A story of emotions

Emotions are intriguing and mysterious. And they are open to interpretation – depending on whose point of view is taken into consideration – the emoter or the interpreter. When you are the emoter then you are said to be in an emotional state. When you are the interpreter you are said to be empathic. When you are the emoter and the interpreter then you are said to be self evolved. Can’t pretend emotions can always be understood or expressed adequately or as intended but they do add little something to our lives which we all seem to value incredibly.

During my days as wide eyed undergraduate I found my psychiatry lessons interesting but I somehow imagined that the subject will always remain in the sidelines as I manage the other real stuff like diabetes, heart disease, kidney problems, and all such pizzazz. Not saying that I didn’t appreciate the significance of mental health but I imagined that knowing my depressions from my anxieties and knowing my psychosis from neurosis will equip me well enough to deal with all that my patients will need from me.

But I have learnt slowly that the psychiatry lessons never stop for a general practitioner and the greatest teachers are the patients. They are way more complex… or perhaps far simpler… than I initially thought, all depending on how I choose to look at them or relate to them.

They have taught me that it’s not possible to put every mental health problem in a few well labelled boxes I brought to the table. In fact I’m finding out that these neat boxes are only the tip of the iceberg in a far more scattered and confusing sea of dysthymias, adjustment disorders, interpersonal issues, personality problems, anger and emotion dysregulation, substance use which are present everywhere around us, sometimes glaring and commanding attention but generally much meeker and quieter and hiding under the layers of  physical health issues which don’t seem to shy away from attention as much as the mental health ones.

Over the years my patients have gently but firmly guided me to strive to gain better understanding of their emotions, making quite clear that unless I understand their emotions I am going to struggle to get best outcomes in managing their health. It’s driven home the fact that I’d read hundreds of times before – chronic and longitudinal care. The relevance of what a GP does for a patient in comparison to 10 other health care professionals involved in their care makes sense now. Every health care worker’s contribution is significant and irreplaceable but it takes the bond of the patient with the GP to keep it all tied together.

I’ve learnt this from the silence I have heard from my diabetic patient who just never seemed to be able to regulate his sugar levels, no matter how hard his GP, endocrinologist, diabetic educator tried. I heard about his non verbally communicated struggles of not being able to control his emotions and the related comfort eating and the seeming non caring for his own health. In the noise of his behavioural problems, I also heard the silent plight of his feelings of guilt and inadequacy in relation to the impact of his poor health on his family and his worry about his ability to continue providing for them. I was at the receiving end of his external frustration which seemed to be directed at everything and everyone but himself. But because he didn’t press all the keys needed to unlock the codes of various mental health boxes I had lined up on consulting table, he kind of just hovered over the boxes, not getting the permission to enter any but refusing to let go either.

This situation seemed to repeat itself with all the health care professionals he came in contact with in his pursuit to achieve better health. It sometimes made him short tempered and angry, acquiring him the label of rude and aggressive patient. This also frustrated his health care professionals as despite their best efforts he just seemed to be help seeking with poor self motivation.

So what’s not working out in this situation? Is it the patient who has been equipped with all the help he needs in managing his health but doesn’t seem to be able to do so? Or is it the health care professionals who can perhaps sense that this is not a happy individual who is not being able to exercise enough will power or restrain in helping himself and there’s little they can do as on more occasions than not they have waiting rooms full of similar patients demanding their time and attention, leaving them under serious time constraints and then they just deal with the superficial layers of physical health issues, hoping that the person will sort out their emotions in due course. Or if they get worse enough then they can be put into a mental health box which then makes it bit less chaotic to deal with the problem.

The patient can generally sense when his health care professionals are getting tired of his confusing and disorganised emotions and behavioural problems with constant and recurring inability to help himself. I regularly come across a number of patients who report judgement from their health care professionals when it comes to confrontation with their out of the box mental health issues.

As time is going by, the only constant I am learning is that emotions are complex, they are individual and hard to be understood in their entirety. But there’s also another constant truth that generally people just want to feel happy and normal, howsoever they interpret normal to be. They don’t want to self harm, take drugs, treat their bodies badly by abusing them with unhealthy diet, lack of exercise and relaxation and general loss of purpose and motivation in their life. If they are doing all these things then they need a friend and guide and not judgement.

And health care professionals are in a fortunate and privileged position to be able to be there for them. People generally figure things out themselves, all they need is some validation and guidance.

The day I stopped telling my patient what to do to manage his health better and started listening without judgement I learnt about the difficult childhood he had growing up in the shadow of a dominant and alcoholic father. As he spoke some more, I quietly put the mental health boxes away and stopped worrying about which one to put him into. We then spoke some more and discussed about how does he ever see himself moving forward, towards better health and he told me that he’d already done this. He’s opened up to his GP about issues that he’d bottled up for 45 years. He had finally accepted what he couldn’t change and decided to change what he could, one small step at a time. He wanted to do this for his children so they don’t go through the same cycle that he did. He reported that he was ready to take some control back.

