Dr. Mark Amerasinghe

Dr. Mark Amerasinghe

Wednesday, April 30, 2014


A Long and Fruitful Association

[This unpublished article was submitted, on request, to the editors of the 50th Anniversary Commemoration Volume, “THE PERADENIYA MEDICAL SCHOOL” . I am posting it on this blog, since it could interest past and present teachers and students alike of that school]
My ‘battle’ to establish myself in Kandy GH, to which I was appointed Orthopaedic Surgeon on  the auspicious day of April 1st 1961, was  greatly helped by the establishment of the Peradeniya Medical School (PMS) in 1962 with the opening of the Anatomy and Physiology departments endowed with the pioneering responsibility of guiding the first batch of students in the new medical school . Sometime that year, on a sunny Sunday morning, I had a most welcome visitor- Wazir Palli, the first Head of the department of anatomy in Peradeniya.  During the period (1953 to ’56) when I cut my teaching milk teeth as demonstrator in anatomy in the only medical school in what was then Ceylon, Wazir Palli was one of the senior lecturers along with Joe Vaaz, Lester Jayawardena and R.Kanagasunderam. 
I knew Palli well, because we used to have frequent discussions on the teaching of anatomy and WP naturally thought of me when it came to the Applied Anatomy lectures for the 2nd MB students. I gladly agreed to his request to give these lectures  and thus started my long association with the Peradeniya  Medical School –starting as Visiting Lecturer in Applied Anatomy,  a ‘post’ which I held till I retired from the Dept of Health in 1983.
Palli was followed by Vaaz and Lester Jayawardena and in later years by Jayatilleka and Eugene Wickramanayake. In the latter’s time, at my request, I confined myself to the limbs, while other areas were handled by other surgeons in GHK.  I enjoyed giving these lectures, in particular, on the limbs. Because, whenever possible, I made them lecture demonstrations, by presenting a patient to the students.  I had the feeling that the students too enjoyed those sessions. 
Kandy hospital, which till then had been just another Provincial hospital, suddenly became a centre of intense activity, since, in a very short time, it had to serve as Teaching Hospital to the Faculty, and this necessitated new buildings, new thinking and an administration mobilized to reacting fast. Chief of all ‘operations’ concerned with the Teaching Hospital was that redoubtable Iron Vice-Chancellor, Sir Nicholas Atygalle. He shook the ancient GHK buildings from foundation to roof.
Things changed fast. A new wing was built to house new theatres and additional wards and clinics. Arrangements were made to accommodate University Units in Paediatrics, O & G, General Surgery and General Medicine. The existing clinical units, including those of the specialities’, would all become teaching units, so that all clinical teaching in general surgery, medicine, paediatrics and 0 & G would be shared by University Staff and  what was then referred to as DHS staff  while the other specialities would be handled solely by GHK staff.
While this inevitably created certain tensions, the arrangement held quite successfully for the many years preceding the establishment of the Peradeniya Teaching Hospital and in fact continued even after that establishment, and prevails to this very day. The bulk of the clinical teaching was and still is done by Ministry of Health Consultants.
In addition to having the opportunity of teaching Clinical students in the clinics and the wards, (I always enjoyed discussion around a patient as opposed to didactic teaching), apart from merely delivering lectures (which delivery at 1 pm in the afternoon put me to sleep more than they did my students!) the Dept of Orthopaedics benefited directly by the extensions to Kandy Hospital and the reshuffling of clinics and wards.
 When I started in 1961, the administration told me that they could not find me a clinic room, wards and OT time. There was only one OT which catered to two Genera Surgery units, one eye, ENT and O & G unit. With the extension to the hospital came, among other areas, new theatres. One theatre was set apart for eye and another for O&G and curiously, but to my advantage, one was (on the insistence of Prof CC de Silva) set apart for Paediatric Surgery.  There was no paediatric surgeon in Kandy, because at that time, even Colombo did not have a special paediatric surgical appointment. 
At a conference where Prof CC won his case for a special paediatric surgery OT, I pointed out that since there was no paediatric surgeon, and the chances of there being one in the near future in Kandy Hospital were very slim, and since a high proportion of my patients were children with deformities following untreated or badly treated polio and rickets, this theatre should by handed over to Orthopaedics. The charming Prof CC after putting up a fight with all his customary flowing gestures and liquid eloquence said, “All right Amerasinghe, you can have it” 
That was how I ‘captured’ OTD! I use the word capture, because this theatre (once it had been set up, with my taking a personal interest in the matter) had to be ‘protected’ from invasion by the envious general surgeons. As was to be expected, particularly when construction work has to be rushed through without sufficient planning, there were many hiccups along the way. I shall deal with one, since it showed the ‘methodology’ adopted by the Big Chief in these matters...
The new OT’s had been built for air conditioning. So they were sealed units.  When the Units were completed, it was found that there had been an error and there would be a considerable delay in installing the air cons. Sir Nick was furious. He wanted surgeons, who said they could not work in a sealed unit without air con, to start immediately. At a conference (where I was not present) Sir N had ‘barked’ at the O & G consultants saying ‘Open the damned windows and operate’. I never came across an obstetrician who did not fear that bark, which could easily be followed by quite a sharp, if not fatal, bite! So OTC started work with open windows and wind-swept leaves floating in from time to time.
 I dug my feet in, saying I could not be picking out leaves from open hips, much to the VC’s annoyance and ire. But then, I was not an obstetrician! So I waited till OTD was ready, air con and all.

