- Study among full-time loaders in the Main Bazaar finds work continuance despite pain, use of substances as pain relief
A significant proportion of loaders (“nattamis” – people engaged in carrying and loading weights as their occupation) in Pettah suffer from chronic widespread pain and stress – due to lifestyle and occupational factors, and which are associated with psychological distress, and which adversely affect the activities of daily life and the quality of life. Yet, they continue to work despite the pain and tend to use substances as a pain relief method.
These findings were made in a research paper on the “Prevalence and the correlations of chronic widespread pain among loaders (nattamis) in Pettah” which was authored by M.A. Prasanna (attached to the International Institute of Health Sciences, Welisara), and P.A.R.I. Kulathunga and P.V. De Silva (both attached to the Ruhuna University's Medical Faculty's Community Medicine Department), and P.N. Kariyawasam (attached to the same University's Allied Health Sciences Faculty's Nursing Department), and published in the Journal of the Ruhunu Clinical Society 28th Volume's First Issue in December of last year (2023).
What is Chronic widespread pain?
Chronic widespread pain is a cardinal symptom of fibromyalgia, which, P. Kumar and M. Clark's “Clinical medicine” mentions, is a non-inflammatory condition of the musculoskeletal system. Chronic widespread pain is, per K.E. Mansfield, J. Sim, P. Croft and K.P. Jordan's “Identifying patients with chronic widespread pain in primary care”, characterised as long-lasting pain in multiple body regions which is associated with physical and psychological problems. P. Andrews, M. Steultjens and J. Riskowski's “Chronic widespread pain prevalence in the general population: A systematic review” found that the prevalence of chronic widespread pain among the general public ranged from 1.4-24%, showing 0.8-15.3% in males and 1.7-22.1% in females. Moreover, “More pain, more tender points: Is fibromyalgia just one end of a continuous spectrum?” by P. Croft, J. Burt, J. Schollum, E. Thomas, G. Macfarlane and A. Silman notes that it has become a highly prevalent condition and a major health problem within the community and working population while it has also been identified as one of the commonest complaints in rheumatology clinics.
According to R. Staud's “Chronic widespread pain and fibromyalgia: Two sides of the same coin?”, J.N. Ablin, D. Buskila, B.V. Houdenhove, P. Luyten, F. Atzeni and P. Sarzi-Puttini's “Is fibromyalgia a discrete entity?”, and F. Wolf and K. Michaud's “Outcome and predictor relation relationship in fibromyalgia and rheumatoid arthritis: Evidence concerning the continuum versus discrete disorder hypothesis”, while fibromyalgia has been considered in some theories to be a distinct disorder, recent research inclines toward the idea that the conditions of fibromyalgia and chronic widespread pain are parts of a severity continuum of pain and distress, along with other chronic pain related conditions. Per F. Atzeni, M. Cazzola, M. Benucci, M.D. Franco, F. Salaffi and P. Sarzi's “Chronic widespread pain in the spectrum of rheumatological diseases”, the characteristic features of fibromyalgia are musculoskeletal pain, chronic diffuse tension and/or stiffness in the joints and muscles, fatigue, sleep and emotional disturbances, and pressure pain sensitivity in at least 11 of the 18 tender points.
K. Kato, P.F. Sullivan, B. Evengard and N.L. Pederson's “Chronic widespread pain and its co-morbidities: A population based study” and S.M. Bigatti, A.M. Hernandez, T.L. Cronan, and K.L. Rand's “Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression” believe that chronic widespread pain co-occurs with various symptom-based conditions such as chronic fatigue syndrome and psychiatric disorders. G.J. MacFarlane, P.R. Croft, J. Schollum, and A.J. Silman's “Widespread pain: Is an improved classification possible?” has shown that chronic widespread pain is associated with depression and other symptoms of psychological distress.
The strongest risk factor for developing chronic widespread pain is the presence of long-standing regional pain. As found in B. Larsson, J. BjÖrk, B. BÖrsbo and B. Gerdle's “A systematic review of risk factors associated with transitioning from regional musculoskeletal pain to chronic widespread pain”, the spreading of pain from local or regional pain to widespread pain occurs in a large proportion of the general population.
Chronic widespread pain can affect any part of the body. Environmental factors such as physical trauma, certain infections, autoimmune disorders, and other regional pain-related conditions may, per D.J. Claw's “Fibromyalgia: Update on mechanism and management” play a role in triggering and maintaining widespread pain in fibromyalgia.
