Low Back Pain

Most people suffer from back pain at some point in their lives. Nowadays there is a lot of anxiety associated with back pain. The anxiety is because we constantly hear of patients undergoing an MRI for back pain and then surgery! Yes, there are surgeries that benefit certain conditions affecting the lower back and MRI is a wonderful tool that helps doctors do a detailed study of the back. But very few patients need an MRI and even less need surgery.

The spine is a complex structure of the human body. It starts from the brain and extends to the pelvis. It comprises of the neck, the upper back and the lower back. The back is made up of individual bones called vertebrae. Each vertebra is separated from the other by discs. The vertebrae conceal the spinal cord which is a downward extension of the brain. There are in addition a number of muscles in the back which make the vertebral column a mobile structure (so you can move your neck and bend your back).

In childhood the back is mobile, flexible and pain free. As a person grows older, the back ages as well. The discs degenerate and the joints wear out (arthritis and spondylitis). This is a natural process that happens to all people. Eventually in old age the back loses its flexibility and becomes stiff. Few lucky people undergo this natural process with little or no pain. Most of us however experience pain at some point during this course. This pain is the typical mechanical pain which most of us have had. It is the pain that is episodic (comes and goes). It is aggravated by exertion … sitting or standing for long periods of time. It is the pain that comes at the end of a long tiring day or during a bumpy ride. It is the pain that we get when we get up in the morning or get up after sitting for a long time. That is the commonest type of back pain and the type that we should not worry about! It does not need an X-ray and definitely not an MRI. We as doctors see this pain more nowadays because of poor lifestyle which includes unearthly working hours, poor postures while sitting, obesity and a lack of physical exercise. People who have this pain need to take rest till pain subsides, do back strengthening exercises and work on their postures while sitting, working and lifting weights. Unfortunately many such patients are unnecessarily over investigated with X-ray and MRI and some are even advised surgery! Patients need to be careful because surgery for this pain fails.

Another type of pain in the lower back occurs because of a problem elsewhere. Sometimes patients with a viral illness have fever, severe body ache and low back pain. This type of back pain is part of the illness and will disappear when the patient recovers from the viral fever. Many women get severe low back pain during pregnancy and after delivery. This is because of the strain of carrying the baby and hormonal changes. Such pain may continue for many months after delivery. But this pain is temporary and will subside on its own and one should not worry about it. Some women also get back pain during their periods. This pain is not related to the back and if it is very severe one should see a gynaecologist. At times a kidney stone causes back pain. This pain is intermittent, colicky and travels to the groin. It is usually very severe and your doctor will be able to diagnose it easily and guide you accordingly.

Which then are the types of back pain one should worry about? If the back pain is sudden and severe or unbearable, then obviously one needs to see a doctor. Most of such pains are due to a severe muscular sprain and these patients get better with rest and medication. Some of these patients have more serious problems like a slipped disc. In older patients the severe sudden pain may be due to a fracture of the fragile vertebral bone (osteoporosis).
One type of back pain that needs to be investigated is the one that doesn't get better. Especially if it interferes in the persons daily life, his/her job or recreation. And especially if routine treatments have failed.
Many times back pain is associated with shooting pain in the legs (sciatica). This is due to nerve irritation usually caused by a slipped disc.Again most patients with sciatica get better with non surgical methods of treatment and very few need an MRI and surgery.
Back pain after an accident needs to be assessed to rule out fracture or other injury.
The most serious types of back pain are due to infection or tumours. Luckily both these conditions are also the rarest.

To summarise low back pain is common. Many people suffer from it. The commonest type of low back pain is related to lifestyle issues like poor posture and lack of exercise. There is no reason to be overly anxious about low back pain. Don't be in a hurry to spend your hard earned money on an MRI!

...ANYTHING BUT SURGERY!! (PART 2)

In the last article, I discussed treatments for knee arthritis that have poor results but are aggressively marketed to make quick profits! These treatments are experimental or commercial, many are non scientific and most result in a huge waste of money for the patient.

So if these treatments do not work, which ones do? What does authentic scientific research say? Why is this scientific research so important? If a particular medicine works for one person without side effects, can it be recommended for all? You may think why not? We do it all the time! Most of us have seen some medicine or treatment work very well in our friends or relatives. Then we start recommending that treatment to everybody! What’s wrong with that?

The problem is that a treatment that works for one person may not work for another. A treatment that is safe for one person may not be safe for another. That’s where scientific trials and statistics come in! If there are hundred patients, scientific evidence tells us if a treatment works for all 100 or it works for 75 out of 100, or 50 out of 100 or for only 10 out of 100.

Now let’s consider the treatment that worked for our friend. What if that treatment worked only in 10 out of 100 and caused side effects in 80 out of 100? Our friend was lucky, wasn’t he? With this information, will you start recommending this treatment to everybody? I’m guessing – NO!

There are multiple scientific review committees all over the world who have formed recommendations for knee arthritis by looking at research, evidence and statistics. The effectiveness and safety of these recommendations has been solidly proven. So what are these recommendations? These recommendations are for osteoarthritis of the knee. They are not for arthritis affecting other joints or for rheumatoid arthritis which is different type of arthritis.