Obstructive Sleep Apnea

  1. Do you snore?
  2. Do you persistently feel tired and sleepy in the daytime?

If you’ve answered yes to these questions then there is a good chance that you’re experiencing a form of sleep disorder called sleep apnea.

Whenever I mention this term to the patients, they almost always seem to have heard of it but almost equally tend to have very little understanding of what it means.

The reason more people are hearing about it is because the rates of it are going up. Statistics show that about 25% of Australian men and about 9% women tend to have clinically significant OSA. Out of these, about 4% will have symptomatically significant OSA. It is relevant and important as it leads to an increase in death rate by about 2.5 folds. People with OSA are 7 times more likely to develop heart disease, weight gain, have decreased levels of concentration and mental sharpness or alertness and up to 9 times more likely to have motor vehicle accidents.

So let’s talk and learn a bit more about it. Apnea comes from Ancient Greek word: a = absence, pnein = to breathe.

So the basic pathology in OSA is a blockage in the upper respiratory tract during sleep that leads to recurrent stops or pauses in breathing.

Now lets explore this blockage business a little bit further. During sleep the air enters through our nostrils and passes via the throat, down into the lungs. Our clever bodies have evolved in a way that allows the muscles at the back of the throat to relax a bit as we are breathing in, to allow this air transition to occur without us having any awareness of it. So if all is going well then you’ll either hear no sound coming from the person sleeping next to you or it may be a gentle and quiet rhythmic sound of deep breathing.

But in individuals with problems in the area, these muscles may relax a bit too much, gradually narrowing the passageway of the air and you may hear the person lying next to you breathe quite noisily and start snoring and the intensity of the snores may keep going up in a crescendo rhythm (partners have described it as the sound of a train approaching the station – gradually getting louder and louder). The over-relaxed muscles at the back of the throat eventually collapse down, completely clogging up the path of the air getting into the lungs and the breathing stops – at this stage you suddenly hear….nothing. This is where the apnea or absence of breathing happens. Then the reflexes of the body kick in, causing the person to gasp for air, which you may hear as a gurgle or startled breathing sound coming from them which then again settles into a gradually increasing intensity of snores and the whole cycle carries on throughout the night.

Quite often the person who is going through it will have almost no recollection or recognition of these events as it is happening in the unconscious state of sleep, albeit the quality of sleep is affected, unbeknownst to the sufferer. It is not unusual for the spouses to come to doctors with the problem with a disgruntled partner who can’t see what the fuss is all about!

So, the above explains what it is and how it manifests but it still doesn’t explain how it can make the sufferer feel so tired and sleepy in the daytime that it has become almost the hallmark of sleep apnea presentation. The tiredness can be explained with the changes in sleep cycle.

During a normal sleep cycle we transition from awake state to drowsiness and then to unconscious state. In medical terms we call these cycles NREM and REM. The Non Rapid Eye Movement state has 4 stages : 1 to 4 and we move from NREM stage 1 (‘light sleep’ stage – even a slight noise can wake us up) to stage 4 (‘deep sleep’ stage ) in about 60-90 minutes and then transition to REM sleep which lasts a few minutes, although as night goes on REM periods get longer. We dream and are in a physiologically aroused state during REM sleep whereas NREM, particularly after stage 2 is associated with all the benefits known to come from good sleep – boosting of our natural defences and metabolism, repair of our body and release of growth hormones. In a healthy sleep cycle we should be spending about 75-80% of the time in NREM sleep and the rest in REM.

In sleep apnea this beautiful sleep cycle is disrupted which results in lot more of REM sleep associated with increase in blood pressure, heart rate, vivid dreams, restlessness. During apneic episode the body goes into fight and flight mode and this continuous stress is not good for the body. So even though a person with OSA would have slept the whole night, snoring away, but the quality of their sleep tends to be much lower and they tend to have far lower levels of oxygen saturation as compared to normal circumstances. This chronic stress on their body results in tiredness and the need for body to rest during the day. Some people tend to have ‘micro sleeps’ in the daytime, sometimes even without knowing. Such a micronap during driving can have disastrous effects and is probably the greatest worry for someone with OSA.

As I have mentioned a few times already, most of the times the people with OSA don’t tend to know it and may not think that there is a problem. But if they are displaying any symptoms then it’s important to alert them of this possibility and encourage them to discuss it with their GP as there are simple tests such as sleep study to diagnose it and to assess the severity of it. There are also various methods of treatment, again depending on the specific nature of problem causing snoring and the degree of severity of sleep apnea.

Amongst the lifestyle factors which can have a positive impact on management of it is limiting intake of alcoholic beverages, particularly of amounts exceeding the daily recommended limits (as alcohol aids the already over relaxed muscles at the back of the throat to relax further – that’s why people tend to snore more after having a few drinks); smoking cessation; weight control and inculcating the habit of sleeping on side and not on the back.

Post Natal Depression

Human mind is a strong and strange thing.

