Osteoarthritis, Symptoms, Causes, Treatment

Osteoarthritis (OA) is a degenerative joint disease. Causes is multifactorial, and still not understood. Commonly it is thought to be wear and tear of joints as one ages.

Two types of Osteoarthritis are recognised –

primary and secondary.

Primary OA: This occurs in a joint de novo. It occurs in old age, mainly in the weight bearing joints (knee and hip).

In a generalised variety, the trapezio-metacarpal joint of the thumb and the distal inter-phalangeal joints of the fingers are also affected. Primary OA is commoner than secondary OA.

Secondary OA: In this type, there is an underlying primary disease of the joint which leads to degeneration of the joint, often many years later.

It may occur at any age after adolescence, and occurs commonly at the hip. Predisposing factors are:

(i) congenital mal development of a joint;

(ii) irregularity of the joint surfaces from previous trauma

(iii) previous disease producing a damaged articular surface

(iv) internal derangement of the knee, such as a loose body

(v) mal-alignment (bow legs etc.)

 (vi) obesity and excessive weight.

Causes of secondary Osteoarthritis of the hip

Avascular necrosis

Idiopathic

Post-traumatic e.g., fracture of femoral neck Alcoholism

Post-partum osteonecrosis

Chronic liver failure

Patient on steroids

Patient on dialysis

Sickle cell anaemia

Coxa vara

Congenital dislocation of hip (CDH)

Old septic arthritis of the hip

Malunited fractures

Fractures of the acetabulum 

PATHOLOGY

Osteoarthritis is a degenerative condition primarily affecting the articular cartilage. The first change observed is an increase in water content and depletion of the proteoglycans from the cartilage matrix. Repeated weight bearing on such a cartilage leads to its fibrillation.

The cartilage gets abraded by the grinding mechanism at work at the points of contact between the apposing articular surfaces, until eventually the underlying bone is exposed. With further ‘rubbing’, the subchondral bone becomes hard and glossy.

Meanwhile, the bone at the margins of the joint hypertrophies to form a rim of projecting spurs known as osteophytes. A similar mechanism results in the formation of subchondral cysts and sclerosis.

The loose flakes of cartilage incite synovial inflammation and thickening of the capsule, leading to deformity and stiffness of the joint. Often one compartment of a joint is affected more than the other.

For example, in the knee joint, the medial compartment is affected more than the lateral, leading to a varus deformity (genu varum).

CLINICAL FEATURES OSTEOARTHRITIS

The disease occurs in elderly people, mostly in the major joints of the lower limb, frequently bilaterally. There is a geographical variation in the joints involved, depending probably upon the daily activities of a population.

The hip joint is commonly affected in a popula habits, while the knee is involved more commonly in a population with Asian living habits i.e., the habit of squatting and sitting cross legged.

Pain is the earliest symptom. It occurs inter mittently in the beginning, but becomes constant over months or years. Initially, it is dull pain and comes on starting an activity after a period of rest; but later it becomes worse and cramp-like, and comes after activity.

A coarse crepitus may be complained of by some patients. Swelling of the joint is usually a late feature, and is due to the effusion caused by inflammation of the synovial tissues.

X-Ray of the knee AP and Lateral views, showing osteoarthritis of the knee

Stiffness is initially due to pain and muscle spasm; but later, capsular contracture and incon gruity of the joint surface contribute to it. Other symptoms are: a feeling of ‘instability’ of the joint, and ‘locking’ resulting from loose bodies and frayed menisci.

EXAMINATION

Following findings may be present:

Tenderness on the joint line

Crepitus on moving the joint

Irregular and enlarged-looking joint due to

formation of peripheral osteophytes • Deformity -varus of the knee, flexion-adduction external rotation of the hip

Effusion – rare and transient

Terminal limitation of joint movement

Subluxation detected on ligament testing Wasting of quadriceps femoris muscle.

