Wednesday, November 18, 2015

PAINLESS - Total Knee Replacement

Total knee replacement is a highly successful surgery. Patients disabled with knee pain who can barely walk on their deformed legs undergone a dramatic transformation after the surgery. They experience complete relief from pain and complete correction of deformity. After surgery they don't need pain killers. They can walk normally without a stick or walker and at a normal pace. 

However the surgery is a major procedure involving cutting of muscle and bone. This leads to a slow and painful recovery. Post surgery pain after knee replacement can be unbearable and remains as a major deterrent to someone who wants to undergo the operation. Traditional methods of pain control include intravenous or intramuscular analgesic injections and epidural pumps. Intravenous medicines have safety issues and are not effective. Epidural pumps involve placing an epidural catheter (a very thin tube) in the epidural space near the spinal cord. Through this tube medicine is administered which numbs the spinal nerves and relieves pain. A well functioning epidural pump is very effective but has certain problems. Firstly, placing an epidural catheter is a blind procedure and many times the catheter is not in an ideal position. As a result it fails to reduce pain. Secondly, epidural pumps may cause a drop in blood pressure in some patients which requires constant monitoring. Lastly, epidural medicines may cause temporary sensory loss and motor weakness in the legs which makes walking after surgery difficult. 

In recent years, technological advancements in the science of anaesthesia and pain management have made painless knee replacement possible. Patients are standing and walking by evening on the day of surgery! Nerve blocks are a known technique of analgesia (pain relief). Two technologies have become available to the anaesthetist in the operation theatre which have revolutionized the efficacy of nerve blocks. First is a nerve locator. As its name suggests it helps in precisely locating a peripheral nerve which then can be blocked by administrating medicine. Second is portable ultrasound. Combining these technologies increases the accuracy of locating a nerve to 95%. This allows the anaesthetist to confidently block peripheral nerves (nerves outside the spinal cord) with predictable success. In the case of knee replacement, a femoral block and an adductor canal block is used to numb the pain. These blocks are effective and safe. There is no drop in blood pressure and no motor weakness. As a result we have successfully eliminated the need for epidural pumps. 

Another advance that we routinely use is called LIA - Local Infiltration Analgesia. This involves injecting a combination of medicines in the local tissues around the knee joint at the end of the surgery. With modern drugs and optimal doses, this technique alone numbs the knee for 12 to 24 hours. Again the technique is safe and effective. it does not require monitoring of blood pressure and does not cause any weakness. 

The last addition is that of pain patches. Newer opioid analgesics (artificial morphine substitutes) are available as pain patches. A single patch can work for a week. The action is not only long lasting but fast as the medicine is directly absorbed in the blood from the skin (bypassing the stomach). 

Not only is total knee replacement a highly successful surgery, it is now a comfortable and pleasant experience as well. Today’s analgesia is safe and effective. All patients are able to walk on the day after surgery and many manage to walk on the same day. Nerve blocks, LIA and Pain Patches are so effective that they have made painless knee replacement a reality today.

Sunday, September 13, 2015

Self Preservation

How often have we seen a personal crisis ruining life? A young man just managing to settle down in life suffers a heart attack! He now faces a prolonged recovery and loses his job. Medical expenses coupled with a loss of income push him into a financial crisis. A young woman juggling her job and family life suffers an accident. A slow recovery means she cannot look after her children. All of us dread a personal crisis but what do we do to prevent it? We must think about self preservation. We must take precautions to avert a potential crisis!

