Journal Articles/Links

 

Neuropathic Pain Treatment Guidelines

 

A variety of medications are now used to treat neuropathic pain and these are summarised below in alphabetical order.

Baclofen
Baclofen is used only for the muscle spasm seen with spinal conditions and for trigeminal neuralgia. It is difficult to use. Tolerance develops very quickly and sedation is a common problem. Note: There is no role for diazepam in the treatment of neuropathic pain.

Calcium channel blockers: Pregabalin and gabapentin
Pregabalin is a calcium channel blocker and an analgesic, anticonvulsant, anxiolytic, and sleep-modulating agent that may be useful as a component of multimodal analgesia and may decrease opiate use. It does not work for all neuropathic pain; for example, it doesn’t work for HIV. It may also reduce post-surgical chronic pain.
Gabapentin, like Pregabalin, is a calcium channel blocker but it has a slower onset.

Ketamine
Ketamine is an NMDA antagonist and phencyclidine derivative with multiple effects. It is given IV, SC, topically, and possibly orally and intrathecally (intrathecal use is not approved, so it is only used in palliative care with the necessary consent).

Lignocaine
Lignocaine is a sodium channel blocker that acts especially on abnormal ion channels. It acute states it is given SC or IV. For chronic allodynia, it is given as a patch.

Opioids
Methadone is a naturally long acting opioid that caused a statistically significant decrease in pain in a small randomised, double-blind, placebo-controlled study (N=18).
Oxycodone is up to twice as potent as morphine and may have some benefit in neuropathic pain but the effect is dose limited.
Tramadol has a low affinity for all opiate receptors and also inhibits noradrenaline and serotonin reuptake, making it helpful in neuropathic pain.
Tapentadol has fewer potential interactions than tramadol and less potential for abuse.

Tricyclics
Tricyclic antidepressants improve all aspects of neuropathic pain but can cause side effects of sedation, cardiac arrhythmias, orthostatic hypotension, and urinary retention that limit dosing. Contraindications include conduction defects, and they should be used with care in the elderly.

Serotonin and norepinephrine reuptake inhibitors: venlafaxine and duloxetine
These have good safety, tolerability, and effectiveness in patients with painful diabetic neuropathy: their role in other neuropathic and nociceptive states is undetermined. Possibly, they have synergistic effects with other agents. There are minimal anticholinergic effects.

Valproate
There is very little in literature about valproate and it is not TGA approved for neuropathic pain. However, it is sometimes used because it is a voltage-gated sodium channel blocker and it increases brain GABA levels. It should not be used in patients with impaired liver function or in pregnancy and it interacts with warfarin. Side effects include weight gain, hair loss/curliness, and drowsiness.

 

Source: Dr David Gronow, The General Practice Education Day, Sydney 2013

 

 ____________________________________________________________________________________________________

 

 

Frequency of Work:

 

Rare:

0 – 5% of total work time (total of 3 minutes in the hour)

 

Occasional:

6-33% of total time work (total of 3-20 minutes in the hour or 1 lift every 30 minutes)

 

Frequent:

34-66% of total work time (total of 20-40 minutes in the hour or 1 lift every 2 minutes).

 

Constant:

 67-100% of total work time (total of 40-60 minutes in the hour or 1 lift every 15 seconds).

 

                Definitions from US Department of Labor, Handbook for Analysing Jobs – Definition of Strength Factors.

 

Work Strength:

 

Sedentary Work Strength:  “Exerting up to 4.5kg of force occasionally or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects including the human body.  Involves sitting most of the time, but may involve walking or standing for brief periods … if walking and standing are required only occasionally and all other sedentary criteria are met”

 

Light Work Strength:  Exerting up to 9kg of force occasionally or up to 4.5kg of force frequently or negligible amount of force constantly to move objects.

 

Medium Work Strength:  Exerting 9-23kg of force occasionally or 4, 5-11kg of force frequently or greater than negligible 4.5kg of force constantly to move objects.

 

Heavy Work Strength:  Exerting 23-45kg of force occasionally or 11-23kg of force frequently or 4.5-9kg of force constantly to move objects.

 

Very heavy Work Strength:  Exerting an excess of 45kg of force occasionally or an excess of 23kg of force frequently or an excess of 9kg of force constantly to move objects.

 

                Definitions from US Department of Labor, Handbook for Analysing Jobs – Definition of Strength Factors.

  

 

Postural Tolerance Activities

 

Postural Tolerance is an essential part of any test of physical function.

All jobs or A.D.L.'s have large elements of static and/or dynamic positions within the overall context of the activity.

These have been broken into components of:

 

Standing Sitting Sitting – Reaching Reaching – Overhead Reaching – Shoulder Reaching Stooping Kneeling

Walking Climbing Balance Crouching Step Squatting Crawling

There may be some positions requiring elements of these in combination and if considered essential, should be included in the test. Essentially these positions are tested by observation of the position over a period of time. In order to assist in this process, an activity should be offered to the client during this period of observation.