Investigations

Radiological examination: The diagnosis of osteoarthritis is mainly radiological. The following are some of the radiological features:

Narrowing of joint space, often limited to a part of the joint e.g., may be limited to medial compartment of tibio-femoral joint of the knee. 

Subchondral sclerosis – dense bone under the articular surface 

Subchondral cysts

Osteophyte formation

Loose bodies 

Deformity of the joint

Other investigations are made primarily to detect an underlying cause. These consist of the following:

Serological tests and ESR to rule out rheumatoid arthritis.

Serum uric acid to rule out gout

Arthroscopy, if a loose body or frayed meniscus is suspected

TREATMENT OF OSTEOARTHRITIS

Principles of treatment: Once the disease starts, it progresses gradually, and there is no way to stop it. Hence efforts are directed, wherever possible, to the following:

a) To delay the occurrence of the disease, if the disease has not begun yet.

b) To stall progress of the disease and relieve symptoms, if the disease is in early stages.

c) To rehabilitate the patient, with or without surgery, if his disabilities can be partially or completely alleviated.

Methods of treatment: To achieve the above objectives, the following therapeutic measures may be undertaken:

a) Drugs: Analgesics are used mainly to suppress pain. A trial of different drugs is carried out to find a suitable drug for a particular patient. Long-acting formulations are preferred.

b) Chondroprotective agents: Agents such as Glucosamine and Chondroitin sulphate have been introduced, claiming to be the agents which result in repair of the damaged cartilage. Their role as disease modifying agents has yet not been established, but these could be tried in some early cases.

Viscosuplementation: Sodium Hylarunon has been introduced. It is injected in the joint 3-5 times at weekly interval. It is supposed to improve cartilage functions, and is claimed to be chondroprotective.

d) Supportive therapy: This is a useful and harmless method of treatment and often gives gratifying results. It consists of the following: Weight reduction, in an obese patient.

Avoidance of stress and strain to the affected joint in day-to-day activities. For example, a patient with OA of the knee is advised to avoid standing or running whenever possible. Sitting cross legged and squatting is harmful for OA of the knee.

Local heat provides relief of pain and stiffness.

Exercises for building up the muscles controlling the joint help in providing stability to the joint.

The local application of counter-irritants and liniments sometimes provide dramatic relief.

e) Surgical treatment: In selected cases, surgery can provide significant relief. Following are some of the surgical procedures performed for OA:

OSTEOTOMY: Osteotomy near a joint has been known to bring about relief in symptoms, especially in arthritic joints with deformities. A high tibial osteotomy for OA of the knee with genu varum and inter-trochanteric osteotomy for OA of the hip have been shown to be useful for pain relief.

     (a) High tibial Osteotomy            (b) Total knee replacement

JOINT REPLACEMENT: For cases crippled with advanced damage to the joint, total joint replacement operation has provided remarkable rehabilitation. These are now commonly performed for the hip and knee. An artificial joint serves for about 10-15 years.

JOINT DEBRIDEMENT: This operation is not so popular now. In this, the affected joint is opened, degenerated cartilage smoothened, and osteophytes and the hypertrophied synovium excised. The results are unpredictable.

ARTHROSCOPIC PROCEDURES: Arthroscopic removal of loose bodies, degenerated meniscal tears and other such procedures have become popular because of their less invasive nature.

In arthroscopic chondro plasty, the degenerated, fibrillated cartilage is excised using a power-driven shaver under arthroscopic vision. Results are unpredictable.

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What is hypothyroidism, Symptoms, treatment

In hypothyroidism Decreased secretion of thyroid hormones is called hypothyroidism. Hypothyroidism leads to myxedema in adults and cretinism in children.

Hypothyroidism (Myxedema)

Myxedema is the hypothyroidism in adults, characterized by generalized edematous appearance.

Causes for Hypothyroidism (myxedema)

Myxedema occurs due to diseases of thyroid gland, genetic disorder or iodine deficiency. In addition, it is also caused by deficiency of thyroid-stimulating hormone or thyrotropin-releasing hormone.