It can have immense control over our bodies and actions and reactions. I can recall times when I have marched through a full blown influenza infection with a mask worn over my mouth and continued to work for full days, and I can also recall times when I have received a two line letter from hospital informing that one of my patients has ended up in hospital due to worsening depression and inability to cope, and I have simply waited for my next day off work and then have allowed myself to be unable to drag myself out of bed even to perform simple necessary tasks like taking a shower or eating, feeling immeasurably sad and a little closer to the human being who had gone through this similar despair, but not for a day and not at a time when convenient to do so but over and over again, every single day, every single moment of their hopeless and tired days, and sleepless and tearful nights.

What I have described above is empathy. It’s an emotion that we can feel, that we have some control over and it’s something that our mind allows us to to feel, sometimes even makes us feel, so that we can adjust to the sadness that the suffering of others has caused us. So I experience the sadness of my patient for the day but then wake up the next day and have the energy to greet the new day. I am open to relating to the joy of my next patient who has just come out of hospital after their hip replacement and are in much less pain and are ecstatic that they can once again walk to their bathroom without crippling pain! The sadness for the other patient still remains but is balanced by the joy of the new one. And the cycle of this balance goes on, allowing me to get on with my work whilst maintaining my sanity.

But depression is very different. All of us have some sort of balance in our life – of joy and sadness, of hope and despair, of successes and failures, of wishes and needs, of restlessness of passions and satisfaction of achievements, of yearning for what we want and being at peace with what we have, of the burden of having expectations laid on us and  the tranquility of knowing we have done our best. Depression breaks this balance.

Depression is something that our mind doesn’t have control over. In fact, oftentimes our consciousness tries to not to allow us to feel it, it tries to make us not feel it.

Generally we all like to have some degree of control over things around us, most of all over ourselves. But depression is very disempowering. It takes away our control. Hence the fight of the mind against acknowledging it.

These are the times when our mind and body can have a disconnect – we go through what I wrote about a few weeks ago – adjustment disorder. We don’t recognise that we are going through depression but our bodies tell us differently. We feel unnecessarily tired all the time, we don’t find much joy in activities we loved previously, we find everyday chores an enormous burden and struggle to get through them day after day. Our friends, acquaintances, work colleagues and even family, who were our constant companions in some way almost on daily basis, may start to seem overbearing and intrusive and judgemental. So we start decreasing our contact with them on one pretext or the other.

And as we don’t really understand what is happening with us, we start being unsure of ourselves. This unsurity tends to be the cause of anxiety, stress, irritability. Its not uncommon to take out these feelings on our closest ones. These are all cries for help, but hidden under the bitterness of arguments and fights, they become a source of further distancing from the very poeple who will most likely help the most, if only they knew or understood that help is needed.

There is no other time in a woman’s life when this is more true than the first few days after giving birth. In the first few days after giving birth the likelihood of some imbalance in emotions is quite highly likely and peaks at about 4-5 days after giving birth.

It’s a whole mix of things – hormones, going through the marathon physical effort of giving birth, exhausted body, sleepless nights and neverending demands of breastfeeding and diapering and looking after a little thing which is quite fragile looking (so causes a huge amount of worry and anxiety about whether you are doing the right thing and handling it correctly) and in the first few days, seems almost completely unresponsive to this slavery like care!

But thankfully we have something we call instincts which kick in pretty fast and together with the support of our social network, we start to get it all in our stride in about 10-12 days after birth, after which it’s generally a smoother sailing in terms of persisting emotional problems. This period is known as postpartum blues and is almost a natural phenomenon as it emphasises that you are just human, dealing with some expected adjustment issues and eventually its going to work out fine for you and your baby. What causes worry is postnatal depression.

The reality is that out of every 100 women who give birth, about 13 will experience postnatal depression. These mums will experience an ongoing period of low mood, lethargy, tearfulness, hopelessness, perceived inability to cope, broken sleep pattern, excessive worrying about the baby, focus on baby’s ‘imperfections’. But have we ourselves not experienced most of these emotions when we are new mums? Who hasn’t either experienced themselves or had a friend describe the new motherhood as sheer physically exhausting experience, sleep deprivation, constant tiredness from not getting enough rest, worrying about whether we are doing the best by our babies and questioning ourselves and seeking reassurances from friends and family and medical professionals (oh, not to forget the grandmaster – Mr Google) about whether ‘we are good enough mums’?

Due to these reasons women and their families, and sometimes their doctors too, fail to recognise when some of these mums have crossed over to the realms of depression. But a separating factor can be that in postnatal depression these symptoms generally fall outside the expected norm e.g. the excessive worry about baby: some examples can be – ‘it’s too colicky’,’its so prone to eczema’, ‘it just never seems to settle’, ‘it just doesn’t feed’, ‘it doesn’t digest food properly’ – all these worries persist despite reassurances from older members of the family, partners, medical professionals. Quite often this can also leads to a degree of resentment towards the baby as it may be seen as the cause of much despair for the mum. This is then followed by feelings of guilt and self deprecation, further accentuating her unhappiness.

