexander Technique: Postural and Neuromuscular Re-education. Dental Hygienist News, Vol. 7, No. 2.

Y Coady, Carol D. The Hygienists? Pain Network: A Communication Forum to Assist Dental Hygienists Who Experience Chronic Work-Related Pain. June 1999.

Y Coady, Carol D. Unraveling the Mysteries Surrounding Cumulative Trauma Disorders. CDHA Journal, April 1997.

Y Fibromyalgia: What Is It and How to Manage It. Handout provided by the American Academy of Family Physicians. Sept. 1995.

What ails you?

A listing of musculoskeletal and secondary disorders reported by participating hygienists in the Hygienists` Pain Network includes:

x Tendinitis

x Carpal tunnel syndrome

x Myofascial pain syndrome

x Temporomandibular joint dysfunction

x Chronic headaches

x Chronic shoulder bursitis

x Ulnar nerve neuropathy

x De Quervain`s disease

x Osteoarthritis of the thumbs/fingers

x Stenosing tenosynovitis

x NSAID-induced colitis

x Degenerative disc disease

x Cervical radiculopathy

x Sciatica

x Shoulder impingement

x Thoracic outlet syndrome

x Fibromyalgia syndrome

x Reflex sympathetic dystrophy

x Chronic back pain

x Osteoarthritis of the spine

x Foraminal stenosis

Support from the network

Materials available through the Hygienists` Pain Network currently include:

- A compilation of Hygienists` Pain Network musculoskeletal disorder experiences as described by participants. These written accounts are selected from a collection of letters and e-mails submitted by participating hygienists. The purpose of this collection is to share knowledge, experiences, and support. Participating hygienists are identified by number only, protecting individual privacy.

- Article listings - including pertinent quotations and additional resources related to musculoskeletal pain and clinical hygiene practice - are also included. This collection includes numerous article listings and quotations from the major dental hygiene, dental, and medical publications, as well as a list of related books, products, and other resources.

- A listing of specific work-related disorders experienced by hygienists. The occurrence of spreading pain is shared by many of the hygienists who have described their pain histories.

- A listing of several articles describing the manner in which clinical hygiene practice might impact the development of musculoskeletal pain disorders and suggestions for preventive and rehabilitative strategies.

About Carol Coady

Carol Coady, RDH, BA, has practiced clinical hygiene for 25 years. She earned her associate`s degree in dental hygiene from Foothill College in Los Altos Hills, Calif., and received her bachelor`s degree, specializing in health education/community services, from California State University at Chico.

In addition to volunteering her time to facilitate the Hygienists` Pain Network, Carol serves as the health educator and program manager for the North (Sacramento) Valley Fibromyalgia Educational Support Group, which provides a multifaceted program at no cost for hundreds of residents in Northern California who experience chronic generalized pain.

Carol is active in the dental hygiene profession as a California Dental Hygienists` Association delegate to the ADHA, as well as serving as a continuing education presenter.

For more information on the Hygienists` Pain Network, RDH readers are invited to check out the Web site at www.cdha.org and click on the phrase "occupational information." Information provided via the Internet/e-mail is free of charge.

To correspond with Carol, e-mail her at carolcoady@aol.com. Readers without an e-mail address may include a self-addressed, stamped envelope in their correspondence to: Carol Coady, RDH, BA, Hygienists` Pain Network, P.O. Box 24, Paradise, CA 95967.

Training with Alexander

Although learning the Alexander Technique is an educational process, students often derive therapeutic benefits. The Alexander Technique promotes release of excessive muscle tension.

This training in postural and neuromuscular re-education teaches how to regain muscle balance, allowing for restoration of muscle tone, spinal lengthening, and proper joint biomechanics. It helps subjects learn how to employ their bodies to maximize performance while reducing the potential for [further] injuries.

Students of the Alexander Technique learn, through a series of 20 to 30 private lessons, about their misuse patterns and how to replace them with healthier neuromuscular patterns and postural habits to better use their bodies. Improvements from this training result in reduction in intervertebral disc pressure. Retraining of old habits requires active participation and willingness to change.

For more information, check out the Web site at www. alexandertechnique.com or call the North American Society of Teachers of the Alexander Technique at (800) 473-0620.

Additional resources

The Complete Illustrated Guide to Alexander Technique: A Practical Program for Health, Poise and Fitness, by Glynn Macdonald (Barnes and Noble Books, New York. 1998)

National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (NAMSIC) under the National Institutes of Health (NIH). Call (301) 495-4484 or visit the Web site at www.nih.gov/niams/. Ask for: AR-91 IP Fibromyalgia 2/98

Fibromyalgia Network Newsletter. For more information, call (800) 853-2929, fax to (520) 290-5550, or visit the Web site at www.fmnetnews.com

The Fibromyalgia Help Book: Practical Guide to Living Better with Fibromyalgia, by Jenny Fransen, RN, and I. Jon Russell, MD, PhD (Smith House Press). Call the publisher at (651) 490-9408, fax to (651) 490-1450, or visit the Web site at www.SmithHousePress. com

Fibromyalgia Exercise Video, by Patty Bourne, kinesiologist. She can be contacted at OTM Hospital, Physiotherapy Dept., 327 Reynolds St., Oakville, Ontario, L6J 3L7 Canada

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