Common cause of myxedema is the autoimmune disease called Hashimoto’s thyroiditis, which is common in late middle-aged women. In most of the patients, it starts with glandular inflammation called thyroiditis caused by autoimmune antibodies. Later it leads to destruction of the glands.

Signs and symptoms of Hypothyroidism

Typical feature of this disorder is an edematous appearance throughout the body. It is associated with the following symptoms:

Swelling of the face

Bagginess under the eyes

3.Non-pitting type of edema, i.e. when pressed, it does not make pits and the edema is hard. It is because of accumulation of proteins with hyaluronic acid and chondroitin sulfate, which form a hard tissue with increased accumulation of fluid

Atherosclerosis: It is the hardening of the walls of arteries because of accumulation of fat deposits and other substances. In myxedema, it occurs because of increased plasma level of cholesterol which leads to deposition of cholesterol on the walls of the arteries.

Atherosclerosis produces arteriosclerosis, which refers to thickening and stiffening of arterial wall Arteriosclerosis causes hypertension. Other general features of hypothyroidism in adults are:

Anemia

Fatigue and muscular sluggishness

Extreme somnolence with sleeping up to 14 to 16 hours per day

Menorrhagia and polymenorrhea

5.Decreased cardiovascular functions such as reduction in rate and force of contraction of the 6. Increase in body weight heart, cardiac output and blood volume

Increase in body weight

Constipation

Mental sluggishness

Depressed hair growth

Scaliness of the skin

Frog-like husky voice

Cold intolerance.

Cretinism

Cretinism is the hypothyroidism in children, characterized by stunted growth.

Causes for cretinism

Cretinism occurs due to congenital absence of thyroid gland, genetic disorder or lack of iodine in the diet.

Features of cretinism

A newborn baby with thyroid deficiency may appear normal at the time of birth because thyroxine might have been supplied from mother. But a few weeks after birth, the baby starts developing the signs like sluggish movements and croaking sound while crying. Unless treated immediately, the baby will be mentally retarded permanently.

3 Month old baby with hypothyroidism (Cretinism)

Skeletal growth is more affected than the soft tissues. So, there is stunted growth with bloated body. The tongue becomes so big that it hangs down with dripping of saliva g of saliva. The big tongue obstructs swallowing and breathing. The tongue produces characteristic guttural breathing that may sometimes choke the baby.

A cretin is different from pituitary dwarf. In cretinism, there is mental retardation and the different parts of the body are disproportionate. Whereas, in dwarfism, the development of nervous system is normal and the parts of the body are proportionate. The reproductive function is affected in cretinism but it may be normal in dwarfism.

GOITER

Goiter means enlargement of the thyroid gland. It occurs both in hypothyroidism and hyperthyroidism. Goiter in Hyperthyroidism –

Enlargement of Thyroid Gland

Toxic Goiter

Toxic goiter is the enlargement of thyroid gland with increased secretion of thyroid hormones, caused by thyroid tumor.

Goiter in Hypothyroidism – Non-toxic Goiter Non-toxic goiter is the enlargement of thyroid gland without increase in hormone secretion. It is also called hypothyroid goiter. Based on the cause, the non-toxic hypothyroid goiter is classified into two types.

Endemic colloid goiter

Idiopathic non-toxic goiter.

1- Endemic colloid goiter

Endemic colloid goiter is the non-toxic goiter caused by iodine deficiency. It is also called iodine deficiency goiter. lodine deficiency occurs when intake is less than 50 µg/day. Because of lack of iodine, there is no formation of hormones. By feedback mechanism. hypothalamus and anterior pituitary are stimulated. It increases the secretion of TRH and TSH. The TSH then causes the thyroid cells to secrete tremendous amounts of thyroglobulin into the follicle. As there are no hormones to be cleaved, the thyroglobulin remains as it is and gets accumulated in the follicles of the gland. This increases the size of gland.