An accident is top on the list. Accidents can occur in a variety of places. They can occur on the road, at home, at work or when travelling. The most common and the most dreaded are road accidents. The road conditions in many developing countries are pathetic and accidents occur rampantly. Yet I see few people thinking about prevention. Wearing a helmet is a simple basic precaution which will save a person from a potentially lethal or paralysing head injury. It is the difference between getting up and walking away from an accident versus an injury which may  lead to permanent disability and handicap if not death. The same applies to wearing a seat belt in a car. Seemingly simple, easy and effective precautions and yet many of us don't do it! Why? Because we don't think about life preservation untill it's too late. Following road rules (like using an indicator or not cutting lanes), avoiding rash driving and speeding, stopping at signals, keeping the vehicle well maintained and regularly serviced go a long way in accident prevention. Talking on the phone while riding a bike or driving a car is another recipe for a catastrophe! What about accidents at home? In the kitchen, be careful with the cooking gas! Old malfunctioning pressure cookers can burst, hurriedly used sharp knives can cut fingers and hot utensils and boiling oil/water can burn. The other danger zone at home is the bathroom. Make sure the bathroom floor is non slippery. There should be support handles for old people to get up. Beware of sharp shelf edges which could injure if one falls.  Don't climb on a chair to reach for a high shelf or clean the fan, use a stable ladder. The same rules apply for the work place or when travelling. We must be extra careful when travelling. An accident in a foreign land can be particularly nasty as we are helpless and often end up with less than ideal medical care.

The next is a medical crisis. We cannot control all the factors that lead to illness! But we can definitely control some of them. Young people get so busy with work and family that they don't have time for health preservation. The modern motto is to work hard now and enjoy the fruits after retirement. But reality is quite the opposite. By the time they retire,  people are bogged down with so many medical problems that their old age is nothing more than suffering, pain, doctors visits and a long list of medicines. Little does one realise that the efforts to achieve a healthy old age need to start when one is young. The idea of an investment which will pay returns in the future appeals to all but they are unable to apply the same logic to health. And yet, the truth is that investing in health remains the most profitable proposition. What factors can one control? Most critical is to stay away from addicting substances like cigarettes, alcohol, tobacco and drugs. These substances guarantee a life of suffering and a miserable old age. Beyond that, a healthy lifestyle boils down to two main factors - diet and exercise. I have written a number of articles on diet and exercise. Interested readers can access them on my blog - A good diet is about good quality foodstuffs and portion control. We must educate ourselves about which food is good for us. We ought to consume more protein and fibre (vegetables and fruits) and less carbohydrates and fats. We need to differentiate between good carbohydrates (chapati) versus not so good carbohydrates (rice) versus bad carbohydrates (potato, bread, maida, cake, jam, biscuits, cold drinks, sugar, mithai, ice cream, bakery products, chocolates and sweets). Stay away from bad carbohydrates. They are poor quality foodstuff. Portion control remains the key to weight reduction. Amount of food to be consumed in each meal should be decided before we start to eat. Eat only small amounts of food for lunch and dinner and compensate by having healthy snacks in between. A heavy meal neutralises the benefit achieved from a long period of starvation or a session of exercise. We must eat slowly to feel satiety with seemingly small quantities of food. Make it a habit to read the ingredients label on food packets to look for hidden sugar. As a thumb rule, food cooked at home will always be healthier than eating out. Be careful when eating outdoors or when travelling as chances of ending up with an upset tummy and loose motions are high. For exercise, do activities that you enjoy! There are no set rules. Choices are plenty from walking, running, cycling, swimming, aerobics, going to the gym or doing yoga. Remember that the only bad workout is the one that didn't happen. Aim to do some exercise for at least half hour, 5 times a week. Ideally one needs to exercise for an hour every day. Today people lead stressful lives, eat poorly, avoid exercise and buy medical insurance. The smart choice would be to work towards health and not ever need insurance.
The last aspect of illness prevention is timely screening for silent diseases and treatment of medical problems. Problems like blood pressure, diabetes and heart disease may not result in any symptoms for many years. An early diagnosis is crucial for preventing permanent damage. So everyone must get themselves screened for these illness' on a regular basis. It does not end with screening. One needs to to take proper treatment of his/her illness. For hypertensive patients, blood pressure should be controlled. For diabetes, blood sugars should be controlled. A diabetic patient must own a home blood sugar testing machine and must check blood sugars every week. Timely and regular intake of medicine coupled with regular testing and doctor's follow up is essential. 