 The early years of the medical school were exciting, productive and challenging. Fortunately, the Faculty was led by that energetic, charismatic and dynamic visionary – Seneka Bibile, Prof and Head of the department of Pharmacology in Colombo who was the only head, to move from Colombo to Peradeniya. He infected a young and determined staff in all departments, Uni and DHS alike, with his own brand of high quality, productive enthusiasm.
 The staff of the fledgling school, were under the constant, disdainful, ‘looking-down-the-nose’ surveillance of Big Brother in Colombo, who thought we could never really match their own established, gold standard. One medical consultant, quite oblivious to  the fact that I was by then actually teaching both pre and clinical students, said to me once. ‘How can you fellows n Peradeniya teach students?’  If not for the fact that I had a high regard for this, otherwise charming and highly competent clinician, who had many years previously been my demonstrator in pathology, I would have reached for my holster!
So, here was a real challenge. The gauntlet had been thrown down and we were determined to prove ourselves. Bibile led his troops from the front and before the first batch of students took their finals, the Peradeniya Medical School escaped from the heavy yoke of Big Brother in Colombo. We had gained our independence. A serious problem had now arisen. The question of uniformity of examination standards, in the two schools. This problem was got over by introducing what was referred to as a ‘Common MCQ’ paper at the Final MBBS. For five years (I think) the analysis of the results of this paper showed conclusively that batches of students in the two schools were comparable, and the common paper was scrapped. This was an acknowledgement of the fact that we had made the grade- a major victory indeed.
Bibile, from the outset, had his own vision of what the new medical school should be. He aimed for academic excellence with an emphasis on improved teaching methods and the inculcation of desirable attitudes of concern for the human being called the patient, with an emphasis on research, in not merely the pre and para-clinical disciplines, but very importantly ,in the clinical fields as well. He encouraged the keeping of good clinical records and the constant evaluation of treatment methods. 
Bibile was responsible for establishing the Working Group of Medical Education (WGME) which, after we gained independence, was replaced by the statutory curriculum committee. I will not go into details of the working of the these two committees the first of which I was very closely associated with,(leaving that story to the medical educationalists – the new ‘elite’ of the Faculty) although I was a DHS and non-university man.  There is one important acknowledgement I must make here. In the years during which I chaired the meetings of the WGME, the real heart of the group was the Evaluation Committee, headed successively by Valentine Basnayake, (and I believe) Hettiarachi, Jayasena and Bandaranaike. This committee made, in my opinion, the most solid and worthwhile contribution to the cause of medical education in this medical school.
Bibile took pains to rope the DHS staff into discussions on medical education and made them feel that they were all in fact ‘University men and women’. One vital aspect of Bibile’s mission I must emphasize.  Although he had visited several medical schools abroad and seen the approach to teaching adopted by them, unlike many a subsequent ‘medical educationalist’ he was not mesmerized and seduced by what were described as ‘modern’ approaches, nor was he prepared to blindly follow any and every ‘imported’ teaching methodology from places where the socio-economic and pre-university educational reality differed vastly from our own.  He emphasized that we must work out our own teaching methods, based on a clear idea of the relevance of our curriculum to the subsequent duties of the newly qualified doctor, whether it be in the pre, para or clinical fields.
One of the earliest medical education consultants Bibile invited to the ‘Faculty was charged with the task of drawing up a plan to study what the newly qualified doctor was actually doing after graduation, and match that reality with the relevance of the current curriculum. From this study would emerge a strategy for improving the teaching content, and the optimum methodology required to get that relevant content across effectively. Unfortunately, that particular consultant was hi-jacked by the Ministry of Health and Bibile’s highly rational approach to curricular change based on recognition of our own ground realities got buried, particularly, since he served as dean only for one term. I believe that in the absence of Bibile’s guiding, down-to-earth hand, medical education in the PMS lost its way! This is my strong personal conviction based on quite a long experience of guiding medical students long before the words ‘medical education’ started having an intoxicating effect on some teachers.