As these new mothers are fraught struggling with the overbearing problems in their baby and their own helplessness to deal with them, they are too distracted to worry about their own health or emotions. Due to these reasons postnatal depression is quite often picked up by medical professionals, family and partners. But sometimes even picking it up doesn’t help as there may be a feeling of shame for the patient as they feel a failure at something ‘that should have come naturally to them, like it does to everyone around them’, particularly their social circle such as mothers/mother in laws/sister/sister in laws/best friends etc. This feeling may lead to denial or poor acceptance of offers to help in the initial stages.

If postnatal depression goes undetected or unaccepted then it may lead to quite serious consequences. Families have broken due to this, children have been neglected, self harm has occurred and in extreme cases even suicide when the woman feels such despair that she sees no way out. Even in less severe cases, there is evidence to state that children of mothers with undetected and unaddressed postnatal depression tend to have developmental delays. So its a very real problem with quite serious consequences. Look out for this around you – yourself, your friend, your relative, your colleague, your neighbour – anyone can be affected and sometimes just reaching out in some way is all that is needed to set them on the way to recovery.

There is treatment available for all stages of depression – from mild to severe. There is counselling, family support, psychotherapy and medications. In some advanced cases, where either the depression has progressed to severe stages due to lack of recognition or if it hasn’t been addressed due to poor patient acceptance or lack of social support, there is provision for inpatient treatment. Best practice now dictates that mothers requiring admission for depression are admitted to a specialist mother and baby unit, unless there are specific reasons not to do so.

In most cases though simple and empathic counselling is all that is needed, as it helps in development of problem solving skills, basic restructuring of thought process, breathing exercises and stress management.

Interpersonal psychotherapy is also used quite successfully as it lays focus on woman’s interpersonal relations in her family and her changing role, and it allows woman to improve her social adjustment so that she can return to being a ‘happy worrier’ – a mum who continues to fuss over her child but is able to enjoy their smiles and soft cuddles and is able to experience the exhilaration, along with the worry, that only comes with being a mum.

She gets the balance back in her life.

Polycystic Ovaries and Polycystic Ovarian Syndrome – understanding the basics

Commonly known as PCOS or PCOD, it is one of the most commonly encountered endocrinological problems in women of fertile age groups i.e. between the ages of 18 to 44 years.

As the title suggests, there are two separate conditions – one is simply polycystic ovaries which means that the woman has simply been found to have multiple small ‘cysts’ seen during an investigative method called ultrasound. She doesn’t have any associated symptoms of the syndrome as discussed in detail in the following part of the article. The incidence of such women is about 25%. These women can have polycystic ovaries (or PCO) on scan but they are completely well with it and don’t have PCOS. These women don’t have the associated symptoms, seen in about 20-25% of women, which lead to development of the syndrome.

So to clarify the prevalence a little bit more:

If I randomly pick up 5 females in fertile age groups from my readers, then:

1 will have polycystic ovaries but not the syndrome

1 or 2 will have PCOS with symptoms

1 will have PCOS without any symptoms

1 or 2 will have nothing wrong

So, I think you’ll agree that it is a pretty common condition but surprisingly it’s no where near as well recognised or understood as some of other well documented and talked about endocrinological problems, such as diabetes or hypothyroidism.

The symptoms associated with polycystic ovaries in women with PCOS (although – just to confuse matters even more – some women can have polycystic ovarian syndrome without having polycystic ovaries at all!!) :

1. Menstrual disturbances : late periods (more than 35 days cycles) or missed periods

2. High levels of male sex hormones, called testosterone – It’s normal for our ovaries to release 3 types of hormones – ‘female hormones’ – estrogen, progesterone and ‘male hormone’ – testosterone. In women with PCOS, the amount of testosterone is much higher than usual. This causes masculinisation symptoms such as male pattern hair growth – coarse hair on chin or chest; male pattern hair loss. The other common manifestation is acne.

3. Infertility – as I am about to explain in the following text, these women do not have normal ovulation and their ovaries do not release egg – either not at all or not in any rhythmic fashion, making it very difficult for these women to track their ovulation and consequently causes fertility issues. It’s not to say that these women can’t fall pregnant but as they don’t have an egg in each cycle, their chances get much less.

4. Insulin resistance – Women with PCOS have fourfold to sevenfold chances of developing diabetes due to the increased incidence of insulin resistance seen in these women. PCOS is not a disease of only obese women as about 10-15% of slim women with PCOS can have insulin resistance but the rate of insulin resistance is more than double, at about 20-40% for obese women, so clearly weight plays a role. Weight and insulin resistance is bit of a chicken and egg situation. Whilst obesity doesn’t cause PCOS as such but weight gain is an important contributing factor to developing PCOS – in some women an increase in weight unmasks an underlying predisposition to developing this condition. So it seems that if you gain weight then you have higher chances of developing PCOS and if you have PCOS then you have higher chances of developing insulin resistance which can cause further weight gain! So the underlying message seems to be that of not gaining weight as far as PCOS is concerned. In fact, in women with established PCOS and significant menstrual problems with absence of periods for months at end, a weight loss of just about 5-10% of total  body weight has been shown to lead to restoration of normal menstrual cycle.