 

 Unlimited Tolerance

 

These tasks, postures or positions required can be performed as a functional task for the job required over a normal eight (8) hour day with regulation breaks.  These tasks are considered tolerated at a frequent basis by DOT (Dictionary of Occupational Titles) – (more than one time every two (2) minutes).  However if a task/posture or position must be performed on a constant basis (more than one time every 15 seconds, it is tested for longer periods for the specific work rate required therefore it is not unlimited.

 

Reduced Tolerance/ Restricted Tolerance

 

Is the task, posture or positions requiring frequent posture changes in order to tolerate an eight (8) hour day but they can safely be performed in activity when required.  This is one time every two minutes.

 

Limited (Impaired)

 

Are tasks, postures or positions that can be safely held; repeated or performed for periods less than 3 minutes, and for less than 3 times the working hour during an 8 hour day.

Not recommended is tasks, positions or postures where the client is unsafe or cannot tolerate the activity at the time of evaluation.

 

Unable to perform

 

These tasks, postures or positions cannot be safely held, repeated or performed.  The client is either unable to safely perform the tasks, posture or position or it is not recommended that it be attempted at this stage in the working environment.

 

NIOSH Lifting Index

 

To help determine whether or not a load can be lifted safely, the NIOSH has created a formula that takes into account a number of factors related to lifting. These are: the horizontal distance from the midpoint of the load to the midpoint between your ankles; the vertical distance from the beginning to the end of the lift; the angle at which the lift starts and ends, calculated from your midline; the amount of lifts made per minute; the duration of the lift or period of lifting; the quality or lack of handles; and the weight of the load. 

Using the NIOSH's equation, a lifting index under 1.0 is acceptable, an index between 1.0 and 3.0 indicates the need for changes to the task and an index greater than 3.0 is unacceptably hazardous. These recommendations can be generally applied to male and female workers of all sizes.

Read more: http://www.livestrong.com/article/397706-weight-lifting-requirements-for-women-in-the-workplace/#ixzz2076HHoA1

 

 

 

Ergonomic workstations for keyboard operators

 

 Prolonged work at a computer can strain your arms, neck, hands and back. In most cases, health problems occur because of a   poorly designed or setup workstation.

 A well designed workstation considers your chair, lighting, noise, and the position of the screen, keyboard and documents.

 

Ways to control hazards

 Assess work methods and workplace setup, and implement ergonomic workstations for keyboard operators.

• Use an ergonomically designed chair with:
  • • a height adjustment (from the floor)
    • an adjustable back rest (in height, angle and depth)
    • a curved seat edge
    • cloth covered seat and back
    • a five-star castor base.

• Adjust the seat so your feet rest firmly on the floor. Take your weight through your feet.
• Adjust the back rest of the chair so you sit in a position where your thighs are fully supported, except for a two-finger width space behind the knee.
• Maintain a relaxed posture, especially in your shoulders and neck:
  • • Keep elbows by your side.
    • Keep forearms and hands parallel to the ground (with about 90 degree angle at the elbow).
    • Do not bend or cock your wrists when typing.
    • Sit at a comfortable distance from the keys (the length of your forearm away).

• There is no single height of a monitor which is suitable for all users. Some people find looking down slightly more comfortable than having the top of the screen at eye level. The height and angle of the monitor affects the gaze angle and inclination of the head. With the newer thinner LCD monitors it is now possible to have a monitor that is about arm¿s length away. The best advice is to avoid extremes of head and neck bending, avoid having to look up at a screen (as this requires the head to be titled backwards and places pressure on the neck) and arrange you monitor so that you feel comfortable.
• Position documents and the screen about the same distance from your eyes. Use a document holder to place the documents.
  • • in a level position beside the screen (when the keyboard is in a central position) or
    • directly below the screen, just above the keyboard.
• Position the screen directly in front of the keyboard if you spend most of the time looking at it. If you spend most of the time looking at a document, place the document directly in front of the keyboard.
• Place the screen at right angles to a window. Alter the angle of the screen to avoid glare and reflection, or use blinds, curtains or screens to block glare.
• Ideally, place screens parallel to overhead fluorescent lights (to avoid rebound reflection).
• Adjust the contrast of text and background on the screen to a moderate level.
• Rest your eyes occasionally. Look out a window or at a wall poster.
• When typing, take short breaks of 30 - 60 seconds. Relax your hands in your lap or on the desk. Change the activity to relieve fatigue. Stand or walk about. Vary your posture as much as possible.
• Remove or control distracting noises. Use acoustic hoods over printers, remove noisy equipment from the work area or use quiet air conditioners.
• Provide adequate ventilation to the work area to counter the heat generated by computers and associated equipment.

Like all electrical equipment, computers emit electromagnetic radiation however the low level is not considered a health risk.

http://www.deir.qld.gov.au/workplace/subjects/manualhandling/workstations/index.htm

 

 

---

 

Links

Australian Story - Playing for Time Transcript   Functional Capacity Evaluations WorkCover NSW

WorkCover Medical certificates for NSW Medical Practitioners Guide 1301