 In certain areas of the world, especially in the Swiss Alps, Andes, Great Lakes region of United States and in India, particu Kashmir Valley, the does contain enough iodine. Therefore, the foodstuffs also do not contain iodine. The endemic colloid goiter was very common in these parts of the world before the introduction of iodized salts.

2-Idiopathic non-toxic goiter

 Idiopathic non-toxic goiter is the goiter due to unknown cause. Enlargement of thyroid gland occurs even with out iodine deficiency. The exact cause is not known. It is suggested that it may be due to thyroiditis and deficiency of enzymes such as peroxidase, iodinase and deiodi nase, which are required for thyroid hormone synthesis.

 Some foodstuffs contain goiterogenic substances (goitrogens) such as goitrin. These substances contain antithyroid substances like propylthiouracil. Goitrogens suppress the synthesis of thyroid hormones. Therefore, TSH secretion increases, resulting in enlargement of the gland. Such goitrogens are found in vegetables like turnips and cabbages. Soybean also contains some amount of goitrogens.

TREATMENT FOR HYPOTHYROIDISM

The only treatment for hypothyroidism is the administration of thyroid extract or ingestion of pure thyroxine in the form of tablets, orally

Thyroid. Symptoms, Treatment and Test

Balance Diet. What should we eat According to ICMR?

A balance diet is defined as a diet, which contains variety of foods in such quantities and proportions that the need for energy, amino acids, minerals, fats, carbohydrates and other nutrients is adequately met for maintaining health, vitality and general well being.

It also makes a provision of extra nutrients to withstand short duration of leanness A balanced diet is a diet that provides all 6 nutrients; carbohydrates, proteins, lipids, minerals, vitamins, water in proper amounts and proportions to maintain good health.

Definition of Balance Diet

A balanced diet provides all the six nutrients; carbohydrates, proteins, fats, minerals, vitamins and water in proper amounts and proportions to meet all the nutritional requirement of the body.

Each nutrient has its specific role in the body. . Carbohydrates (sugars and starch) provide energy. Fibers provide roughage action. .

Proteins are vital for growth (body building), maintenance and tissue repair. . Lipids provide energy as well as act as carriers of fat soluble vitamins.

Importance of Balance Diet

Vitamins and minerals are required for growth and also for regulation and control of metabolic processes.

Water provides the medium for all body metabolisms. Water is also required to flush out the waste products and remove the toxins.

It is a total cleanser. A balanced diet should meet the energy requirement of the body and also need for growth, maintenance and tissue repair. Balanced diet contributes towards good health.

Principles and Points to be considered while planning balanced diets:

A balanced diet should ensure the proper amounts and proportions of all the six nutrients to maintain optimal health.

Minimum RDA of all nutrients should be met

Factors like age, sex, physiological states (pregnancy, lactation), growth, physical activity, dietary habits, individual likes & dislikes, economic status and food budget of the family, family composition etc. are considered while planning a balanced diet.

Guidelines for calculating individual nutrient amounts of balanced diet. Main purpose of food is to supply energy.

But, while planning the balanced diet, body’s need for growth, maintenance, repair, protection, regulation must be fulfilled first (by proteins & fats) & then the total energy requirement is made up by carbohydrates.

In a balanced diet, the ratio of proteins, fat & carbohydrates would be 2:2:6 (or 1:2:7).

Proteins: First and foremost, the daily requirement of proteins (both qualitative and quantitative) should be met. This amounts to about 10-20% of total energy need.

Paneer and Cabbage protein rich diet with low carbohydrate.

Lipids: Lipid (mainly fats) need is considered next. It is recommended that the lipids provide about 20% of the total energy requirement.

Lipids should not exceed 30% o the total energy need & minimum should be about 10%. Saturated fat should not exceed 10% of total energy need and at least 10% of the total energy requirement must com from unsaturated fats (poly & mono).