In the second paragraph I’ve highlighted the term ‘cysts’. This is because these are not really cysts (= fluid filled sacs) but are follicles.

To explain the term follicle bit more in detail we will have to look a bit deeper into our physiology. and get to grips with some basics:

Every woman is born with her quota of eggs in her ovaries which are called oocytes. There are about 1 million of these at the time of the birth but only about 500 get used in our lifetime during ovulation and the rest are wasted! Women that have to go through the process of IVF will pay somewhere around 2-4K AUD for undergoing the scientific process of acquiring one of these guys and making it do the job it was naturally meant to do!

These egg cells are contained in structures called follicles, which we are talking about today. As she enters the age of menstruating, each month, around the time when the woman is somewhere in the middle of her menstrual cycle, one of these egg cells will start maturing and increasing in size. To give you an idea in simpler terms, you can imagine having a plate full of peas (= these are the egg cells) and one of them will start looking like a grape ( = distinctly bigger and clearer to see: these are the structures that the sonographers see when they do an ultrasound and comment on a ‘maturing follicle’ or a functional cyst) . Eventually this maturing follicle (grape in the plate of peas) will rupture, leading to the  release of the egg (=ovulation). This egg will either get fertilised,leading to a pregnancy, or the associated hormonal changes will bring about menstruation, in about a fortnight after the release of the egg.

In polycystic ovaries this fundamental natural clockwork routine is broken and many follicles try to mature at the same time. So our plate that was full of peas and was meant to have one large grape will now have about ten-twenty, or sometimes even more, blueberries! So these blueberries are representatives of the same follicles (peas in our analogy) that are part of our natural anatomy but just started misbehaving by not letting one of them to take the lead and be the boss for that month (so no grape).  So in the end no one wins and there is no release of the egg. Too many blueberries but no grape –> no egg –> no menses. So that’s why these women typically tend to have periods that are generally quite late and they can sometimes even miss periods for months.

I hope that the talk about peas, grapes and blueberries hasn’t confused you even further but I find it quite a useful way to explain to patients when they are having difficulty understanding the concept of multiple ‘cysts’ and their immediate first reaction is to look at ways of getting rid of these cysts as they believe that the cysts are the problem and they often feel that if they can get rid of them then their periods will get back to normal. As you can see, it’s not the case. The cysts are not the cause but are just a manifestation of the syndrome. If you get rid of some of the blueberries from the plate then the rest of the peas will simply make more blueberries and this cycle goes on in PCOS.

It’s cause can be genetic or environmental in nature. About 35% of mothers and 40% of sisters of PCOS patients are affected as well. This clearly shows that it can run in families. An important environmental contribution is weight excess or obesity and lack of enough physical activity. So one of the most important management options for PCOS is weight control which will be the topic of our next conversation.

Core Strengthening exercises – simple program to follow

Pilates is a great form of exercise for strengthening lower back and core muscles which are crucial for maintaining a strong and pain free back.

The person who developed this form of exercise, Joseph H. Pilates, originally called it Contrology due to the strong emphasis he placed on the principal of control in this exercise program.

Control is important in everything we do. Control the muscles, positions and speed as you exercise. And eventually this self control will start spilling into everything else you do during your daily routine, bringing calmness with it and reducing stress.

Another important aspect of exercising is breathing. Calm deep breathing is relaxing for muscles and for brain. Short, shallow breathing or holding the breath as you exercise tenses the muscles due to building the pressure in the muscle. Shallow breathing can result from a number of factors including stress, engaging in mainly sitting activities, smoking etc.

Controlled breathing is important for pilates, yoga or for any other form of exercise concerned with increasing body awareness. It can sometimes be bit confusing to figure out the rhythm of breathing as you initially start cultivating the awareness of it, so to make it simpler remember that when in doubt, exhale during the most difficult part of the exercise.

Also please don’t forget to warm up and cool down prior to any exercise routine, no matter how light or how short. It pays to spend those extra 10 minutes prepping and relaxing your muscles with some stretches.

So let’s get started:

  1. Tiny steps – This exercise works the lower abdominal muscles in the small of the  back. It develops lower abdominal stability, protects the lower back and strengthens the muscles in the hip region.

Steps to do it: i) Lie flat on a mat

ii) Bend your knees, keeping your feet flat on the floor

iii) Place your hands on your hips to stabilise them

iv) Exhaling, pull your naval towards your spine and raise your right knee towards your chest as much as you comfortably can. Inhale and hold position.

v) Exhale again, continuing to pull your naval towards your spine. Slowly lower your right leg onto the mat in the original position

vi) Alternate legs to complete the full movement. Repeat 8-10 times.

2. Bridge – bridging is the perfect exercise for toning thighs and buttocks. It not only strengthens the core but also benefits the lower back by making the weak areas stronger and protecting it from future injuries. It’s also great for the pesky weak bladder. So if you worry about leaking when you have a hearty laugh or cough and sneeze then bridging is for you.