Recommendation – patient education. Education by the doctor, physiotherapist or counsellor or patient self education from books or internet tremendously helps patients with arthritis. One may wonder how? Most fear and anxiety is out of ignorance!  Patients who learn about the problem, how and why it has happened to them, what will make it worse, what will make it better etc are less anxious. And as anxiety goes down, so does pain. Patients with knowledge look after themselves better, are more likely to follow advice and treatment recommendations and stay away from quack therapies.

Recommendation – weight loss. Weight loss is strongly proven by multiple studies in different countries to help decrease pain in patients with knee arthritis. I have written about weight loss in a previous article. It’s not easy to lose weight! But it’s not impossible like most of my patients think. It is a full time job. It requires huge efforts and 100% commitment. A conscious effort to adopt a healthy diet, reasonably restrict quantity of food consumed and daily exercises will result in weight loss in 9 out of 10 people. The problem is that we are lazy. We don’t want to put in any effort. We want some magic medicine or some belt or some therapy to melt the fat away. Unfortunately none of these work!

Recommendation – exercise. Exercise is a recommendation that I give all the time. I have written extensively on exercise in the past. I have dedicated multiple articles on the subject. This recommendation is backed by solid scientific research! Exercise is the magic pill you are looking for. It’s cheap and has no side effects! And it works. And it will work in all patients. But a lot of my patients tell me ‘exercise didn’t work for me!’  Exercise does not work in 2 situations. First is when arthritis is very advanced. And the second and most common reason is that patients don’t do exercise properly. Exercise is something which is taken very lightly. People will go to driving school for a month to learn to drive their car but will refuse to go to a physiotherapist for 10 days to learn the right way to do exercise. People will research the internet thoroughly to find a good doctor but will not research to find the different types of exercise that will benefit them. Exercise is a gold mine, my friends. The physiotherapist and the doctor will only show you the way... they will only show you the tip of the iceberg. It’s up to you to dig deeper after that. 10 minutes of doing a few repetitions when you wake up in the morning doesn’t help. You have to spend effort and time to achieve results.

Recommendation – braces and footwear modification. There is no strong evidence in scientific literature for or against braces (knee caps and belts) and footwear modifications. There is no harm in trying braces! Patients who find benefit in braces should continue to use them.

Recommendation – assistive devices for walking. Again... a very effective recommendation. Using a walking stick decreases pain and increases the distance that the patient can walk. It would also decrease the requirement for medication, buy time and postpone surgery. But most patients refuse to use a stick because of some misplaced sense of shame! As a patient, I would give little importance to what other people think especially because I am suffering and others are not!

Recommendation – medication. So which medications are recommended for arthritis? Is there a medicine that will cure the problem? The answer unfortunately is NO. No medication, whether it is allopathy, ayurveda, homeopathy or Chinese has been conclusively proven to cure knee arthritis. Lot of them ‘claim’ to cure arthritis but there is no concrete scientific evidence. That means that the chances that a particular medicine will work for you are as good as the chances that drinking a glass of water will work! Another common misconception is to take calcium supplements for arthritis pain. Osteoporosis or weak bones is a problem that accompanies arthritis or joint inflammation. Calcium supplements are used to treat osteoporosis. They have no role in the management of arthritis.

Medications are however recommended to control the pain of knee arthritis. The main medication is Acetaminophen (Crocin). Acetaminophen is a mild analgesic with a very good safety profile. It does not cause acidity in majority of people and does not affect the kidney even with long term use. It has been scientifically proven to be safe even if used for a long period of time. Other analgesics (pain killers) can be used as short term treatment to control attacks of severe pain. Topical analgesics (pain killer ointments) are also strongly recommended and useful. They are also safe for long term use. What about Glucosamine? There have been extensive studies carried out on the effects of glucosamine. The results say that all it does is give relief of pain in some patients. It does not cure the problem or cause cartilage to grow back. It is safe. The recommendation is to use it (if you can afford it) only if it gives relief from pain.  

 To conclude, I recommend my readers to develop a scientific outlook while assessing treatments especially new miraculous cures promoted by aggressive marketing. Here Science, Statistics and Evidence all become your friends as they protect you from being cheated of your time, energy and hard earned money!

Recommendations from

•        AAOS 2008 (American Association of Orthopaedic Surgeons)

•       OARSI 2007 (Osteoarthritis Research Society International)

•       NICE 2009 (NHS, UK)

•       RACGP 2009 (Royal Australian college of General Practitioners)

•       NGC 2007 (Singapore)

•       EULAR 2003 (European League Against Rheumatism)

...ANYTHING BUT SURGERY!!

Fear to do undergo surgery is common and well justified. Any normal person would not want to undergo knee replacement by choice and would look for ways and means to avoid surgery. While this is a sensible approach, I see many patients taking it too far. They will avoid surgery at all costs, no matter how much pain they have to suffer. Fear instilled by friends and family adds to the problem.

Many crooks are trying to make a quick buck at the expense of this fear. Newspapers, pamphlets, TV, Internet etc are flooded with advertisements of products promising a miraculous cure for arthritis. I see patients getting duped and cheated by these thugs on a regular basis. My readers call me often to enquire about the authenticity of these products!

Stem cells, oils, lasers, Cytotron, rope therapy, expensive knee injections etc are just some examples of alternative treatments being promoted. While some of these are in an experimental phase, others are plain ridiculous! None of these treatments have been proven to work.
Oils for massage, as a remedy for pain, have been around for centuries. Oils work! There is a strong scientific rationale for their use in arthritis pain. But they do not cure arthritis! At best they give some hours of relief from pain. They work better in early stages and their effect decreases as arthritis advances. I myself recommend patients to use oils. But when an oil is advertised as a cure and it is expensive to buy, then I have a problem with that oil! If you are buying a bottle of oil that is costing thousands of rupees, you are surely being cheated. Please don’t get carried away with tall claims made in advertisements. It is a big scam!