Carbohydrates: Carbohydrates (rich in natural fiber) should make up the remaining energy.

It is recommended that the carbohydrates provide about 60-70% of the total energy requirement, making it the chief source of energy. At least 40% of the total energy requirement must come from carbohydrate to prevent ketosis & muscle wasting Vitamins and Minerals:

The RDA of all vitamins and minerals should also be met When the energy and protein requirement is met and the food is selected from all food groups, the requirement of vitamins and minerals are automatically fulfilled. However, RDA’s of vitamin B iron, calcium and sodium are carefully considered.

Dietary Goals (Recommendations for a balanced diet): Main food: Cereals form the main sources of energy in diets. At least 40% of energy comes from cereals in a balanced diet.

Energy from cereals should not be more than 75% At least 60g of pulses should be taken. Ratio of cereal & pulse should be at 4:1 to ensure the better protein quality (by complementary action).

For non vegetarians 50% of pulses are replaced with one egg or 30 grams of meat or fish. If there are no pulses in the diet, amount of fish, meat or eggs are doubled.

Milk: There should be a minimum of 100 ml of milk included in every ml of fat-free or low-fat milk or milk products is recommended day’s diet. 300

Water: Diet should be containing adequate water to ensure the passage of 1.5 liters to 2 liters of urine per day. Fibers & antioxidants.

Diet should be contain adequate dietary fibers and antioxidants. At least 1 medium sized fruit & green leafy vegetables are recommended per day.

Energy: Total energy supply suggested to be + 50 of RDA.

Protein: Protein should account for about 10 to 15% of the total energy. • Balanced diet must be low in saturated & trans fats, cholesterol, added sugars, salt:

Total fat intake should not exceed 20 to 35% of calories. Lesser than 10% of calories should come from saturated fatty acids. Cholesterol intake should be less than 300 mg/day and trans fatty must be restricted.

Total calories from refined carbohydrates like sugars should be about 5% of total energy requirement. It should not exceed 20% of total energy requirement.

Salt intake should be limited to less than 5 mg/day.

Alcohol: Do not consume more than one alcoholic drink per day for women, two per day for men. Certain individuals should abstain from alcohol completely.

Junk foods: Colas, ketchups & other foods that supply empty calories must be reduced.

ICMR recommend balance diets

In India, Indian Council of Medical Research (ICMR) is responsible for setting up. reviewing and revision of balanced diet.

Balanced diet is prescribed by Nutrition expert committee of ICMR based total energy requirement and RDA for all the essential nutrients.

Balanced diet for reference man and reference woman based on portion size & exchange system (ICMR values) is given here. on daily basis.

This accommodates daily total energy requirement & RDA for all the essential nutrients for the reference group.

ICMR Blalanced Diet Table

For Adults (Reference Men (60Kg) & Reference Women (50Kg).

Food Gropus Exchange List	Portion  Size (g)	Number of Portion (ICMR Values)       Sedentary                        Moderate                           Heavy  Men          Women        Men           Women        Men          Women
Cereals and millets	30	14	10	16	12	23	16
Pulses	300	2	2	3	2.5	3	3
Milk (Ml)	100	3	3	3	3	3	3
Roots and Tubers	100	2	1	2	1	2	2
Green Leafy Vegetables	100	1	1	1	1	1	1
Other Vegetables	100	1	1	1	1	1	1
Fruits	100	1	1	1	1	1	1
Sugars	5	5	4	8	5	11	9
Fats/Oils (Visible)	5	4	4	7	6	11	8

For Non Vegetarians

Exchange 1 Pulses portion with 1 egg or 1 Portion (50g) of meat/Chicken/fish (or both pulse serving can be exchanged with 2 eggs or 2 portion (100g) meat/chicken/fish.

An Indian reference man and reference woman:

Age is between 20-39 years, weighs 60 Kgs and surface area is 1.62 m².