Steps to do it: i) Lie flat on a mat with knees bent and feet placed flat on the ground, slightly apart, say about 15 cm

ii) Exhale and press your feet into the mat and squeeze your buttocks together, raising your hips until your body makes a straight line from your shoulders to your knees

iii) Inhale and hold the position

iv) Exhale and lower your body onto starting position on the mat. Repeat 5-10 times

3. Side Leg Lift Prep – This exercise is great for core stability and is also helpful for toning and strengthening the leg and torso.

Steps to do it: i) Lie on your right side. Prop your head with your left hand, resting on your elbow. Place your right hand in front of your torso. Focus to keep your chest supported and neck elongated.

ii) Drawing your naval towards your spine, lift both legs up in the air, squeezing them tightly

iii) Without moving your hips or torso, bring your legs forward as much as is comfortable. Take care to keep your hips and shoulders aligned as you’re doing this movement.

iv) Squeezing your abdominals and legs, lift your legs and return to the original position. Repeat 6-10 times on each side.

4. Child’s Pose – this is a relaxing stretch for the lower back that can be done at any stage of exercising routine to relieve the tension in the back and hips.

Steps to do it: i) Kneel on the mat on your knees and on the outstretched arms with palms placed flat down on the ground

ii) Staying knelt, sit back on your hips to rest on your heels. Lower your chest onto your thighs.

iii) Keep lowering your chest to your thighs until your head in tucked just in front of your knees and extend your arms and hands in front as far as comfortably possible.

iv) Stay in the position for one full breath and then return to starting position. Repeat 5-6 times.

These are very basic simple exercises which are possible for any beginner, at any fitness level and if done with proper control they will not aggravate lower back even at the time of an ache which some other intense forms of exercise can do.

Once you gain confidence in these basic exercises and are more in command of muscle control and breathing then move onto slightly more complex and more fun exercises such as the plank (start 15 seconds and aim gradually for 2-3 minutes) , side plank and the superman (lie face down on the mat and lift your left arm and right leg off the surface simultaneously and hold for one breath. Then repeat with right arm and left leg. Repeat 8-10 times).

Exercise can be fun, easy and immensely rewarding. Try child’s pose instead of a panadol next time you have an aching and stiff back and see for yourself!

Back pain: self help measures

So back pain is common and it’s quite likely that almost all of us will experience it at some point. Not the most cheerful note to start the conversation but a reality all the same!                                                  Most of the times it will be just the temporary muscle imbalance from a poorly judged weight or from the extent of excessive bending or stretching that goes into doing that activity and on other occasions it can be a recurring injury or a chronic problem.                                               So what are the things that we can do to help ourselves when we do land with these problems? And even better, what can we do to reduce our chances of running into these problems in the first place?                                           It’s time to get back to the basics:                                       1. The fundamental need of a healthy back is a good posture. The direct result of a good posture is less strain on your back for the simple action of holding you upright. A good standing posture is where your  head is up and chin in, shoulders are back but dropped ( initially you have to consciously do this by relaxing the shoulder and neck muscles), chest out and tummy tucked in. It seems like a lot of motions and a lot of things to remember for the simple act of standing! But if we don’t get this step right then the next ones will tend to yield lesser gains. When sitting we have to remember to sit back, preferably with some support at the small of the back, commonly known as lumbar support, with both feet resting on the ground. This is very important for those doing sitting desk jobs most of the times. If you’ve felt that nag in the lower back at the end of the day then monitor your posture actively for a fortnight and see the difference. Lifting weights with your legs and not your back is another part of maintaining correct posture – when bending to lift stuff, remember to bend the knees and feel the tension in the quads ( thigh muscles) and not the back.                                           2. Maintaining a healthy weight is crucial for a healthy back. Carrying excessive weight is like walking around with a backpack at all times. It’s going to tire you out quite easily, particularly if that weight is around the midriff.                                              3. Core muscle strengthening is very beneficial for the back. I get asked quite frequently about which exercises are the best for this and I’m a big advocate of exercises that increase your body awareness such as yoga, Pilates, tai chi, amongst numerous others. These exercises involve stretching, help muscle strengthening, improve balance, help improve posture and are calming for the mind. Swimming is great as well. But this doesn’t mean that other forms of exercises can’t help back. I’ll revisit this section as a separate topic to talk about at a later date as there are lots of simple routines that can be done even at home or work that can help strengthen the core muscles.                                     4. Relaxation – it’s all about maintaining the balance. So once you’ve done the hard yard of maintaining good posture and having done the exercises, do remember to relax. Massage is a wonderful way of doing it and is certainly quite helpful in relieving the tension from the muscles but just not adequate or enough on its own.                                                         5. Good diet – adequate calcium is important for the bone health. A cup of milk has about 300 mg of calcium and our daily recommended need is roughly about 1000mg. If you have low fat milk then the calcium content tends to be higher as the fat in the milk doesn’t contain calcium. A cup of yogurt has about 450 mg of calcium.  There are plenty of non dairy foods that are rich in calcium such as broccoli, spinach, figs, fortified orange juice, tofu, fish etc. Some fortified cereals can have up to 1000 mg of calcium in 1 cup. An average multivitamin has about 600 mg of calcium. So it’s quite easy to get your daily recommended dose of  calcium from diet only. And just as its important to have adequate calcium for optimal bone health, it’s equally important to avoid too much of it as it can be harmful for the heart muscle and can lead to kidney stones when taken in excess.             6. Adequate vitamin D – best source is sunlight but it shouldn’t come at the expense of risking skin cancer! The best times are before 10 am & after 4 pm on exposed or bare skin which soaks up direct sunlight for about 15-20 minutes. For those of us that stay covered up most of the times, have sun sensitivities or have jobs at desks from dawn to dusk, the best alternative is a good supplement – 600 IU to 1000IU, depending on what is the baseline status of vitamin D levels in the body.                                                        7. Some good studies have been done recently which have shown benefit from taking high strength fish oil. It’s effect has been shown to be similar to that of a mild anti inflammatory agent which is quite impressive.                                         Hope you’ll see and agree that these simple looking measures go a long way in avoiding and managing back pain. In the next section I’ll talk bit more in detail about some core exercises, physical therapy and other alternative methods of treatment such as acupuncture.