This criticism is not made with the purpose of hurling bricks at any individuals but springs from ideas nurtured organically without a heavy dose of imported fertilizer. During Bibile’s time a former Vice President of the Royal College of Physicians was on a WHO mission here to introduce us to the use of MCQ’s. Before his arrival, Valentine Basnayake held a workshop for a group of interested teachers (including this DHS man) and explained quite clearly to us and ‘drilled’ us in  what then were the ‘mysteries’ of the MCQ. Dr John Stokes, a charming and brilliant clinician who had played a major role in the improvement of the evaluation methods used in the MRCP was pleasantly surprised that his ‘pupils’ were no neophytes.
I must make myself very clear. I am not saying that the PMS was one man’s offspring. Oh no!  Bibile (who inevitably had his severe critics as well as his admirers) was the enthusiastic leader of a dedicated band of pioneers, both Campus and Non-campus or using the terminology of that period of development – Uni and DHS. Bibile would have been the first person to acknowledge the debt owed by this school to those pioneers. The close co-operation (fostered by Bible) between the two groups was evidenced by the fact that a DHS man (the Orthopedic Surgeon, GHK) was, for many years, chairperson of the important and highly active WGME, on 2 occasions chaired the NMU committee and was a member of the Faculty Board (as DHS representative) over a period spanning the deanship of Bible through that of those who followed, up to Malcolm Fernando. I took Faculty meetings very seriously and in spite of a heavy workload in GHK (being the only orthopaedic surgeon) hardly missed a meeting.
Faculty meetings particularly in the early days were most interesting. Many thorny questions arose. The medium of instruction, the explosive fear that  with an overall decision that University education should be in both Sinhala and Tamil the Sinhala consultants in the General Hospital Kandy  would be transferred out,  the pressure exerted on the Faculty, from time to time, to take in a ‘favoured’ applicant who had completed part of the MBBS course in a foreign university, (the Faculty wisely decided that a pass in an examination held by a foreign university –however prestigious- would be recognized by Peradeniya only if that recognition were mutual;  It was an expression of our confidence in the validity of our own testing methods), the guide lines for appointments to the Faculty, just to mention a few. The feature of the latter was that the then University Grants Commission had decided on those guidelines and then asked the Faculty for its views – a clear example of the dictatorial attitude of the Chairman UGC at that time.
The media of instruction problem was seemingly ‘solved’ by introduction of classes in English and Swabasha in the pre-clinical years and then, by sleight of hand, the policy being accepted on paper but not in fact! As at the present moment, the medium of instruction was English.  This genuine problem of the medium of instruction has in my opinion, been the most vital problem that faced both staff and students in this Faculty. 
The best efforts of the ELTU were negated by the fact that neither the Faculty nor the UGC has to this day really faced the problem squarely and being prepared to spend the required resources of time and money in launching an effective strategy.  Particularly at a time when students came into campus not earlier than at least 6 months after selection to the Faculty, the only possibility of running an effective course in English learning was a form of “English language immersion course”. The students had to be ‘incarcerated’ in a ‘teaching village’, where they were compelled to obtain their needs of daily living by going to the ‘Kade’ manned by those who  were fluent in English, making their demands only in English. Communication in any other language would be banned during this ‘commando’ course. There is no question that this calls for careful organization and the provision of buildings and other resources at a certain cost – but the method would produce the desired result. Successive governments have tried various experiments without determining the answer to a fundamental question. ‘How does a student In Sri Lanka, from a non-English speaking/reading background, to whom English is not a second language, but truly a foreign language, learn this language?’ The only exposure to English that the weak student received was during the English classes given by the ELTU. English was not needed for their day –to – day survival and no amount of preaching about the importance of English would motivate them to learn the language, unless their very survival (during a commando type course) depended on a knowledge of the language.
 Marking essay type questions was often most depressing and I was driven to a form of schizophrenia, where I was unable to decide whether the poor answer  was due to lack of knowledge of the subject being tested or a genuine difficulty of expressing oneself ,in what to many a student from a non-English utilizing environment, was a foreign language.
As the years glided on, I got the impression that the Faculty had slipped into an ‘idling engine’ mode and much of the initial enthusiasm and drive of the early years had been dissipated in attempting to import educational models from abroad and blindly follow the dictates of a fellowship bestowing WHO– a philosophy which seemed to dominate curricular matters where so-called ‘experts’ attempted to call the shots ,in  some disciplines, even though they knew next to nothing about the discipline and in particular of the problem of helping students in our social milieu to master that discipline ; and most importantly, the importance of that discipline to the future medical practitioner.
 I shall now jet propel myself over the years to the second phase of my association with this medical school, a phase which commenced two years after I had ceased to be a visiting lecturer in the Faculty. In 1985 I  joined the Faculty ( a fully fledged University man) as Senior lecturer in the anatomy  department, headed by Prof Eugene Wickramanake, whose views on the teaching of regional anatomy  were akin to mine. I had happily gone through a full cycle –starting off as a demonstrator and then passing through a long period of clinical orthopaedics during which time I was a visiting lecturer in two disciplines, and was now rounding off my exciting teaching career as Senior Lecturer in the Depart of Anatomy – a post which I held from 1985 to 1999.