The next famous treatment is lasers! Lasers work beautifully in eye and kidney stone surgery, but have little effect on arthritis. Cartilage is a tissue that has poor capacity to regenerate and repair itself. Many people have tried a number of different ways to repair cartilage and most of them have failed. Lasers too have little effect if any on cartilage growth and repair. Besides in advanced stages of arthritis, the leg becomes deformed. Logically, till the deformity is corrected, arthritis pain can never completely go. Lasers do not correct deformity. Again an expensive treatment that doesn’t work!!

Cytotron is based on Rotational Field Quantum Magnetic Resonance – RFQMR – technology. The promoters claim that “The beams are precisely controlled and focused onto tissues ...which in turn stimulates cartilage growth in case of diseases such as Osteoarthritis or stops the tumor's growth in Cancer.” Again claims of a miraculous cure from a new, expensive and experimental treatment. There is a contradiction in their statement! How can the same therapy promote one cell type to grow (cartilage) and cause another cell type to die (cancer cells)? Whenever some therapy claims a cure and is expensive, we all should ask ourselves one question. Why has this therapy not been accepted by the international community at large? If it really worked then arthritis patients would have stopped getting knee replacements by now and cancer patients would have had nothing to fear!

Another treatment is rope therapy. Here an attempt is made to correct the deformed or crooked legs by literally pulling them straight with ropes. This has been attempted by orthopaedic surgeons in the past and is called ‘traction’ in medical terms. Traction fails to correct legs deformed by osteoarthritis. Small corrections are achieved sometimes but are lost quickly after therapy is discontinued. While on this therapy some patients experience pain relief but again this is temporary.

Stem cells have become the miracle cure for every illness nowadays! Stem cell therapy has a definite role in arthritis treatment. The procedure is known as ACI (autologous chondrocyte implantation). This procedure works very well in early stages in which the knee has a small area of cartilage loss. A small amount of cartilage is taken from the patient’s knee and it is grown in the laboratory by stem cell technology. The grown cartilage is then implanted in the defect. This therapy has shown promising results. But it only works in patients who have a defect and that too, a small one. It cannot work in advanced stages where the knee is excessively damaged and the legs have become deformed. Stem cells have limitations!              

Medicines are now available that can to be injected into the knee as treatment. Injections have a definite role and can give tremendous relief to the patient when used correctly and judiciously. But injections are unpredictable. Some patients are hugely benefitted while in others, there is no effect. Because of the unpredictable results, I would be hesitant in using very expensive injections. As a patient, one will feel the pinch if an expensive injection doesn’t work!

To conclude, arthritis of the knee is a difficult problem to solve. Fear of surgery has led patients to look for alternative cures. Many crooks have taken advantage of this situation and are selling quack treatments. These treatments do not work and are very expensive. Many patients are being cheated of their hard earned money. So I plead with my readers to be careful when looking for alternative treatments. Beware! 

  

RECENT UPDATES IN KNEE REPLACEMENT

Knee replacement is one of the most successful surgeries in all of medicine. Pioneering work in knee replacement was done in the early 70's by prominent scientists and surgeons in the US and UK. Since then knee replacement has come a long way. 

Surgeon experience has grown. Surgery is faster, more precise and with minimum errors. Anaesthesia is better. Pain management is better. All this has resulted in faster recuperation for the patient. The patient walks independently on the second day after surgery. The patient is discharged in 5 or 6 days. Replacing both the knees in one sitting is now possible and the advantages are obvious. The knee replacement prosthesis’ have undergone a tremendous evolution as well. Better prosthesis translates into better function and a longer life for the joint. Most patients enjoy a near normal knee function postoperatively with the knee bending completely. In fact for patients needing knee replacement, things have never looked as promising as they are now! 

Fear to do undergo surgery is common and well justified. Any normal person would not want to undergo knee replacement by choice and would look for ways and means to avoid surgery. While this is a sensible approach, I see many patients taking it too far. They will avoid surgery at all costs, no matter how much pain they have to suffer. Fear instilled by friends and family adds to the problem. If feel this kind of attitude is unwarranted. 

Unqualified people classically will see a result as black or white. This person selling fruit is good, that petrol pump is bad, this school is terrible, etc. There may be some truth in the statement but it can never be a whole truth. This is because life is never black or white, but many shades of grey! Let me try and explain with an example. If a surgeon did one thousand knee replacements in a year, and one surgery went wrong, he would have a success rate of 99.9%, right? Sounds good? Now let's consider the surgery that went bad. What would that patient’s relative say? He would obviously tell you that knee replacement is a bad surgery and no one should get it done (black or white response) Is he justified in making such a statement? May be. But is he saying the truth? No! 

Are we as doctors justified in denying 999 people an excellent result because of the possibility of one case going wrong? No! 

I urge everyone to take any decision rationally and sensibly. It is unwise to base your decision on one particular example. There are too many variables. Some hospitals have better infrastructure than others, some joint replacement prosthesis are better than others, some surgeons are better than others and some patients are more suitable for this surgery than others!! Do your homework well and you will be rewarded with an excellent result. 