A mention must be made here about the weekend warrior. These are the people who indulge in contact sports like football only on the weekends. Such sports require a high level of physical fitness which can come only with vigorous daily exercise. Those who don't exercise have weak muscles which offer poor protection to the joints. Hence the weekend warrior is much more prone to injury to the shoulder, wrist, knee or ankle than the physically fit person. Those who don't exercise daily are better off avoiding weekend sports.

Self preservation is an awareness that must be cultivated in the mind. A constant vigil will reduce the chances of a potential tragedy. Simply put it is the difference between happiness and suffering. The choice is really ours to make. Is it worth riding a bike for thrills or spending all your time at work or gorging on meals till your shirt buttons pop? We ought to rely on ourselves to look after our health rather than medical insurance ...... prevention will always remain better than cure!!

Thursday, July 02, 2015

The Secrets to losing weight…

Many want to lose weight and many need to. Many try but few succeed. What is the secret of their success? Is there one secret or are there many? Do doctors know all the answers? Maybe, but aren't there lots of obese doctors around? 
In my practice I have had the opportunity to speak to both types of people; the ones who have lost weight and the ones who have failed. I myself have struggled for many years to lose weight only to find success recently. So what are these secrets? 

Secret 1: Sincerity. People who successfully lose weight have a deep commitment and sincerity in their effort. It is akin to a project that they have taken up and need to see it to completion. They work hard to lose weight, they have pride in their effort and they celebrate their achievements. Quite often the commitment comes due to a life altering mishap that they have suffered like a heart attack or a complication from diabetes. It is only after a major near death experience do they realise how fragile life is and how much they have taken for granted. I urge readers to take weight loss seriously and not wait for their wake up call!

Secret 2: Exercise or Diet? Is dieting enough to lose weight? or is exercising enough? or do we need both? the reality is that diet is far more crucial to reduce weight than exercise. Exercise helps but diet is the key. Those who exercise but continue their usual eating habits almost never lose weight. Of the weight one loses, 75% will be due to changes in diet and 25% will be due to exercise. 

Secret 3: Quality of food. Is it acceptable to buy petrol mixed with water? We are so particular about quality of the things we buy, however we stop thinking of quality when it comes to food. We are ruled by taste. What tastes good is good. Its time to stop and think about what we consume. We ought to eat only quality food. We should avoid deep fried foodstuff. We should also avoid artificial sugar. Avoiding sugar doesn't stop at adding Splenda to tea. One cannot imagine the extent to which artificial sugar has infiltrated our eating habits! Biscuits, chips, packaged snacks, cakes, chocolates, sweets, mithai, cold drinks, ice creams etc etc are all loaded withartificial sugar. This modern sugar stresses the body's mechanisms to control blood sugar. The body converts all this excess sugar to fat and stores it, resulting in a pot belly. The hotel industry, the biscuit manufacturer, the bakery, the chocolate industry, the Paani-Puri Wala or the Wada-Pav Center are not interested in your health. They thrive on our weakness for taste. So when I say avoid fried foods and artificial sugar, I really mean one must avoid eating packaged food (what is typically stocked at a Kiraana store) and one must avoid eating outdoors. Home cooked meals will always have the quality you are looking for! In addition to this we must reduce our consumption of the GREAT FOUR! They arerice, potatoes, pasta (and other maida products) and bread (bakery products). These products are similar to sugar and have high carbohydrate content which will be converted to fat. Once one learns to avoid these poor quality foods, what remains is all healthy. Wheat (or jowar, bajra) chapatis, dals, vegetables, meat (in limited quantity)  and nuts are healthy to eat. To this we can add cereals(without sugar), muesli, oats, milk and eggs. Milk products without sugar like dahi and chaas are good. The sugar in fruit is natural and far far superior to artificial sugar. One can safely consume all types of fruits unless diabetic. Raw vegetable salads (without unhealthy mayonnaise dressings) are a complete winner. Now with this knowledge lets assess the quality of some of our foodstuffs - first the seemingly harmless 'wada-pav'. It has got potato, maida and bread. Plus it is deep fried. Its a total disaster, isn't it? Lets see another scenario: a visit to MacDonald's. What do we end up eating? A fried patty in bread? Still not so bad one may feel. But lets see the accompaniments. A sugar filled cold drink and fried potato chips! Another disaster. What about the people who drink many cups of tea in the day? Not much harm done? Actually lots of harm done if the tea has sugar! All the sugar just ends up in one's belly. 