Back pain : Introduction and causes

I am consciously sitting up and straightening my back as I sit down to write this article.

Back pain is common and figures in the top seven conditions that bring people to consultation with their GP.

Estimates of figures show that 9 out of 10 people experience back pain at some time in their life and about 1 in 5 experience it at some time each year.

From a GP’s perspective, chronic back pain is 11th most common problem managed in primary care.

So just a quick glance at these figures shows that even though it has significantly high incidence, it must settle itself in quite a few instances and even in the cases that end up in GP’s consulting room, not  quite as many progress to chronic disease. Less than 10% cases end up requiring any surgical interventions.

From society’s perspective chronic back pain is one of the most common reasons of missed work in a given year.

Due to the vastness of the topic, I’ll break up the reading on this topic into separate segments over the coming days.

Back pain is said to be acute in the first 12 weeks and thereafter it is termed chronic.

It is termed cervical (neck), thoracic (truncal), lumbar (lower back) or sacral (tail bone), depending on which anatomical part of the back is affected.

It can originate from soft tissue structures of the back which comprise of muscles, ligaments and the protective sheaths called fascia. This tends to be the most common cause of back pain we encounter.

This pain is typically localized only in the area of the back affected which tends to feel quite stiff with significantly reduced range of movement. Those mornings when you wake up with painful and stiff neck or lower back, which seems to come out of nowhere, is the most commonly encountered example of this type of back pain. As the main problem lies with the muscle component, it tends to improve with activity as the day goes on and the gradual warming up of the muscle but then gets worse towards the end of the day due to the fatigue of the injured muscle.

The other possibility of origin of pain may be from the intervertebral discs which are fibrous and cartilaginous structures which lie between adjacent bones of the spine called vertebrae and allow slight movement of the vertebrae and also act as shock absorbers.

These discs can slip (medically termed herniation) at times of unbalanced mechanical pressures such as unusually high demand physical activity, accident or trauma, and the most common cause – chronic low grade trauma which results from poor posture.

This pathology commonly tends to cause radiation of pain down into the buttocks, thighs, legs and even up to the feet. It generally feels different to muscle pain and may be described as burning, stabbing or tingly in nature. It has higher likelihood of being associated with numbness or altered sensations.

It there is any association with problems holding full control of bowel or bladder then it is a very worrying sign and warrants urgent review with your GP.

The remaining possibility of the origin of pain is from the bones called vertebrae. This is uncommon and seen in < 2% cases.

In the next section I will write about treatment modalities with focus on self help strategies.


Today I went to watch the musical Aladdin. It was a joyful experience! The genie had the audience in stitches on more than one occasion:)    The atmosphere in the theatre, the glamour of the stage, the artistry of the performers and the general cheerfulness of the theatregoers was infectious.                                                        Relaxation is not only fun but also an integral part of our health and wellness. It plays an equal role, along with good diet and regular exercise, in helping us maintain a sound physical and mental health.           When we are stressed our body releases stress hormones like ephedrine/adrenaline, cortisol which act to stimulate us by increasing our heart rates, increasing our blood pressure, increasing blood sugar levels ( remember that ‘crash’ you always feel when an important and urgent task is done?), diverting attention away from ‘non urgent’ body responses like immune system (and making it weaker in the process – may remind you of the tendency to catch every cold going when you’re overworked) stimulating energy levels – this explains how we seem to get superhuman strength and stamina at times of stress like preparing for exams or meeting important work targets, or just the simple daily routine ( but stressful nevertheless) of early morning rush of getting the kids and yourself ready, fed and dropped to school in time & somehow managing to get yourself to work in time! And so on and on…..                              What should normally happen is that after the stressful event the hormonal change in the blood should go back to normal. But if there is constant stress, as we tend to experience in most of our lives nowadays, then this normal fight or flight response always stays active. This results in us experiencing various physical effects of persistently high levels of these hormones, such as headaches, concentration and memory disturbance, sleep disturbance, abdominal disturbance, depression, anxiety, weight gain.                     That’s why it’s very important to find ways to counter the continuing effect of these stress hormones. Exercising and relaxation stimulates release of happy hormones such as endorphins, dopamine, serotonin, oxytocin. That heady feeling we feel when we win first place in a race or competition is dopamine, that mushy feeling we get when we are with a loved one is oxytocin, that ‘I own the world and the world is a happy place’ feeling we get after sweating it out for an hour in the gym is endorphins and serotonin. So make sure that in your pursuit of health, you don’t just focus on the latest fad in the diet but also on an enjoyable form of exercise and having some down time doing something you totally love – it may even be doing nothing! Or try spending an afternoon in the company of a genie who behaves like a pop diva at every given opportunity:)