Progress in any field is welcome and inevitable. Even though knee replacement has progressed tremendously, more progress continues. 

Computer assisted surgery (CAS) is one such recent advance. Computers have brought accuracy in all fields. May it be computerised matching of colours or computerised cut out of designs. Humans cannot match computers in accuracy. CAS improves the accuracy of knee replacement. This results in better restoration of alignment of the leg and better fitting of the components. 

Another advance is custom knee replacement or knee replacement using custom made instruments and implants. Knee replacement is about fitting components of the right size into patients. Just as a custom made suit fits far better than a readymade one… similarly custom made instruments increase the accuracy of knee replacement. For this an MRI of the patients knee is done before surgery and sent to the company (mostly abroad) The company then manufactures instruments tailor made to that knee based on MRI and ships them to us. We then use these instruments to do knee replacement with perfect accuracy and therefore better results. 

The knee has three compartments and all are involved in a typical case of advanced osteoarthritis. However in a few patients, only one or two compartments are involved. Nowadays it is possible to do partial knee replacement in these patients (uni-condylar knee replacement and bi-condylar knee replacement). These surgeries are more bone and ligament saving. Because we remove less, patients feel the knee is more natural after surgery. Also revising these implants to a total knee replacement is easier later. 

And lastly I'll just mention Robotic Surgery. Yes robots have arrived in the field of knee replacement. In knee replacement we have to cut the bone accurately to allow accurate replacement with implants. In robotic knee replacement, the bone is cut by a robotic arm. This ensures extreme accuracy and therefore superior results. Robotic surgery is still in its infancy in India. 

To conclude, knee replacement is a fantastic surgery. It is getting better every day. With recent advances, success is almost guaranteed. But every surgeon cannot do it and every hospital is not equipped for it and every patient is not ideal for it! Do your homework! 

WHEN NOTHING ELSE WORKS...

Most patients with advanced knee arthritis are still looking for that elusive cure. They are unable to accept that they need surgery. They strongly believe that something or someone somewhere can solve the problem with some magic medicine. They will keep trying fancy treatments like acupressure, rope therapy, braces, etc. The list goes on and on.

In all joints like the knee, the bone ends are covered by a smooth lining called cartilage. Cartilage ensures smooth, painless knee movements. Damage to the cartilage marks the beginning of arthritis. In advanced cases the cartilage lining is completely eroded. The bone below the cartilage gets exposed and bone starts rubbing on bone. This leads to severe pain. The real problem here is that cartilage does not regenerate or grow back. No matter what you try or which medicine you take, the original cartilage doesn’t come back. As the disease progresses and more and more cartilage is lost, the leg starts getting deformed at the knee. This makes matters worse. A crooked leg condemns the patient to more pain and disability. This pain can never go till the cartilage comes back and the leg becomes straight. Both these goals are impossible with non operative treatment!

So why does knee replacement work when everything else is failing? To understand this we need to understand the history of knee replacement. Researchers, scientists and doctors worldwide were struggling to solve the issue of arthritis since centuries. Initially they tried to replace the cartilage with other substances from the patient’s body like fat, fascia etc. But none of the structures they used had the qualities of cartilage and they would breakdown very fast and the procedure would fail. Then in the 60’s a genius called Sir John Charnley made a few landmark discoveries. He invented an extremely strong plastic called high molecular weight polyethylene. This plastic resembled cartilage very closely. The friction between this plastic and metal was as low as between two bones lined by natural cartilage. In addition to its fantastic friction properties, this plastic was also extremely strong. The other landmark discovery was of bone cement. This cement anchored the artificial joint to natural bone so strongly that the union lasted many years. These two discoveries changed the face of replacement surgery. Sir John Charnley designed an artificial hip joint which lasted 10 to 15 years. This was the first successful replacement. Using these landmark discoveries scientists started working on knee replacement. Finally after many attempts they achieved success and durable artificial knee joints were designed.   

Knee replacement works because it achieves both the desired goals. Cartilage is replaced by a strong and durable ‘cartilage like’ plastic. Furthermore the deformity is completely corrected after the surgery. As the damaged cartilage is replaced, the patient gets complete relief of pain. And as the leg becomes straight, this relief lasts many, many years. 

So does knee replacement work? Yes! It is one of the most successful surgeries of modern medicine. But it is a complicated surgery. To work it has to be done properly. The surgeon has to learn the technique and spend an adequate time in training. A well trained, experienced surgeon will do a good job almost every time. Infection is a constant threat to any surgery. In replacement surgery, infection can ruin everything. So in addition to a good surgeon, you need a good operation theatre.

These two factors are the reason, this surgery fails. An inadequately trained surgeon in a poor operation theatre is a recipe for disaster. Because of these issues, this wonderful surgery has earned a bad name.

 Instead of avoiding surgery because of fear which stems from a lack of awareness, I encourage patients to educate themselves regarding the pros and cons of this surgery and gain benefits.

What you KNEEd to know...

What is knee replacement?

Knee replacement is a surgery in which around 1cm of diseased bone and cartilage is removed and replaced by artificial metallic caps. The new joint surface restores normal joint movements and eliminates pain.

When is a patient ready for knee replacement?