Secret 4: Portion control. Now we come to the most difficult part of weight reduction. We may be very motivated to lose weight and we may be willing to let go of our tasty snacks, but are we ready for portion control? What does one mean by portion control? It means that one has to control the quantity of food consumed at a particular time.  This is very critical for the major meals which are lunch and dinner. I have devised the 1 to 2 rule. For lunch or dinner one should not consume more than 2 chapati's or 1 chapati and 1 small helping of rice. Obviously this is hugely difficult as we will feel hungry. There are 2 secrets here to succeed. First is to reduce the speed of eating. It takes time for the stomach to send a signal to the brain that it is full. If we eat too fast, we have already over eaten by the time the signal reaches the brain. Vice versa if we eat very very slowly, we will feel full even with seemingly small quantities of food. One should chew slowly and swallow only after chewing the food completely. One should not put another morsel in the mouth till one has swallowed the previous morsel. The second secret is to eat healthy snacks in between meals. So one can have a fruit or a salad or some nuts at 11:00 am and in the evenings at 4pm and if required even at 7pm. If one feels hungry after dinner, one can have a healthy snack at 10pm. This way we can counter the hunger we will feel because of portion control. I must emphasise here that the snack must be healthy! People have a habit of skipping meals and then binge eating at dinner time. They feel proud of skipping a meal and think it will help reduce weight. Then they feel the need for a reward and feel justified in eating a heavy meal. Little do they realise that all the benefit from skipping a meal is not only lost in the binge eating, in fact more harm is done than good. Binge eating can never result in weight loss! The tough truth is that we can never have a heavy meal ever, if we are serious about weight loss! 

This is a sure shot way of losing weight! Many of us feel that we don't eat much food, we eat healthy and still we don't lose weight! But I request you all to introspect sincerely! You must take into account exact quantity of food consumed rather than your best estimate. You must look at the quality of food as well. Learn to pay attention while eating and actually count the chapatis and helpings of rice. Also every small unhealthy snack eaten in between, like a chocolate, a biscuit, a piece of cake or a few chips, matters! 
Armed with these secrets, I am confident that all of us can start losing weight and move towards a more healthy and happy life! 

Wednesday, January 28, 2015

My Website

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Friday, January 16, 2015


Many patients with knee pain feel helpless when their surgeon advises a knee replacement. There must be some other option! Won't medicines help or exercises or braces? How about alternative medicine like Homeopathy or Ayurveda? Maybe magnetic therapy, laser or acupuncture can reduce the pain. Then starts the long and fruitless journey from one doctor to another and from one treatment to another. Patients end up spending lots of money and wasting lots of time only to realise that nothing works. I see patients going through this cycle again and again. Patients need to understand why knee replacement is the only ultimate solution. If the knees are in a early stage of arthritis then obviously don't go for surgery. But if the knees are badly damaged and the legs have become crooked, don't waste more time. Go for surgery! 

So why does knee replacement work when everything else is failing? The ends of the bone which form the joint are covered by a smooth lining called cartilage. This allows for friction free, painless motion. In arthritis, the cartilage gets damaged, eroded and eventually completely destroyed. Cartilage tissue has poor ability for repair and regeneration. No available medicine (Allopathic, Ayurvedic or Homeopathic) can induce cartilage growth and repair. Similarly no treatment method like traction, braces, acupuncture, laser or magnets have any effect on cartilage. These modalities act as mere pain killers. That is why they fail. The second problem in arthritis is the crooked bones or bow leg deformity. Once the legs become crooked at the knees, a vicious cycle ensues. The deformity progresses irrevocably till walking becomes impossible. Again no medicine or treatment method can straighten the knees. Till the legs become straight the problem of pain will not go away. 