When I joined the department I thought I would retire into the obscurity of the anatomy block and help students to learn with understanding, and without tears, this very important discipline which, with physiology and pathology in its broadest sense, formed the very foundation of medical practice. It is interesting, actually unfortunate, that many a medical education ‘expert’, in an attempt to ‘decapitate’ anatomy, that favourite whipping boy of the medical educationalists in general, overlooked the simple fact that structure and function are just the two sides of the same coin, just as much as in the physical world one could not dissociate matter from energy. So, if physiology was important, so was anatomy.
Prof Wickramanayake requested me to take over the task of re-organizing the teaching of regional anatomy and gave me a free hand – a freedom to institute changes that I had long pondered over.  As a result of this, an Introductory Course in regional anatomy was introduced; content was cut down with an attempt to concentrating on anatomy that would be of relevance to the student in his clinical years, living anatomy was emphasized and overall, an insistence on the importance of ‘body anatomy’ as opposed to ‘book anatomy. Body-side tutorials (like the ‘signatures’ of old) were brought in, in spite of the difficulties because of the large numbers of students.
 I took up once again, my practice as a demonstrator in the fifties, of revising my anatomy by dissecting and re-dissecting the human body, as the soundest means of learning anatomy with understanding. These dissections were responsible for my being able to publish a 4 volume set of Practical Anatomy Manuals, which were used by several batches of our students from 1995 to 1999. Apart from having as my aim the main teaching points emphasized above, two further objectives aimed at in the manuals were the use of English which was as simple as I could possibly make it and the provision of a low cost manual, since the majority of our students were by no means affluent.
The pleasure of writing those manuals, based on a deeper insight into the, discipline cannot be measured. Neither t author nor departmentt gained financially by this publication, since the manuals were printed by the Faculty Printing Unit and the volumes were given to our students at a price taking into consideration only the covering of the costs of production. Unfortunately, although the manuals were used by several batches of students, without heavy bricks being hurled at them, I mean the manuals, the use of the manual, was discontinued the moment I left the department in 1999 and Cunningham Manuals which were discontinued by Prof Jayatilleke on the grounds that the English was too difficult for the students, were re-introduced. 
At this point I must stress that with over 50 yrs of acquaintance with the discipline of anatomy and many years of experience of helping both undergrads and post-grads to learn the subject with understanding, I am of the unshakeable opinion that the best approach for the student to the study of anatomy – a method tested over the centuries and second only to study in the OT or post-mortem room- is the exposure and handling of structures, by the student himself, in the dissecting room. The time needed for putting this method into practice can be reduced by intelligent planning by those who know the subject and understand how it should be presented to the student. 
The use of ‘prosected’ specimens, models and computer assisted teaching are just aids. I shall refrain from going into further detail but would like to caution this medical school, as it hopefully aims for a well-deserved century, that it should learn, in the interests of student learning, to render unto Caesar the things that are Caesar’s. Those who know little or no anatomy and less about teaching it, should not be allowed to experiment with students by foisting on them poorly tested methods which are thrust upon them, under the obscure cloak of ‘modern teaching methods’  and ‘curricular revision’.
 Being new to the politics on campus, when I started work as a permanent member of the Faculty, I did not realize for some time that Peradeniya Campus was a key centre of JVP activity. During the years ’87 and ’88 the JVP star was in the ascendant. Student activists used to walk in unannounced into the Vice-Chancellor’s office and make various demands. Fortunately the Senior Student Counsellors managed to talk to the activists and explain to them that problems could be solved more easily if they were first discussed with us. We used to meet them as far as possible once a fortnight with profit to both sides. This was the period when staff, academic and non-academic, was threatened on pain of death, not to come to work.  Some teachers were on occasion compelled to march the streets of Peradeniya and an Assistant Registrar was murdered, I believe, inside the senate building. The most gruesome incident was the ‘garland’ of heads arranged by counter terrorist death squads in a grisly circle around the Lotus Pond.
 My dream of confining myself to the Anatomy Department was not realized, since I got involved in various committees, and though on reaching the retirement age of 65 I resigned from all official posts, I continued as Senior Lecturer, on extension (at the request of the Head Anatomy) till 1999, when I finally took leave of a very profitable association with this medical School, an association spread over nearly 34 years.
 For a variety of reasons mainly that of relatively poor health, I progressively lost touch, with faculty affairs. I gather that in recent times, there has been deterioration in the relations between the University teachers and the Ministry teachers.  This fratricidal situation will benefit no-one and would in particular be detrimental to the interests of our students. I urge a more rational, constructive and conciliatory approach on both sides of the unwarranted divide in the handling of questions of common  interest, and a return to the harmonious relationship that existed in the early days of the Medical School, particularly under the guidance of the 1st dean Prof SW Bibile
Finally I must acknowledge my debt to a large body of students whom I had the privilege of hopefully helping, even in a small way, in the understanding of two disciplines. While I enjoyed my clinical work as an orthopaedic surgeon, when this Surgeon Anatomist (now relaxing in the ‘recovery room’ after ‘hanging up his gloves’) looks back, he can honestly conclude that he derived the greatest pleasure and satisfaction in trying to guide students in their learning.
What I miss most in retirement from my professional career is the constant contact with young minds, a contact which compels a teacher to be on his toes without passing into the complacency and somnolence of seniority.
One of the greatest pleasures for me is to see a former Peradeniya student climb to the top of the academic ladder and also to meet a former student responsible for looking after me ,when hospitalized, who  comes up to me and asks ‘Sir, can you remember me.’ Yes, of course, I remember the face, but sorry, not the name! Most reassuringly, sometimes the boss of the Unit has been a former student during my first teaching phase in the faculty!