1.       When pain is unbearable and constant

2.       When walking even short distances takes a lot of time and effort

3.       When the patient needs a walker or stick support to walk

4.       When the patient stops going out of the house for recreation, work or to attend social functions in fear of pain

5.       When deformity or limp becomes very severe

What are the advantages of this surgery?

1.       Complete relief of pain

2.       Complete correction of deformity

3.       Patient walks independently without help of a stick

4.       Patient can walk as much distance as he/she desires

5.       Patient can climb stairs

How long will a knee replacement last?

Knee replacement typically lasts for 15 to 20 years after which it may become loose and need a revision surgery.

How long will a patient have to be in bed after a knee replacement?

A patient usually walks within a couple of days after the surgery. The patient is able to go to the toilet on his/her own whilst in the hospital itself.

Is this surgery painful?

Most patients experience postoperative surgical pain. This pain can nowadays be well controlled with modern pain management techniques.

How long is the recovery?

Most patients need 1 – 2 months to recover completely and experience a pain free joint

What are the complications of this surgery?

Infection is the most feared complication. With modern theatre setup and discipline, infection rate is less than 0.6%. All other complications are rare.

Armed with this knowledge, the arthritic patient need not suffer anymore!

Knee Replacement at concessional rates at Inamdar Hospital, Pune

http://inamdarhospital.com/index.html

The Ultimate Vaccine

We all know about vaccines. A vaccine is any preparation used to confer immunity against a specific disease.  It’s an amazing discovery of medical science and a very appealing concept indeed. You take the vaccine and you will be protected from the illness forever. As soon as a new born baby is born, parents are rushing to the doctor to get him/her vaccinated.

Wouldn’t it be wonderful if there was a vaccine for blood pressure or diabetes? Or a vaccine for knee arthritis or spondylitis?

What if I tell you that there is such a vaccine? And it’s not a new invention. It’s been around for some time. And better still, it’s free! Would you believe me?

Believe it or not, it’s true. Such a vaccine does exist! .... Unfortunately we have forgotten about it. This vaccine is EXERCISE!

Imagine that you have just bought a new expensive car or jewellery that you have been wanting for a long time. You will look after it well. The car will be cleaned and serviced regularly. The jewellery will be kept carefully in a box. Your body is a gift from God! Close your eyes and ask yourself, have you been good to your body? Have you looked after it? If you don’t maintain your car, it will give you trouble. It won’t run properly. But still most people will look after their cars far better than they will care about their own bodies. A bad car is an inconvenience, but a bad body means suffering!!

A healthy body is crucial to be able to enjoy life. All the money in the world is a waste, when you don’t have health. Without health, you cannot enjoy your new car or house or your vacation. And at times it is too late. You cannot even buy health. So how do you vaccinate your body against disease? How do you look after this beautiful gift?

Prevention is better than cure. If you don’t want to suffer with ill health and disease, you have to act now. Physical fitness with exercise is the best way to avoid lifestyle related illnesses like blood pressure, heart disease and diabetes. And it only works if you do exercise regularly throughout life.

As young people we get busy with work. We want to work hard so that we earn and secure our future. Many of us get obsessed with work. We lose track of priorities and we lose perspective. What is the point of working so hard and abusing your body? You may or may not end up becoming very rich, but you definitely will end up with a lot of illnesses. So all the hard earned money is then spent to become better and many times in spite of the money spent, you remain ill.

So my sincere request to young people is to not lose the wonderful days of their youth in work. Everything should be in moderation which is true also for work. Work is important and everyone has to work but draw your limits. The human body is not designed to work 24/7. Earn a little less but enjoy it by remaining healthy. Extra money earned is useless as it is at the cost of health.

What type of exercise should we do? There are three basic types of exercise. The most important exercise is aerobic exercise. Aerobic exercise is any activity that increases your heart rate (you can hear and feel your heart beating fast) and your breathing rate (panting). Regular aerobic exercise is the best vaccine against lifestyle disorders. Everybody cannot do aerobic exercise. Especially if you are a heart patient, you need to check with your doctor before starting aerobic exercises. Those who are not accustomed to aerobic exercise should start slowly. Eventually one should increase to the recommended 30 to 40 minutes of aerobic exercise daily. Some examples of aerobic exercise are brisk walking, jogging, running, cycling, swimming and rowing. Aerobic exercises have become famous as ‘cardio’ exercises in modern gyms. While doing exercise, it is important to remember to go to the next level of difficulty, just like a student progresses to the next grade or standard in school. Cycling is a safe exercise for those suffering from knee pain.

The next exercise is Yoga or stretching exercises. These exercises are good for the health of joints and they are a vaccine for arthritis and spondylitis. Yoga exercises ensure that all joints move through their complete natural range of motion.

The third type of exercise is individual muscle strengthening exercises. These are exercises which ‘body builders’ do. Strong muscles protect joints from damage. Most people do not need to use weights. Anti gravity muscle endurance exercises are sufficient.

Many patients ask me if yoga is enough. All three types of exercises are important. So yoga on its own is not enough. Yoga will complement aerobic exercise to give you a better result.

Many patients tell me that they are working in the office or the kitchen all day and that is enough exercise! Physical work is better than sleeping in bed but it is poor exercise. Work generally results in exertion and exhaustion rather than exercise. Those who exercise regularly develop enough stamina so they can work harder, faster and more efficiently without getting tired.