The development and persistence of chronic widespread pain, per S. Bergman's “Psychological aspects of chronic widespread pain and fibromyalgia”, are associated with several socio-demographic, psychosocial and lifestyle related risk factors including having a low educational level, being in a low socio-economic class, having a family history of chronic pain, not having social support, and smoking. A Canadian study showed features of somatisation, self reported poor health status and sleep disturbances to predict the development of chronic widespread pain.
According to the “Manchester definition” of widespread pain, which is one of the most commonly applied definitions to diagnose chronic widespread pain, the latter is defined as “pain reported in at least two sections of two contralateral limbs and in the axial skeleton, and which has been present for at least three months”.
Although chronic widespread pain can occur at any age and in any sex, a Spanish study has recognised it increasingly in teenagers and most commonly in middle aged females between 40 to 65 years of age.
Pettah is one of the busiest commercial areas, where most of the trade takes place. One of the biggest market complexes in Sri Lanka which is called the Pettah market is also located in this area. Most of the shops and shopping complexes in this area use physical manpower to load and unload heavy weights and to carry loads from one place to another. Almost all these loaders are found to be males and they are of a low socio-economic status and low educational level compared to the general population. One of the common problems identified among these loaders is musculoskeletal pain in multiple sites of the body. Further, accompanying this body pain, they have, per A. Gupta, A.J. Silman, D. Ray, R. Morriss, C. Dickens, G.J. MacFarlane, Y.H. Chiu, B. Nicholl, and J. Mcbeth's “The role of psychological factors in predicting the onset of chronic widespread pain: Results from a prospective population based study”, psychological distress with their busy and heavy work.
The majority of the patients with fibromyalgia and chronic widespread pain, per C.M. Henriksson, G.M. Leidberg and B. Gerdle's “Women with fibromyalgia: Work and rehabilitation”, experience work-related limitations due to their pain, fatigue, and cognitive symptoms; but, with individual adjustments to their work, many patients with fibromyalgia manage to stay active at work. The symptoms of chronic widespread pain often have a complex aetiology with multiple causes, which make it challenging to find measures to support these patients.
Statistics: Pettah full-time loaders
Prasanna et al. conducted a descriptive, cross sectional study using 174 loaders (selected using the convenience sampling method) who were occupied as full-time loaders in the Main Bazaar in Pettah (employed as loaders in the said area for a continuous period of more than six months). Data were collected using a pre-tested, interviewer administered, structured questionnaire. A validated, perceived stress scale was used to identify the psychological distress among the loaders.
The total number of respondents was 174. All were males. The majority of the participants were within the 30-39 years and 50-59 years age groups (27.6%). The mean age of the study population was 42.65 and ranged between 19 and 66 years. The majority were Tamils (53.4%) followed by Muslims (32.2%) and Sinhalese (14.4%). The religion of the majority was Hindu (46%), followed by Islam (32.2%). The majority were married (83.9%). The level of education was average (Grades 6-11) among 65.1% and 9.2% had never gone to school.
Most had worked as a loader for more than five years. The mean value of the working years was 20.84 years, ranging from 1.5 to 50 years. The majority worked six days per week (64.4%) and 95.4% worked more than eight hours per day. The mean weight that they carried at once was 62 kilograms (kg), ranging from eight kg to 125 kg. Most stayed within a two-20 kilometres (km) distance from their working place (48.3%) and 42.5% lived less than two km from their working place. Most travelled to their working place through the public transport service (bus) (60.9%).
The site of pain included (for 167) the lower back, the shoulder, the calves, the knees, the spine, the feet, the elbows, the neck, the forearms and the chest. A total of 165-167 participants (96%) had suffered from body pain at multiple sites of the body during the course of the previous year. Lower-back pain (64%) was the major complaint followed by shoulder pain (39%), calf pain (39%) and knee pain (33%).
Among the loaders who complained of pain during the course of the previous year, 29.4% had pain for more than three months. A considerable number of loaders were unable to attend to their routine work due to the pain (44.3%). However, most of the loaders who complained of chronic pain had not taken leave (55.7%).
The way of taking treatment and medication (for 167) included none, taking medications/painkillers from a pharmacy without consulting a medical practitioner, consulting a medical practitioner, home remedies, getting rest for some hours/days, following Ayurveda medications/treatments, and other. A total of 32/18.4% of the loaders fulfilled the criteria for chronic widespread pain. The number of participants who complained of pain was 167 and among them, eight/4.8% did not use any medication when they suffered from pain. The major mode of getting medication was buying medication or painkillers from a pharmacy without consulting a medical practitioner. Some used several methods to get medication.