Knee replacement solves both these core issues beautifully. Knee replacement replaces the damaged cartilage with a new artificial joint surface. This surface is made of polished alloy which is nearly as smooth as cartilage. Knee replacement also corrects deformity completely. Crooked legs become straight after surgery. This is the basis of success of this procedure. Replacement of cartilage and correction of deformity. No other treatment has even come close to solving these 2 problems. With modern technological advances, knee replacements last for 15 to 20 years providing a truly effective and lasting solution. 

I see patients procrastinating and delaying their decision for surgery because of fear. It's unfortunate because time is wasted in suffering. They become slaves to pain and cannot lead productive lives. Knee arthritis today is a treatable disability. No one needs to suffer. Choose the surgeon and hospital wisely and go ahead. After surgery patients forget that they ever had knee pain! 

Friday, October 17, 2014


Neck pain is common and most of us have experienced it at some point. It brings with it the anxiety of a serious illness like spondylitis!  Fortunately most cases of neck pain are not due to spondylitis. One of the commoner and less understood causes is trapezitis!
The Trapezius Muscle
The trapezius is a large muscle that forms the nape of the neck. It extends from the neck to upper back and fans out to the shoulder. The muscle has many functions but the most relevant one is to lift the head to look upwards. Any work that requires the head to be stable like working on a computer, reading a book, working on a kitchen table, driving for long or watching television etc. brings the trapezius into action. With our modern lifestyle, one can imagine the extent of overuse and often abuse this muscle faces!
Fatigue and inflammation of this muscle leads to trapezitis. The symptoms are typical. It starts with mild pain or discomfort in the nape of the neck at the end of the day. Initially a good night’s rest solves the problem. In the early stages, massaging the muscle or a hot water bag brings relief. As time passes, the attacks become more frequent and painful. The muscle goes into spasm and feels hard to touch. The pain becomes constant and is not relieved easily. Eventually the pain and spasm can become unbearable. At this point, the patient seeks medical intervention and needs muscle relaxant tablets to decrease the spasm. Understandably this disorder is confused with spondylitis. However it is a different illness with a different approach to treatment.
An acute episode of trapezitis is treated with anti – inflammatory, muscle relaxant tablets. In addition, patients require physiotherapy modalities, a soft cervical collar and rest. A physiotherapist will use interferential therapy (IFT) and short wave diathermy (SWD) to reduce the spasm. The severe pain settles in 7 to 10 days.
We cannot avoid our daily routine and daily work! So how do we protect our trapezius from fatigue and bouts of inflammation? Firstly one must strengthen the muscle so that it can take the rigours of our routine. One needs to do neck and shoulder exercises regularly. Here I will emphasise the importance of doing exercises that involve the hands going above the head (overhead exercises). Swimming is an ideal exercise for trapezitis and regular swimmers seldom get such pain. The second philosophy of treatment concentrates on the ergonomics of work! Poor postures are ripe environment for trapezitis. Working with a laptop on bed or watching televisions lying down are a strict NO. Chairs at work should have a lumbar support. One should sit erect. Avoid slouching. The computer screen should be at eye level. A break is necessary every 20 minutes during long hauls in front of the computer or long drives. One should get up, move around and stretch the neck, shoulders and back.   

Trapezitis is a modern day epidemic brought on by our lifestyle. Awareness of the issue and a logical approach to the problem will help most people avoid it all together!  

Wednesday, August 20, 2014

The Sunshine Vitamin

As research continues to shed new light, scientists are realizing that vitamin D has many critical functions in the body. It works more like a hormone rather than a vitamin and affects the performance of almost every cell of the body. 