To all present and future teachers Uni and non-Uni I say: “Remember that the Student Body is the very heart and soul of a medical school and you are the custodians of the education and nurture of that body, and when you revise the curriculum do so with the interest of the student in mind and not for the satisfaction of some pet whim or fancy of yours’
To my young surgical colleagues who have grown up in an increasingly technology dominated surgical environment and are now guides and models to our students, I commend the words of that eminent, brilliant scholar-physician, the late Lord Henry Cohen of Birkenhead, (1900 -1977) former Professor of Medicine at the university of Liverpool, words which should be enshrined in neon lights at the entrance to every theatre complex:
While hoping that the Peradeniya Medical School will, with skilful stroke-play and balanced judgement proceed to accomplish a century of sound achievement and scholarship, and will continue to produce caring, competent, confident (though not ‘cocky’) medical men and women who would learn to place the interest of the patient as priority, Number 1, let me say to The School (by which I mean the campus and the two associated Teaching Hospitals) from the depths of my heart:

Mark Amerasinghe

Friday, April 25, 2014

Knee pain.

'First published in Medicine Pages of Sunday Times, Sri Lanka of April 20, 2014'

Simple must-do exercises

By Dr. Mark Amerasinghe
There are many causes of pain in the knee, though the majority of these pains are of mechanical origin and not due either to infection or malignancy.
I would like to recommend a simple exercise which in my opinion is helpful, whatever other treatments you may be taking, for this common knee problem, often referred to as ‘osteoarthritis’.
Rationale of the exercise:
The knees are constantly subject to the stresses and strains of weight bearing when standing and walking. These stresses are increased when climbing stairs or slopes or coming down the same. In fact , while you might feel that it should be easier to come down the stairs than climb them, the reverse is the case.
When we stand up, what prevents us buckling  at the knees and falling down, as a result of the action of gravity, is the strong muscle on the front of the thigh (the quadriceps), which is contracted strongly to prevent our knees bending. When we straighten out a bent knee the muscle that performs this action is this strong muscle. The quadriceps muscles are the most powerful muscles giving support to the knee. They form strong, active splints which keep the knees straight and help greatly in maintaining the standing posture. When negotiating steps or slopes these muscles contract more forcibly, the contractions being greater when going down than when climbing up.
If you have pain in the knee the quadriceps tends to weaken and get thinner, so that the support to the knee is reduced. As a result, although the knee may not actually buckle under you, every time you bear weight on the limb the knee joint tends to bend ever so slightly, unnoticed by you. So the knee joints are constantly subjected to tiny ‘shocks’ which can only aggravate the mechanical problem you have.
It is very essential to prevent the powerful quadriceps from weakening and wasting whatever the cause of a painful knee. The strength and bulk of this muscle is maintained by doing quadriceps exercises.
The Quadriceps Exercise:
This exercise can be done both when lying in bed and when seated.

Before getting out of bed in the morning:
* With your knee straight,  straighten it to the maximum so that the back of the knee is pressed firmly against the bed. To do this you have to tighten the muscle (quadriceps) on the front of the thigh. (If you tighten this
muscle effectively; you can feel and see the muscle tighten; you will not be able to move the knee-cap from side to side.)
*             With the muscle firmly contracted, count 5.
*             Now keeping the knee straight, raise the leg slowly off the bed through an arc of about 60 degrees.
*             Bend the knee and straighten it out again.
*             Bring the leg down to the starting position.
*             Repeat the same, as described above, with the other leg.
*             When you have exercised both limbs as described the exercise has been done once.
*             Repeat the above (on both sides),on the first day 5 times, and gradually work up to 10 times.

The exercise while seated:
*             Sit on the chair, preferably a chair with arm rests. Keep your trunk at right angles to your thighs and bend your knees to a right angle.
*             Now plant your feet firmly on the ground and attempt to stand without actually doing so. If you chair has arm rests press down on them with elbows bent. You will feel and see the thigh muscles getting firmer (contracting).
*             Hold the contracted position for a count of 5 and relax.
*             Repeat 5 to 10 times.
This exercise can be done without anyone noticing that you are exercising! You can do it while seated at the computer, or at your desk or at the dining table.
The more often you do this exercise the stronger your quadriceps will be and the more support and protection your knees will have. Start slowly and gradually increase the number of times you do the exercise, but always stop short of developing pain while doing the exercise.
The success of this regime depends on your doing the exercise regularly, whether you have pain or not. Once you start, it’s a life-time exercise. It prevents recurrence of a pain that has left you and also prevents aggravation of the mechanical problem responsible for the pain. Furthermore, it delays the onset of knee pain which many people tend to get as they get along. I like to think of this problem as ‘shock-absorber problem’!
One last bit of advice. When sitting, particularly squatting, do so slowly and smoothly. When straightening up do so in a similar fashion.
The reason for this is that when moving from the straight knee to the bent knee position, while bearing weight or when straightening out from the bent position, the thigh bone turns on the leg bone with a grinding motion. By doing the movement slowly and smoothly the stresses on the knee joints are reduced.

'One important fact needs to be emphasized. You need not wait until you have a knee problem to do this exercise. I recommend it to anyone and every one as a regular, daily and lifetime exercise .Even elderly  people and those with cardiac problems can profit by it, provided they stop short of tiring themselves out. The quadriceps exercises help to prevent/delay the knee problems we are prone to, as we get on in years.'

(The writer is former Orthopaedic Surgeon, General Hospital, Kandy)

Monday, April 21, 2014


Backache: You can prevent this common but disabling problem’
[This two part article was first published on 19 July(Part1) and the followint August(Part 2) 2009, in the Sunday Times, Sri Lanka]

Part one:
Getting to know your anatomy to understand simple yet vital posture tips
By Dr. Mark Amerasinghe