Engaged in 8 hours of moderate work, sleeps for 8 hours, 6 hours of light activity. Engaged in 2 hours of active recreation.

An Indian reference woman:

A Age is between 20-39 years, weighs 50 Kgs and surface area is 1.4 m². Engaged in 8 hours of moderate work, sleeps for 8 hours, 6 hours of light activity. Engaged in 2 hours of active recreation.

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Thyroid. Symptoms, Treatment and Test

Thyroid is an endocrine gland situated at the root of the neck on either side of the trachea. It has two lobes, which are connected in the middle by an isthmus .

THYROID GLAND

Thyroid gland is composed of large number of closed follicles. These follicles are lined with cuboidal epithelial cells, which are called the follicular cells. Follicular cavity is filled with a colloidal substance known as thyroglobulin, which is secreted by the follicular cells Follicular cells also secrete tetraiodothyronine (T, or thyroxine) and tri-iodothyronine (T). In between the follicles, the parafollicular cells are present. These cells secrete calcitonin.

It weighs about 20 to 40 g in adults. Thyroid is larger in females than in males. The structure and the function of the thyroid gland change in different stages of the sexual cycle in females.

Its function increases slightly during pregnancy and lactation and decreases during menopause.

HORMONES OF THYROID GLAND

Thyroid gland secretes three hormons

1. Tetraodothyronine or T4(thyroxin

2. Tri-iodothyronine or T3

3. Calcitonin

FUNCTIONS OF THYROID HORMONES

Thyroid hormones have two major effects on the body: 1. To increase basal metabolic rate.

II. To stimulate growth in children.

The actions of thyroid hormones are:

1-BASAL METABOLIC RATE (BMR)

Thyroxine increases the metabolic activities in most of the body tissues, except brain, retina, spleen, testes and lungs. It increases BMR by increasing the oxygen consumption of the tissues. The action that increases the BMR is called calorigenic action.

In hyperthyroidism, BMR increases by about 60% to 100% above the normal level and in hypothyroidism it falls by 20% to 40% below the normal level.

2- FAT METABOLISM

Thyroxine decreases the fat storage by mobilizing it from adipose tissues and fat depots. The mobilized fat is converted into free fatty acid and transported by blood. Thus, thyroxine increases the free fatty acid level in blood.

3-VITAMIN METABOLISM

Thyroxine increases the formation of many enzymes. Since vitamins form essential parts of the enzymes, it is believed that the vitamins may be utilized during the formation of the enzymes. Hence, vitamin deficiency is possible during hypersecretion of thyroxine.

4. BODY TEMPERATURE

Thyroid hormone increases the heat production in the body, by accelerating various cellular metabolic processesand increasing BMR. It is called thyroid hormone induced thermogenesis. During hypersecretion of thyroxine, the body temperature increases greatly, resulting in excess sweating.

5. GROWTH

Thyroid hormones have general and specific effects on growth. Increase in thyroxine secretion accelerates the growth of the body, especially in growing children. Lack of thyroxine arrests the growth. At the same time, thyroxine causes early closure of epiphysis. So, the height of the individual may be slightly less in hypothyroidism.

Thyroxine is more important to promote growth and development of brain during fetal life and first few years of postnatal life. Deficiency of thyroid hormones during this period leads to mental retardation.

6. BODY WEIGHT

Thyroxine is essential for maintaining the body weight Increase in thyroxine secretion decreases the body weight and fat storage. Decrease in thyroxine secretion increases the body weight because of fat deposition.

9. BLOOD

Thyroxine accelerates erythropoietic activity and increases blood volume. It is one of the important general factors necessary for erythropoiesis. Polycythemia is common in hyperthyroidism.