The practice of substance use included consuming alcohol, smoking, chewing betel, and using other substances, also for relieving pain when suffering from body aches or pain. Among the participants, 153/88% used one or more substances, nine/5% did not use any substance and 12/7% had never used any substances.
All the loaders had stress. A total of 51.7% were found to have high levels of perceived stress.
Age and substance use were considered as lifestyle based risk factors and the number of working years and the amount of weight that they carry at once were considered as occupational risk factors. Moreover, the association between the perceived level of stress and chronic widespread pain among these loaders was significant.
There was a highly significant association between chronic widespread pain with the ascending order of age and perceived stress. Substance use, the number of working years as a loader and the amount of weight that they carried at once did not show any association with chronic widespread pain.
Prevalence
There was a significant prevalence of chronic widespread pain among the loaders in Pettah (18.4%). Age and psychological distress were significantly associated with chronic widespread pain. When compared to the prevalence of chronic widespread pain in the general public, the prevalence of chronic widespread pain among the loaders showed a comparatively similar prevalence. Increasing age showed a significant association with musculoskeletal pain.
A total of 35.5% had been working as a loader for more than 26 years which indicates that most had started working as a loader when they were teenagers. As the main mode of income of loaders depends on the amount of weight that they carry, most carried 31-60 kg (55.2%) and 27% carried 61-90 kg at a time, and had many turns in a day. Nearly 80% worked more than five days per week and 95% worked more than eight hours per day. The reason for this was that if they did not attend work for one day, they were unable to compensate their own and their family's cost of living for several days. A total of 91% lived less than 20 km from their working place. A total of 27% attended their workplace on foot and the public transport service (bus) was the main mode of transport of the others (60.9%). Some were from a long distance (up country) and were boarded in Colombo, living apart from their family members and visiting their family once a month or once in two months.
A total of 96% had suffered from body pain at single or multiple sites of the body during the course of the previous year. Lower-back pain was the most prevalent individual problem (64%). Other commonly reported problems included shoulder pain (39%), calf pain (39%), knee pain (33%), spinal pain (16.8%), foot pain (15%), elbow pain (12.6%), neck pain (10.2%), forearm pain (9.6%) and chest pain (8.4%). A total of 70.6% revealed that they had persistent pain for more than three months, mainly when they got some rest or during the night-time.
This indicates that their chronic pain was masked by their heavy work during the daytime. Although the majority suffered from body pain, only 44.3% revealed that they were unable to attend work due to the pain. Among them, 41.3% had taken leave for less than one week due to the body pain. Because of their low socio-economic background, even with the pain, they attended their work and had medication to relieve the pain. Some used more than one method to get medication for pain. Buying medication or painkillers from a pharmacy without consulting a medical practitioner was the health seeking behaviour practised by the majority.
According to the Manchester definition of chronic widespread pain, 18.4% fulfilled the criteria for chronic widespread pain and were found to have chronic widespread pain.
Croft et al. revealed that chronic widespread pain was strongly associated with other somatic complaints, depression and anxiety.
The use of substances is a common behaviour among people with a low socioeconomic background and it is a triggering factor for chronic widespread pain. A United States study among wage based and salaried workers found that approximately 63.09% could easily bring alcohol into work, use alcohol while working, use alcohol during lunch and other breaks, or obtain alcohol at work, while similarly, 59.05% could easily engage in the same behaviours regarding illicit drugs.
The instant study revealed that 88% currently use substances. Among them, 85.6% consume alcohol, 64.7% are smokers, 41.8% chew betel, and 10.5% use other substances. Heroin (6.6%) and cannabis (3.9%) were the commonly used other substances. Also, 70.6% used substances to relieve pain when they suffered from body pain.
All the loaders were found to have stress and 51.7% had a high level of stress with their lifestyle and occupational factors.
Awareness
The prevalence of chronic widespread pain showed an increasing trend with the ascending order of the age group and revealed a highly significant association with stress. No association was found between chronic widespread pain and the use of substances, the number of working years as a loader and the amount of weight that they carried at once. Consuming alcohol or substances was the most common habit and pleasure related activity among the loaders.
Hence, Prasanna et al. made a number of related recommendations: Implement programmes to routinely screen loaders for chronic widespread pain; increase awareness on proper treatment modalities; introduce them to methods to minimise chronic pain including modified ergonomics for carrying loads; establish a system where loaders can have adequate rest in-between their working days and can practise relaxation therapies; and offer rehabilitation based therapies along with pain related coping strategies to the loaders detected with chronic widespread pain at the time of detection, and facilitate them during their recovery periods.