Constipation in Children

Constipation is a fairly common problem in children. In roughly every 100 children encountered in a given population about 30 are likely to have some issues relating to constipation. It causes not insignificant amount of worry to parents.

Constipation can either be defined in time frames – the acceptable norm is to have at least 3 bowel movements a week; and the other definition, which is also more applicable medically, is the consistency of the stool and the discomfort it causes to the child whilst passing it.

So a hard and difficult to pass stool is more likely to fit the bill of constipation rather than how frequently it is passed.

The good news is that even with this high rate of occurrence, it is rarely related to a serious medical cause – over 90% cases are related to diet and behavioral issues.

Diet – A diet that is lacking in fluids or fiber is more likely to cause constipation but it must be said that the studies done so far have only shown a weak link with this. What it means is that its important to review the amount of these in child’s diet but just focusing on increasing the water consumed is unlikely to resolve the problem fully.

Milk – too much of a good thing can be bad applies to this case well. Children that have diet rich in milk tend to suffer more constipation. It is linked with high milk consumers also being fussy eaters and hence consuming less fiber.

Behavior – children can develop the behavior of avoidance quite quickly. If the child has experienced difficulty passing stools on occasions then child can learn to associate passing poo with pain. So they tend to hold it back until they can. These are the children that run away and hide under the tables or in the corners when they need to poop! Once they have done it long enough the amount of poo in the end part of the gut, called rectum, increases in size and becomes increasingly hard to pass. This creates an ongoing cycle of hard poo –> child holding back –>stool getting harder and larger –> more painful to pass –> child holding back even more. In some advanced cases it may even lead to leakage of small parts of soft stool in the child’s undies without them being aware of it.

The things that can help parents is intervening with diet where possible, reduce milk and help the child when they observe the behavior of avoidance of passing stool in the child. Some strategies are to teaching the child to have regular times to sit on the toilet seat with a foot stool – recommendations is for about 4-5 minutes at a time and about 3 times a day, reward charts and stickers, if child noted to be displaying  stool holding behavior (crossing legs, straining and simultaneously running to hide etc) then encourage them to sit on the toilet.

It is safe and in fact encouraged to use laxatives to help the children to transition from a phase of constipation to passing a soft, easy to pass bowel movement. Your GP can help in the matter of guidance of which and how  much laxative to use.

Although laxatives are not the long term solution but sometimes you have to use laxatives for months, occasionally even years, before full treatment is achieved.


We are constantly adjusting. As we move through different phases of our life, we experience diversity of changes – in our bodies, our ways of thinking, our social role and our relationship to our environment. Each such change is accompanied with adjustment.

Some instances of adjustment that we witness on daily basis are: transition from infancy to childhood (when we witness and experience this adjustment from the other side of the fence as a parent we often term it as ‘terrible twos’),  childhood to adolescence (this adjustment is well known and accepted in our society as ‘typical teenage behavior’), from teenage to young adulthood when we adjust to our changed role in the society, new work related roles and responsibilities, financial independence related challenges etc. New relationships and parenthood can be one of the most significant of these adjustments. Some adjustments can be at a much smaller but more personal level eg adjusting to a change in routine or adjusting to something someone has said etc.

Adjustment can be easy and smooth in some instances and bit difficult to understand and undergo at others.

When this adjustment is difficult to understand or comprehend it can potentially create a sense of dissatisfaction and disharmony in our internal environment. This can then manifest in symptoms of low mood, irritability, lack of motivation or concentration, sleep problems, apathy towards self with neglect of such simple basic activities as eating a balanced and healthy diet, exercising, relaxation – the core three elements of maintaining good health.

There is always a risk of medicalising this adjustment disorder as depression or anxiety and turning towards medications to help the symptoms. But as you can perhaps see that all that is needed to restore health and well-being in these situations is adjusting. Adjusting can be achieved by recognition of what the problem is (self awareness), what are the steps you can take to solve this problem (critical analysis) and how are you going to implement these steps(cognitive and behavioral therapy).

It may seem complicated at first but what you have to remember is that you are already an expert at adjusting – haven’t you already navigated your way through the adjustment from infancy to the stage where you are reading this blog? We mostly do great things without knowing we are doing them. The key in adjusting is gaining the awareness. That’s all.