10. CARDIOVASCULAR SYSTEM

Thyroxine increases the overall activity of cardiovascular system.

i. On Heart Rate

Thyroxine acts directly on heart and increases the heart rate. It is an important clinical investigation for diagnosis of hypothyroidism and hyperthyroidism.

 ii. On the Force of Contraction of the Heart

Due to its effect on enzymatic activity, thyroxine generally increases the force of contraction of the heart. But in hyperthyroidism or in thyrotoxicosis, the heart may become weak due to excess activity and protein catabolism. So, the patient may die of cardiac decompensation.

 Cardiac decompensation refers to failure of the heart to maintain adequate circulation associated with dyspnea, venous engorgement (veins overfilled with blood) and edema.

11-CENTRAL NERVOUS SYSTEM

Thyroxine is very essential for the development maintenance of normal functioning of central nervous system (CNS).

i. On Development of Central Nervous System

Thyroxine is very important to promote growth and development of the brain during fetal life and during the first few years of postnatal life. Thyroid deficiency in infants results in abnormal development of synapses, defective myelination and mental retardation.

 ii. On the Normal Function of Central

 Nervous System

Thyroxine is a stimulating factor for the central nervous system, particularly the brain. So, the normal functioning of the brain needs the presence of thyroxine. Thyroxine also increases the blood flow to brain.

12- SLEEP

Normal thyroxine level is necessary to maintain normal sleep pattern. Hypersecretion of thyroxine causes excessive stimulation of the muscles and central nervous system. So, the person feels tired, exhausted and feels like sleeping. But, the person cannot sleep because of the stimulatory effect of thyroxine on neurons. On the other hand, hyposecretion of thyroxine causes somnolence.

13- SEXUAL FUNCTION

Normal thyroxine level is essential for normal sexual function. In men, hypothyroidism leads to complete loss of libido (sexual drive) and hyperthyroidism leads to impotence.

In women, hypothyroidism causes menorrhagia and polymenorrhea (Chapter 80). In some women, it causes irregular menstruation and occasionally amenorrhea. Hyperthyroidism in women leads to oligomenorrhea and sometimes amenorrhea.

14- OTHER ENDOCRINE GLANDS

Because of its metabolic effects, thyroxine increases the demand for secretion by other endocrine glands.

Hyperthyroidism

Increased secretion of thyroid hormones is called hyperthyroidism.

Causes of Hyperthyroidism Hyperthyroidism is caused by:

 1. Graves’ disease

 2. Thyroid adenoma.

 1. Graves’ disease

Graves’ disease is an autoimmune disease and it is the most common cause of hyperthyroidism. Normally. TSH combines with surface receptors of thyroid cells and causes the synthesis and secretion of thyroid hormones. In Graves’ disease, the B lymphocytes (plasma cells) produce autoimmune antibodies called thyroid-stimulating autoantibodies (TSAbs).

These antibodies act like TSH by binding with membrane receptors of TSH and activating CAMP system of the thyroid follicular cells. This results in hypersecretion of thyroid hormones.

Antibodies act for a long time even up to 12 hours in contrast to that of TSH, which lasts only for an hour or so. The high concentration of thyroid hormones caused by the antibodies suppresses the TSH production also. So, the concentration of TSH is low or almost zero in plasma of most of the hyperthyroid patients.

2. Thyroid adenoma

Sometimes, a localized tumor develops in the thyroid tissue. It is known as thyroid adenoma and it secretes large quantities of thyroid hormones. It is not associated with autoimmunity. As far as this adenoma remains active, the other parts of thyroid gland cannot secrete the hormone. This is because, the hormone secreted from adenoma depresses the production of TSH.

Signs and Symptoms of Hyperthyroidism

1. Intolerance to heat as the body produces lot of heat due to increased basal metabolic rate caused by excess of thyroxine.