Moreover exercise comes with pleasant side effects! People who exercise feel a sense of pride and satisfaction like the proud owner of a new diamond set. This translates into a positive energy in their daily lives. So they work better, they maintain better relations with their loved ones and they are more happy.

If you are one of the people who says ‘I don’t have the time for exercise’ then I feel sorry for you. If there is time to eat, if there is time to sleep, if there is time to pray, if there is time to watch television or read a newspaper then there can be time for exercise. It is a question of priority and commitment.’ Where there is a will there is a way’  

The worst enemy of exercise is laziness. It is an enemy of many things. There is no glory in laziness. We have to fight this enemy in every living moment of our lives!

So my dear readers, if you want the gift of good health then you have to work for it. Get up and get going and grab that vaccine!

Update (11/04/2020)-

I had written this way back in 2012. Today the world is being threatened with the COVID19 pandemic. People are looking for immunity boosters. It’s not going to improve with some magical pill or supplement. My experience has taught me that exercise is crucial to build immunity to fight infections. It’s the disciplined people who pay attention to their nutrition and who exercise regularly that have the best chance to beat the corona virus!

In a review published in 2019 (Journal of Sport and Health Science 8 (2019) 201À217 - The compelling link between physical activity and the body’s defense system. David C. Nieman, Laurel M. Wentz), the authors concluded

With near daily exercise, the changes to the bodies white blood cells enhance immune defense activity and metabolic health.

Studies consistently support the inverse relationship between moderate exercise training and incidence of URTI. These data led to the development of the J-curve model that links URTI risk with the exercise workload continuum. Several studies also suggest that regular physical activity is associated with decreased mortality and incidence rates for influenza and pneumonia.

Regular exercise training has an overall anti-inflammatory influence mediated through multiple pathways. Studies consistently show decreased levels of inflammatory biomarkers in adults with higher levels of physical activity and fitness.

There is increasing evidence that the circulation surge in cells of the immune system with each exercise bout and the anti-inflammatory and antioxidant effect of exercise training have a summation effect over time in modulating tumorigenesis, atherosclerosis, and other disease processes

Immunosenescence is defined as immune dysregulation with aging. Emergent data support that habitual exercise is capable of improving regulation of the immune system and
delaying the onset of immunosenescence.

WHAT'S WRONG WITH MEDICINE IN INDIA TODAY?

Medicine in India has evolved tremendously in the past few years. Advancement in technical knowledge and skill of doctors, infrastructure of hospitals, technology and management has made the country famous for good medical care. The large number of international patients flocking to the country adequately substantiates this claim. However just as every coin has two sides, so it is with medicine in India! Something somewhere is wrong. The picture is not as rosy as it seems. I know it, you know it. Everyone knows it. So what is wrong with the medical field in India?

Is it that medicine has become too commercial?

If that means it has become expensive then that's due to inflation. Even I wish I could get petrol for Rs 20 per litre like in my school days!
If becoming commercial means that hospitals and doctors are marketing themselves, then that too is necessary. It's a survival tactic for the hospital/doctor and useful for patients. Useful as it helps the patient become aware of a service or expertise.
If commercial means cut practice, then that's an evil we all would like to avoid. But that occurs because of a problem in the system. So corruption flourishes in medicine like it does in almost any other field in India.
From a patients’ perspective, I don't think commercialisation of medicine is the real problem.

So then is it that surgeries are unsuccessful and complications are more?

Actually the situation is the exact opposite. Complications are a part of surgery. They always were and they always will be. Nobody wants a complication. The doctor wants it even less than the patient. But when a complication does happen the patient finds it all too easy to blame the doctor. I think we as patients need to stop being all emotional about this. A little maturity and rational thinking is the need of the hour. Just as the fear of an accident doesn't stop us from using a car, so it must be with surgery and complications.
And though road accidents are on the rise, medical complications are decreasing due to advancements in technology, infrastructure and medical knowledge and skill.

So then is it that doctors aren't as good as they used to be?

 Again the opposite is actually true. Today's doctors have the advantage of better training. They also have the advantage of learning from the mistakes of the past. Add to this the beauty of specialisation. A specialist basically means a better result and fewer complications.

So then what is wrong with medicine in India today?

The main problem is unindicated surgeries, procedures and investigations. To understand this we have to understand the meaning of the word indication. The dictionary meaning is "a special symptom or the like that points out a suitable remedy or treatment or shows the presence of a disease" Simply put an indication is a criteria that helps a doctor decide if a certain procedure is suitable for that patient. An indicated procedure means that the patient will benefit from the procedure. An unindicated procedure means either the patient will not benefit or the patient will benefit from a simpler, less invasive procedure as well. It is important to understand the last part of the previous sentence.
Some doctors do more invasive, aggressive procedures or investigations to make more money. The procedure generally gives the desired result but it was unnecessary and simpler things would have worked just as well. This is a shameful practise and must be condemned.
A classic example is MRI. Many times doctors prescribe MRI's when it is not indicated at all. Another example is in cardiology. Some cardiologists advice angioplasty even though the patient needs a bypass! The reason for doing this is obvious.

Another problem is a doctor attempting something he is not adequately trained for. A classic example is knee replacement. It seems nowadays that every orthopaedic surgeon is a specialist in knee replacement. An untrained, inexperienced surgeon attempting a complicated surgery is a recipe for failure. And if the surgery is unindicated, it is a recipe for disaster!

So how does a patient deal with this problem?