 Here are a few suggestions that will help avoid backache and prevent a recurrence of pain in those who have had the problem.
Prevention is based on the recognition that backache is commonly a result of faulty posture throughout the day and strains, particularly during our activities of daily living. Some important anatomical facts will help explain the rationale of the advice given below.
The low-back which bears the weight of the head, chest and upper limbs, as well as the stresses of walking, jumping and running, transmitted to this vulnerable region through the lower limbs via the pelvis, is hollowed out. This is because the spine in this region is curved and projects forwards. The vertebrae which together form the spine consist of a strong block of bone (the body) in front and weak arched struts of bone at the back, hollowed out to accommodate the spinal cord, from which the spinal nerves arise.
Between the very strong bodies which are built to withstand weight, are the crepe rubber-like strong intervertebral discs. The more curved the spine in this region, the more marked the hollow of the low-back[the lumbar lordosis] and the greater the strain on the back part of the disc and the weak arches.
Furthermore, just as the discs are firmly attached to the bodies of the vertebrae by strong ligaments which prevent them actually 'slipping' in relation to each other, the arches are connected to each other by elastic ligaments which allow movement between the vertebrae, while more fibrous ligaments prevent excessive movement. The movement between the arches occurs at tiny joints between small slivers of bone projecting from the arches. These joints permit smooth movement between the arches and like the bigger joints such as the knee joint, if subjected to excessive or abnormal stresses, can swell up.
 These tiny joints form the back wall of the opening between the arches of two adjacent vertbrae. The spinal nerves leave the spine through these openings [the intervertebral foramina].Hence, a spinal nerve when leaving the spine can be pressed upon from the front by a protruded/prolapsed disc or irritated from behind by a strained and swollen joint. Strain or sprain of these joints or injury to the associated ligaments is likely to occur as a result of bad posture, particularly during activity.

The more curved the low-back, the greater the shift of stresses to the back and the greater the chance of straining the ligaments and tiny joints. Furthermore, the weight of the upper part of the body and the stresses of activity are thrown more on the back part of the disc which is thinner and weaker than the front part.

The flatter the low-back, the less the forward curvature of the spine, the less the strain on the back part of the spine and the more evenly is the weight distributed throughout the disc, thus relieving excessive pressure on the back part - the vulnerable part.

Strong abdominal muscles connect the lower chest with the front part of the bony pelvis which transmits stresses from the lower limbs to the low-back and vice-versa. Since these muscles are in front, when they are well developed or further tightened, they pull strongly on the front part of the pelvis tilting it upwards so that the forward curve of the spine is reduced.

The hollow of the low-back is reduced and even flattened out completely. So tucking your tummy in , by tightening (contracting) the abdominal muscles, flattens the low-back and reduces the stresses and strains on it. (The so-called middle-age spread with the resulting prominent protruding tummy is often due more to lax and flabby abdominal muscles than to the accumulation of fat.)

Simple advice for daily activities
Sitting – whenever possible, sit in a chair with a firm, upright back-rest which permits sitting straight. The trunk should be at right angles to the thighs and be pressed firmly against the chair back, in such a manner that the hollow of the back is flattened out as much as possible. To achieve this desirable position it is necessary to sit with your knees bent at a right angle, leaving a space of a hand's breadth between the edge of the seat and the back of the calf. In this position tuck your tummy in by tightening your abdominal muscles.

When you perform this action as described, you will actually feel that you have increased in height. In fact you have, because you have converted a hollow low-back into a straight one. Arm rests are helpful in achieving the correct sitting posture.

When getting up – draw your feet back, under the front edge of the seat, bend your straight trunk forwards at the hips so that it is poised over your feet, which serve as a firm base for the next move. Press your flat feet firmly down on the floor, while placing your hands on the arms or the sides of the chair and push yourself up, without twisting your body. The major push comes from the pressure of the feet on the ground.

The above posture is very important to get used to, because the majority of sedentary workers spend so much of their waking hours in the seated position. It should be possible to use a suitable straight-backed chair in the workplace. But, unfortunately, sitting-room chairs are more often than not, designed for beauty and elegance and not for function, without danger to one's back, They tend to have sloping backs and sloping seats which are so deep that when you sit well back, your back is not upright and your knees cannot be bent to a right angle.

When getting out of a chair of this type, move well forward so that your buttocks are close to the edge of the seat, assume the straight back posture and push up as described above. Do not wiggle out of the chair twisting your back in the process. This way of sitting and getting up may at first be difficult to get used to, but it is worth the initial effort.

When you get into the driving seat of your car – before you fasten your seat belt, adjust the position of your seat so that you can sit upright with your back pressed flat against the seat upright, which should not be sloping, or if at all, only very slightly. At the same time, your feet must rest comfortably on the pedals, and your hands comfortably on the steering without slouching or leaning backward. Adjust rear and side mirrors, so that you do not have to twist your body when reversing.

Always avoid twisting your body when turning. Turn your entire body in one piece, as if you were spinning on your own axis.

At the wash-basin – do not stoop over a low wash basin. Stand with your feet well forward under the edge of the basin with one foot slightly ahead of the other. If you have to bend, bend at the knees and lower yourself while at the same time bending slightly at the hips. Your back should be straight without being stiff.

In the kitchen or pantry – often kitchen or pantry table tops have cupboards below them. This entails stooping when cutting food items. There should be a special cutting area, where there is no cupboard below it, so that you can get your feet well under the table and bend forwards at the hips with the back straight. Alternatively sit comfortably on a stool and get on with your work.

When ironing – if you have seen an experienced carpenter planing wood at his work table you will note that the table is of such a height that he can stand comfortably and do his job with only a slight bend at the hips. In similar fashion adjust your ironing board so that you can work without stopping.

Opening heavy-bottom drawers – Never stoop and pull on the drawer! Stand close to the chest of drawers, bend your knees with the hips slightly bent and your back straight and drop down, so that you can place your hands on the handles with the elbows bent to a right angle. You can now pull, taking all the weight on the legs, without putting any stress on the back.

