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FALL 1994 ISSUE ■ SINAI HOSPITAL

HealthNews

Physicians Look at Death and Dying

s

Writers cramp, which can coexist with carpal tunnel syndrome, is especially common among
accountants, nurses, students and others who are required to write quickly and extensively.

SPECI AL ADVE RTI SEMENT

Writer's Cramp Is Not
Just a Pain

tudents feel the pain after
lengthy lectures. Musicians'
ds feel strained after long re-
earsals. The muscles in their
hands and forearms feel sore and weak.
In each instance, these problems may be
a task-specific malady sometimes called
writer's or musician's cramp, which in
medical terms is "carpal dystonia."
"Writer's cramp is often misunder-
stood as simple muscle strain or
stress on the joints," says Peter Le-
Witt, M.D., a Neurologist at Sinai's
Movement Disorders Clinic and Clinical
Neuroscience Center in West Bloomfield.
"Carpal dystonia, however, is a dis-
order that originates in the brain and is
sometimes progressive and extremely
disabling."
Dr. LeWitt and Richard M. Trosch,
M.D., are actively conducting research
into the treatment of dystonia. Dystonia
is an abnormal activation pattern of
various muscles. Sustained abnormal
posture, involuntary movements, or in-
coordination for specific activities are
some of the symptoms of dystonia.
Writer's cramp is one of the most corn-
mon dystonic disorders and is often mis-
taken for carpal tunnel syndrome.
Carpal tunnel syndrome is caused by
nerves that become compressed in the
wrist. Writer's cramp, which can coexist

with
carpal
tunnel
syndrome,
is especially
common among
/ accountants, mu-s-
/ es, students and oth-
ers who are required
to write quickly and ex-
tensively.
Since 1988, Sinai's Clini-
cal Neuroscience Center has treated
writer's and musician's cramp and a va-
riety of other movement disorders char-
acterized by dystonia. These include
involuntary eye closure (blepharospasm)
and tremors or spasms of the neck (tor-
ticollis). Both Drs. LeWitt and Trosch
are experts in the treatment of writer's
cramp and other dystonic disorders. One
available therapy is Botox, or botulinum
toxin, which, when injected into affect-
ed muscles, can reduce pain, involuntary
movements, and other disabilities.
"Because the causes of writer's cramp
and other dystonias are not known, pre-
vention is not possible," says Dr. LeWitt.
"However, with Botox and other forms
of treatment, we can often reduce the
disability and its accompanying dis-
comfort within a few days of beginning
therapy."

ince 1990, Michi-
gan has been at
• the forefront of a
heated debate
over physician-assisted
suicide. During 1993, the
Michigan legislature en-
acted Public Health Act
270, which made physi-
cian-assisted suicide ille-
gal. However, the ban has
since been found uncon-
stitutional, and the con-
troversy continues over a
patient's right to die and
the physician's role — if
any — in carrying out a
patient's wishes.
Sinai Hospital Psychi-
atrist Linda Logsdon,
M.D. served on the
Michigan Commission on
Death and Dying, a 44-
member multidisciplinary
panel that met from Au-
gust 1993 to June 1994.
The commission exam-
ined the aid-in-dying is-
sue and presented its
findings to the Michigan
legislature in June.
"On the commission,
we looked at the broad is-
sue of physician-assisted
suicide," says Dr. Logs-
don, who specializes in
the psychiatric treatment
of people with chronic
physical illness and in-
jury. "Then we focused on
the types of patients who
would be included in the
aid-in-dying option and
developed guidelines
based on those types of
patients." These patients
included those with

"chronic, debilitating, pro-
gressive and terminal ill-
ness" and those whose
pain and suffering were
not treatable with med-
ication or additional corn-
fort care.
One section of the com-
mission's document pro-
poses guidelines in the
event that physician-
assisted suicide or aid-
in-dying is legalized in
Michigan. The first guide-
line requires that the pa-
tient request aid-in-dying.
"It's important to note
that it must be the pa-
tient's request, not a fam-
ily member's wish," adds
Dr. Logsdon.
Secondly, the patient
must be seen by health
professionals from four
areas of expertise. The pa-
tient's primary care physi-
cian must first establish
the presence of a physical
illness that is resulting in
unbearable pain and suf-
fering. Next, a psychia-
trist or doctorate-level
psychologist must deter-
mine that the patient is
mentally competent in de-
cision-making and has no
treatable mental illness.
A specialist in pain man-
agement then evaluates
the patient to determine
if the pain is treatable
with therapy or medica-
tion. Finally, a represen-
tative from a social service
agency meets with the pa-
tient to determine if out-
side assistance would

alleviate the patient's
difficulty. After all four
evaluations have taken
place, the information is
given to the probate court
for verification that prop-
er procedure has been
followed and that the pa-
tient meets the criteria.
Once everything is veri-
fied and in order, the pa-
tient may then proceed
with his/her aid-in-dying
wishes.
"With aid-in-dying, the
physician must be present
but does not have to ad-
minister the drug to bring
on the patient's death,"
says Dr. Logsdon.
The commission's doc-
ument is only a proposal,
not legislation. As Dr.
Logsdon notes, the mem-
bers of the commission
were not in complete
agreement on the propos-
al, an indication of the
fierce debate that will con-
tinue on this issue in the
state of Michigan and
across the country.
"There are diverse
thoughts on the aid-in-
dying controversy stem-
ming from religious
and professional back-
grounds," says Dr. Logs-
don. "The events of the
last four years have forced
the medical profession to
look at this question. It's
important that physicians
discuss this complicated
issue."

Another unique service of Sinai's Department of Psychiatry is the program for Holocaust Survivors
beaded by Dr. Charles Silow. Holocaust survivors and experts in post-traumatic stress disorder
discuss the effects of the Holocaust on survivors and their families.

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