The first most obvious thing to do when one is advised an expensive procedure or surgery is to take a second opinion. There are 2 types of second opinions and both are important. The first is an opinion of another doctor, preferably a well known specialist in the field. Many times a second opinion increases the confusion. In that event take a third or even a fourth opinion. The other type of second opinion is a second opinion of another patient of that doctor. Please ask your neighbours, friends and relatives about the doctor. You may be surprised!

The second thing to do is to ask your doctor the right questions. Most patients end up asking stupid questions like ‘Doctor, is there a guarantee of the result?’ You are not buying a washing machine. This is medicine! There are no guarantees.  A more sensible question is ‘Doctor, what are the indications of this surgery?’ or ‘what are the potential complications and the percentage?’ or ‘is there a simpler procedure which can do the same job?’ or ‘what is the percentage of success?’ or ‘can this procedure be delayed?’ or ‘what is the risk/benefit analysis for this procedure for a patient like me?’. It is your right as a patient to know everything about a procedure from your doctor before you agree to it. If he is not willing to answer, ditch him immediately. Another advantage of asking many questions is that it will blow his cover if he is lying.

The next is research. Just like we research the market before buying a cell phone, all patients should research the internet about a procedure before agreeing to it. If your doctor doesn’t tell you the complications of a procedure, the internet surely will. Just type ‘indications of angioplasty’ in Google and your question will be answered.

Many of us have a close friend or relative who is in the medical field. He/she may be a doctor or a nurse or a technician etc. It doesn’t matter what they do in the hospital. The point is they are part of the system. They know the inside story! They know which doctor is really good and which one only shows that he is good! They know the complications and results of commonly done procedures like knee replacement, etc. Always consult them before taking a major decision.

Almost all Doctors are good people. They deserve your trust and faith. They will do what’s best for you whether you ask the right questions or not. They will not cheat you even if they can. Doctors in India are also amongst the best in the world. Sheer experience and volumes have made them better than their western counterparts. A successful result from a procedure or surgery is far more likely now than ever before. The whole world is coming to India for medical care and we are lucky to have it at our doorstep. My purpose is not to scare you away from doctors and hospitals. Your trusted doctor still deserves your trust!   

My purpose is to make you aware that there are a few rotten tomatoes out there. If we keep our eyes open we can avoid them!

The Obesity Factor

Obesity

Obesity is a big problem. To start with it kills self esteem. You don't feel good about yourself. There is a constant feeling of guilt. You don't look attractive. Your clothes don't fit well. You are embarrassed of your weight and what people may think of you.

Some feel, you shouldn't bother about what people say. Maybe they are right. But wouldn't it be awesome of you could shed that fat?

Apart from being a social issue, obesity is a much bigger medical problem.

The obese are more likely to suffer from hypertension (high BP), diabetes and ischaemic heart disease (heart attack). They are prone to get lumbar spondylitis and knee arthritis. In summary, obese will live shorter lives and that life will have more suffering.

So those who say "I live to eat" or "I love food", I'd like to warn them that they will pay a heavy price for their indulgence.

If you are still not interested in loosing weight, you don't need to read further! I say this because loosing weight is not simple or easy. It is a Herculean task, nothing less than a complicated project that needs your full concentration till completion.

First step is to rule out medical illness. Many disorders for eg thyroid problems lead to weight gain. It is only logical to address these medical issues before trying to lose weight.

You can lose weight by diet AND exercise. Even a small child will tell you that. What is important to realise is diet alone or exercise alone may not be enough. So diet has to go hand in hand with exercise.

Which diet?
There are many diets out there that guarantee weight loss. Each claiming to be better than the other. They all work! It's common sense. If you starve you will loose weight. The issue here is how long can you sustain a diet? The more fancy and effective the diet the less likely it is for you to stick to it. And once you are off the diet, all your weight is back in a few months. So how do you approach the problem?
I feel your diet should not change drastically. Obviously less oil, less salt, less sweet! More importantly less quantity. We have been brought up to think that it is nothing less than a crime to stop eating before your stomach is overfull. We need to loose that habit. We have to train ourselves to get up from the meal with a hungry stomach. It takes a lot of effort and determination to do this.
Just one useful tip. Usually dinner is the heaviest meal for most people. I believe that if you can attack this one meal consistently you can achieve your goal. One way is to eat of bowl of fruits and raw vegetable salad one hour before dinner. That way your tummy is full and you can easily avoid a heavy dinner.

Which exercise?
To loose weight you need aerobic exercise. This means any exercise that increases your heart rate (you can hear your heart beating) and your breathing rate. For eg brisk walking, jogging, swimming, cycling, rowing etc. The recommendation is to do aerobic exercise for half hour everyday.

Many people are not able to loose weight. Some of them genuinely cannot loose weight and they need medical attention. But most of them fail cos they fall short in effort. Loosing weight is a full time job that needs a high level of sincerity and commitment. Commitment so that you don't give up and sincerity so that you don't take short cuts. The biggest enemy of those who don't loose weight is usually laziness!

To conclude, obesity is not only a social problem, it is more serious medical issue. Loosing weight is essential. With determination and motivation, most people can shed their fat. Two proverbs come to mind - "where there is a will, there is a way" and "try try till you succeed"

YOU CAN BECOME THIN!!

The Weekend Champion

Playing a sport is equivalent to being fit. We have been conditioned to think that if we play we will achieve fitness. Many people take on some sport in the hope to gain fitness or to lose weight.