It is essential that when you lift or push or pull on a weight, the stress is taken by the legs and not by the low back, hence the necessity to let your body drop to the level of the weight.

Lifting heavy weights like flower pots etc.– place your feet on either side of the pot. Go down to the pot, knees bent, hips slightly bent and back straight. Grip the pot firmly. Now lift by pushing down on the floor, straightening your knees, taking the weight and thrust on your legs and saving your back Ensure that the weight is as close as possible to the body.

Avoid holding the heavy object away from the body because it subjects the low-back to a very strong levering force. It helps if when carrying out these activities, you tighten your abdominal muscles, and tuck the tummy in. Watch a professional wrestler and you will understand what I mean.

Sweeping under a bed – again, go well down by bending your knees and hips so you can see where your broom is going!

Next issue: Some simple exercises

 Part 2
Helpful exercises, back pain or not
By Dr. Mark Amerasinghe
Some useful exercises
a) Sit on the 'correct' type of chair. Tuck your tummy in by tightening the abdominal muscles. At the same time press the hollow of your back to flatten it out against the chair back. Count to 5. Relax and repeat. Do not hold your breath while doing this exercise.
You should be able to carry on a conversation comfortably while doing it. Pushing down with your arms on the sides of the seat or with your elbows on the arm rest helps greatly. You may have some difficulty in doing this exercise at first, but it is worth trying. It pays dividends.

Bending the wrong way to pick up something off the floor.

After completing the exercise, when getting up from the chair (in the manner described earlier), try to keep the abdominal muscles contracted and the back flat and see if you can maintain this position in the standing and walking position.Initially repeat 10 to 15 times then gradually increase the number till you come to 20 or 30. You can do this exercise any time of the day (avoid the two hours after a meal) as no one will notice that you are exercising.
You will automatically have a better posture and you will walk and talk tall!
b) Once you have mastered this exercise on the chair, you can do the same in bed, before you get out of bed. You need a firm mattress or you need to have a plank under the mattress.
Lie on you back, bend you legs up at the knees and hips, keeping your feet on the bed. Keep your hand on your abdomen, so you can feel the muscles contracting. Tighten. Count to 5. Relax. Repeat at first, 20 to 30 times. IF YOU HAVE A CARDIAC PROBLEM GET YOUR CARDIOLOGISTS APPROVAL PARTICULARLY IN REGARD TO NUMBER OF REPEATS PERFORMED!!!!
c) Assume the same posture as in b), Lift your head up slowly while your hands are on the abdominal muscles. Usually with the head lift alone, the muscles tighten. If not just raise the shoulders very slightly off the bed. Count to 5 then relax. Before you raise the head, take a deep breath and as you raise the head let the breath out slowly. When getting back to the starting position, breathe in again. Repeat initially 10 times and gradually work up to 20.
These exercises can be done even when you are having back pain, provided the pain is not unbearable, and they help to relieve the pain.
Many a patient has testified to the efficacy of these exercises, provided they are done regularly, back pain or not. Do not let up because you are free of pain.
You do not have to sleep on a plank, but your mattress must not sag. So either it must be firm or have a plank underneath it.
During an acute attack of pain, sleep on a side with your legs tucked up (roughly in the foetal position) so that the back is flat or slightly rounded. Hug a pillow and have another pillow between your tucked-up knees. The idea is that your body is not even slightly twisted. Furthermore, when your legs are well tucked up the hollow of the back is flattened out. When you turn roll yourself like a log in one piece, using the legs for leverage.
When getting out of bed, get close to the edge of the bed, turn on your side with legs tucked up, push yourself up while slipping your legs out of bed. Then push yourself up and out of bed as you did when seated.
As has been pointed out less than 5% of people with backache have a prolapsed disc and less than 10% of people with a prolapsed disc need surgery.
In summary
Most backaches are posturally induced.
At all times avoid twisting your body.
Bend by bending the knees and hips without stooping. Remember this when  picking up even a slip of paper from the floor.
When pulling, pushing or lifting get the push, pull or lift from your legs, with your back straight.
Sit with a straight back on a straight-back chair or on the driving seat.
Keep your abdominal muscles strong.