1.      We all know that vitamin D is critical in maintaining adequate amounts of calcium and phosphorus in bones and teeth. In simple words it helps keep bones and teeth strong and protects against osteoporosis and dental caries. However we need vitamin D for many other roles. 
2.      It is important in the regulation of the immune system. It produces anti - bacterial and anti- viral substances and helps fight infections like common cold and influenza. 
3.      It helps to keep the brain functioning normally in later life and prevents mental illnesses like dementia, Alzheimer's disease, schizophrenia and depression
4.      Vitamin D helps maintain ideal body weight. Those with vitamin D deficiency are likely to be obese and fail at attempts to reduce body weight via diet and exercise. 
5.      It plays a role in preventing inflammatory disorders like Rheumatoid Arthritis (multiple joint pains), inflammatory bowel disease, psoriasis and eczema
6.      It reduces the frequency and severity of asthma and allows for speedy recovery from tuberculosis
7.      It reduces the risk of heart attacks and protects against high blood pressure and diabetes. 
8.      Vitamin D has recently been shown to be critical for a normal pregnancy. It prevents pregnancy related illnesses, reduces risk for premature deliveries and reduces infertility
9.      It reduces risk of all types of cancer. 

What are the daily requirements of this valuable vitamin? Most authorities recommend around 600 IU of vitamin D daily. Infants less than one year old need 400 IU and adults above 70 years of age need 800 IU.

Now that we realise the critical benefits of vitamin D, we must find out how to get it! Unfortunately getting vitamin D from diet alone is an uphill task. Few foodstuffs are a good source of vitamin D. Vitamin D rich foods include beef liver, egg yolk, certain types of cheese and certain types of fish. One egg gives approximately 40 IU of vitamin D. Unfortified milk (milk is fortified with vitamin D in America and European countries as a government initiative) is a poor source of vitamin D. 
Sunlight is an additional source of vitamin D. It is important as dietary sources of vitamin D are few. Ideally we should get 90% of our daily vitamin D requirement from sunlight. UV rays in sunlight convert a type of cholesterol found in the skin to vitamin D. Modern lifestyle has limited our exposure to the sun. There are many variables that affect the ability of the skin to produce vitamin D. As a result it is difficult to recommend how much sunlight is enough. Most authorities recommend between 5 to 30 minutes of sun exposure to your unprotected face, arms, legs or back between 11 am and 3 pm two to three times a week.  Early morning or late evening sunlight does not work as UV rays are not able to penetrate the atmosphere. Ability to produce vitamin D also depends on the colour of the skin. Fair skin people need less sunlight than darker ones in whom melanin (skin pigment) restricts entry to UV rays. Exposure to sunlight should be direct as UV rays are restricted by glass (window panes) and sunscreen. Weather conditions, cloud cover, pollution and clothing also affect vitamin D production in the skin. At the same time too much sun exposure is detrimental.

Certain groups of people are at higher risk for vitamin D deficiency. These include pregnant and breast feeding women, children between 6 months and 5 years, persons older than 65 and persons who keep their skin covered or stay indoors (don't get enough exposure to sunlight). At risk individuals need to discuss with their doctor and get vitamin D supplements. In America and some European countries, milk and fruit drinks are fortified with vitamin D.

Few sources of vitamin D in diet coupled with poor exposure to sunlight and lack of fortified foodstuffs (especially in India and Asia) makes huge sections of the population at risk for vitamin D deficiency. Everyone should get their blood levels of vitamin D tested. If deficient, appropriate changes must be made in lifestyle to increase exposure to sunlight. If that is not possible, vitamin D supplements are necessary.

Vitamin D deficiency is a modern and very real epidemic that has silently contributed to increase rates of osteoporotic fractures, heart attacks, influenza, rheumatoid arthritis, cancer and premature births! The general public needs to become aware of this hidden deficiency and take immediate corrective measures!