At the same time most of us are busy in our work. We are so busy that we don’t have time for exercise and sport. The only relief we get is on the weekend. It’s therefore not uncommon to find people engaging in sport over the weekend. I call these people the weekend champions.  

  

A weekend champion is a brave soul. I say this because he or she risks suffering a severe sports injury. Though playing some sport will keep you fit, you also need to be fit to enable you to play the sport safely.

It’s not a good idea to play a sport to gain fitness. This is especially true for competitive sports like football, tennis or cricket. Most sports involve sudden spurts of running with sudden stops or turns. They also involve heavy use of certain muscle groups for e.g. throwing a cricket ball puts a heavy strain on the shoulder muscles and ligaments. To add to this is the risk of falling. Muscles that are in tone and fit can handle such excessive strain and can protect the neighbouring joints. But this kind of strain is too much for the unfit person and he is at a high risk to strain or pull his muscle or ligament. His muscles are also too weak to protect his joints and he may suffer an injury. The knee is the most common joint involved in such injuries.

So a venture started to gain fitness often proves deleterious and one lands up with a sports injury.

The right way is to give the sport the respect it deserves. One should play for fun, recreation and healthy competition. One should train to be fit to play. Most sports involve running so one should jog or run daily to tone the muscles of the thigh and leg. Stretching exercises are also critical and ought to be part of a warm up routine before you play. Specific strengthening exercises are also important. For e.g. shoulder exercises for a cricketer.

Once one is fit to play, then he or she truly benefits from the sport. Not only does one gain joy and satisfaction but the sport makes you fitter. And the risk of injury is considerable decreased.   

To conclude I caution one from being a weekend champion. Don’t just get up one fine day and start playing competitive sports like football. You will pay a heavy price. Instead train to become fit and then enjoy the true benefits of sport. 

Osteoporosis

Most people assume that any bone or joint problem they are experiencing is due to a lack of calcium and they start popping calcium pills (myth 1). This obviously is not true. Calcium related disorders like osteoporosis form a small percentage of bone and joint disorders and it is not correct to assume that all ailments are related to calcium. The most famous misconception is that calcium deficiency causes joint pain (myth 2). Arthritis (joint inflammation and pain) has little to do with calcium.

The most well known calcium related disorder is osteoporosis. Bone is made of calcium and phosphate. Normal bone undergoes constant renewal in the body. Old bone is removed and new bone is laid down. If there is calcium deficiency or calcium is not absorbed from the intestines, the rate of new bone formation becomes less than that of bone removal. This results in a quantitative reduction in bone mass. Once the bone mass decreases beyond a critical level, the condition is termed as osteoporosis.   

Bones are like calcium ‘banks’. Deposits of calcium in bone are made during the first twenty five years of life. Therefore adequate calcium intake is essential for all growing children. This ensures maximum calcium deposition and strong bones. I recommend 2 glasses of milk every day for all growing children unless they have lactose intolerance (recommendation 1). After twenty five years calcium is slowly lost from the bones over time. Some people have poor deposits to start with or they lose calcium at a faster rate and become osteoporotic.

The main cause of osteoporosis is a lack of female hormones oestrogen and progesterone after menopause. These hormones help keep calcium within the bones.  A woman looses tenfold more calcium than normal for the first ten years following menopause.  Poor dietary intake of calcium contributes to osteoporosis. Vitamin D helps absorb calcium from the intestines and deposits it in bones. Dietary deficiency of vitamin D can cause osteoporosis. A thin frail (poor diet), post menopausal woman with a family history of osteoporosis is at a high risk for osteoporosis. Men also suffer from osteoporosis but at an older age.

Osteoporosis is a perilous disease as the weak bones are at a risk of fracture with no or minimal trauma (easy fracture). The hip and spine are the most common sites and also the most dangerous. 

Contrary to popular belief, osteoporosis is a silent disease. This means it has no symptoms. Pain due to osteoporosis occurs in only the advanced stages. Often the first symptom is a fracture, but by then it is usually too late!

The best way to detect osteoporosis is by doing a DEXA scan (recommendation 2). This test should ideally be done at menopause and repeated every 1 or 2 yearly. Based on the results your doctor can give you recommendations on supplementation and treatment. Needless to say that early diagnosis and timely treatment will go a long way in avoiding fractures.

Modern tests allow objective assessment of body calcium. Blindly taking calcium supplements for ‘bone pains’ or as a ‘good habit’ (myth 3) is not recommended or justifiable.

There remains a lot of confusion on dietary recommendations for calcium and vitamin D. Most authorities recommend at least 1,200 milligrams per day of calcium and 800 - 1,000 international units per day of vitamin D. Diets rich in calcium include milk and milk products like cheese and yoghurt, green leafy vegetables and fish. Diets rich in vitamin D include liver (cod liver oil), fish, meat, milk and milk products and egg. Exposure to sunlight also helps your skin to manufacture vitamin D. Early morning or evening sunlight is preferred. I recommend allowing children some play time in sunlight (recommendation 3).

Certain exercises can reduce the risk of fracture in patients with osteoporosis (recommendation 4). Weight bearing exercises like walking or jogging and resistance exercises like free weights or stretch bands are recommended.

Even after extensive awareness campaigns, osteoporosis still remains a very misunderstood disorder which causes a lot of anxiety and confusion.