Thursday, April 17, 2014

Pain in the neck

 That Pain in the neck 
                 By Dr. Mark Amerasinghe 
 [This article was first published on 21 February, 2010 in the Sunday Times Sri Lanka]
Neck pain, like backache, is a common problem, particularly among the over forties. The spine in the neck, the cervical spine, is made up of seven blocks of bone -the cervical vertebrae. It projects to the front, as is evidenced by the hollow of the neck at the back. As a result, when the spine is subjected to stress along its length, this stress is borne more by the back part of the vertebrae. 
Each vertebra consists of a strong block of bone, the body, and a weaker portion behind, consisting of an arch of bone enclosing a hollow. From the upper and lower margins of the arch are, on either side, two little projections of bone known as the facets. The back surface of the upper facet and the front surface of the lower facet are polished and smooth, so that one vertebra can sit comfortably on the vertebra below, coming into contact at the facets, forming a joint (the facet joint) where movement can occur between the vertebrae. 
The bodies of neighbouring vertebrae are connected to each other by a strong but compressible disc of tissue (the intervertebral disc) which binds the bodies firmly to each other, while, because it is compressible, allowing movement between them. The vertebrae are also bound to each other by bands of tissue –the ligaments passing between the arches. 
When the vertebrae are piled one on top of each other, the hollows enclosed by the arches form one continuous canal (the spinal or vertebral canal) which lodges the spinal cord running down from the brain above. From the spinal cord arise the spinal nerves on either side.
These nerves leave the spine through little spaces on the sides. An important anatomical fact is that part of the front wall of this space (foramen) is made up of the outer portion of an intervertebral disc and the back wall is formed by a facet joint. A slight bulge (protrusion) of the outer part of the disc – something which can occur in a disc that has undergone changes with age - can irritate the nerve.
In like manner, a swelling of a facet joint lying behind the nerve can do so. Just as when you twist (sprain) your knee or ankle the joint can swell up and needs rest, in similar manner, a twisting strain of a facet joint can give rise to a tiny, not easily demonstrable, yet painful swelling which needs to be rested. The forward curvature of the spine in the neck tends to throw a greater strain on the back part of a vertebra. Thus, our daily activities, looking up, down, bending and turning our heads, can without much difficulty cause a strain of the facet joints and the ligaments joining the arches, apart from pressing more on the weaker back portion of the disc, leading to a slight bulge (protrusion). Depending on the particular nerve/s irritated, pain can occur in the shoulder blades (a common site) or even down the arm or going up to the back of the head. 
These facts help us to understand the distribution of pain arising from disturbances of the cervical spine and place us in a better position to take action to prevent these disturbances and also to handle them effectively when they do occur.
When you lie on your back, you can easily pass your hand under your neck, which, because of the hollow, is unsupported and thus under strain. There are two ways you can provide this support.
 Using a ‘bole’ pillow 
The long cylindrical type of pillow (used for babies) which can be tucked easily into the hollow, provides support to the spine. Supporting the neck in this manner is very useful in reducing and relieving neck pain.
 The butterfly pillow
• Use two pillows, the softer one being on top. 
• Tie the top pillow in the middle so that it looks like a butterfly.
• When you lie down rest your head on the bottom pillow, while your neck rests on the ‘waist’ of the butterfly.
• The position of your head will depend on the size of the bottom pillow. You can start off with your neck being straight. If you use a thinner bottom pillow, your head will fall backwards, while a thicker pillow or a rolled up towel tucked under the pillow will push your head forwards. You will have to find out the position that suits you best, by trial and error.
I have personally found a butterfly pillow most useful. If you are too lazy to be tying up pillows, just push a crushed up very soft pillow into the hollow of the neck, and you will note the difference it makes!
 Once you have found the desirable position on the butterfly pillow, you do not have to sleep staring at the ceiling; you can turn towards one or other side ‘wing’ while your neck still rests on the waist of the butterfly.
 Use of a collar
A well fitting collar helps to reduce pain. It does so, by preventing sudden, jerky and twisting movements and thus resting the small facet joints. It is important that the collar is properly selected. Your head should be in a neutral position with the eyes looking straight ahead. 
This is the position of least strain on the spine. It is the vertical height of the collar which determines this. The collar should rest on the two bony prominences at the inner ends of the collar bones and run up to the level of the chin, with the head held in the neutral position.
Those who have had a bout of neck pain should always use the collar when travelling in a vehicle, even if they are pain-free at that moment.
 Neck relaxation exercise
When you have a neck pain you often find that the muscles at the back of the neck and/or over the shoulder blades are tense and tight. They are in spasm, due to the irritation of the nerves that supply them
• Sit in a comfortable position with head in the neutral position, looking straight ahead.
 Let your head drop down very slowly as if you are dropping off to sleep. Let it go as far as possible without forcing it. Now come up, again very slowly to the starting position.
• Turn your head first to one side, then to the other and get back to the starting point.
• Let your head drop backwards and get back to the starting position. 
It is important that the head be allowed to drop under its own weight and very slowly. Just let go. Do this exercise daily, before you get out of bed, and again, just before you drop off to sleep i.e. at ‘nodding time’ 
If you do this exercise daily, you will find that the range of movement possible progressively and slowly increases. But do not concentrate on the degree of movement. Just relax.
 Attention to certain activities of daily living 
• In your pantry cupboards, items used infrequently should be on the top shelf while items used regularly should be at or around eye level.
• Avoid looking up for long periods of time. It increases the stain on the weak part of the discs and the facet joints.
• In like fashion avoid looking down for long periods. It strains the ligaments. Hairdressers in particular should try to do most of their work at or around eye level. I presume that their clients sit on a chair, the height of which is adjustable. The relaxation exercise can be particularly helpful for hairdressers.
• Ensure that the monitor of you computer is so placed that again you are working, most of the time, at around eye-level. If you are looking at a document when working, see that it is as the same level as the monitor, so that you do not have to be looking down and to the side, frequently.
• At all times avoid sudden jerky movements.
• People having neck pain and those over 40yrs, in my opinion, should avoid ‘head stands’
Paying attention to these matters can pay dividends by sparing you that neck pain if you are fortunate not to have suffered from it, and if you have, it can help relieve the pain and prevent a recurrence. One final word. Do not get alarmed by reading reports of radiological examinations and scans. 
They often sound more terrifying than the reality of your condition., because they are written in a special language that can be understood only by those qualified to interpret them. Remember that, there are many people going around with ‘horrible’ looking X-rays of the neck, but who have no complaints!