2. Increased sweating due to vasodilatation

3. Decreased body weight due to fat mobilization

4. Diarrhea due to increased motility of GI tract

5. Muscular weakness because of excess protein catabolism

6. Nervousness, extreme fatigue, inability to sleep, mild tremor in the hands and psychoneurotic symptoms. such as hyperexcitability, extreme anxiety or worry. All these symptoms are due to the excess stimulation of neurons in the central nervous system

7. Toxic goiter 

8. Oligomenorrhea or amenorrhea 

9. Exophthalmos (see below)

10. Polycythemia 

11. Tachycardia and atrial fibrillation

12 Systolic hyperthyroidism

13 Cardiac failure

TREATMENT FOR HYPERTHYROIDISM

 1. By using Antithyroid Substances

Antithyroid substances are the drugs which suppress the secretion of thyroid hormones. Hyperthyroidism in early stage can be treated by antithyroid substances. Three well-known antithyroid substances are:

 i. Thiocyanate

 ii. Thiourylenes

 iii. High concentration of inorganic iodides.

 i. Thiocyanate

Thiocyanate prevents synthesis of thyroxine by inhibiting iodide trapping. The active pump which transports iodide into the thyroid cells, can transport thiocyanate ions also. So, administration of thiocyanate in high concentrations causes competitive inhibition of iodide transport into the cell. So, iodide trapping is inhibited, leading to the inhibition of synthesis of thyroxine.

 ii. Thioureylenes

Thioureylenes are the thiourea-related substances such as propylthiouracil and methimazole, which prevent the formation of thyroid hormone from iodides and tyrosine. It is achieved partly by blocking peroxidase enzyme activity and partly by blocking coupling of iodinated tyrosine to form either T, or T..

During the use of these two antithyroid substances, even though the synthesis of thyroid hormone is inhibited, the formation of thyroglobulin is not stopped. The deficiency of the hormone increases the TSH secretion, which increases the size of thyroid gland with more secretion of thyroglobulin. Thyroglobulin accumulates in the gland and causes enlargement of the gland, resulting in non-toxic goiter.

iii. High concentration of inorganic iodides

lodides in high concentration decrease all phases of thyroid activity, including the release of hormones. So,the size of the gland is also reduced with decreased blood supply. Because of this, iodides are frequently administered to hyperthyroid patients for 2 or 3 weeks prior to surgical removal of the thyroid gland.

2. By Surgical Removal

In advanced cases of hyperthyroidism, treatment by using antithyroid substances is not possible. So, thyroid gland of these patients must be removed. Surgical removal of thyroid gland is called thyroidectomy. Before surgery, the patient is prepared by reducing the basal metabolic rate.

It is done by injecting propylthiouracil for several weeks, until basal metabolic rate reaches almost the basal level. The high concentration of iodides is administered for 2 weeks. It decreases the size of the gland and blood supply to a very great extent. Because of these precautions, the mortality after the operation decreases very much.

THYROID FUNCTION TESTS

 Functional status of thyroid gland is assessed by the following tests:

1. Measurement of plasma level of T, and T.: For hyperthyroidism or hypothyroidism, the most accurate diagnostic test is the direct measurement of concentration of “free” thyroid hormones in the plasma, i.e. T, and T

2. Measurement of TRH and TSH: There is almost total absence of these two hormones in hyperthyroidism. It is because of negative feedback mechanism, by the increased level of thyroid hormones.

3. Measurement of basal metabolic rate: In hyper thyroidism, basal metabolic rate is increased by about 30% to 60%. Basal metabolic rate is decreased in hypothyroidism by 20% to 40%.

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What is Nutrition? Nutrition- from a need to a trade

Most of us tend to view nutrition through green-colored lenses a lifestyle that symbolizes all greens and zero flavors. A dietary choice that forces you to leave behind the multicolored world of grease and cheese to step into a green-colored one filled with peculiar sounding vegetables like kale and healthy smoothies. You’d be surprised to know that the World Health Organization (WHO) has defined nutrition as the intake of food, following the body’s dietary needs.’

Importance of Nutrition 

Food has become our confidante in happiness, sadness, and fashionably so in fitness. While fitness may have gained more screen footage in recent times, we’ve lost the path that brings us good health. With newer and stranger diseases on the rise, this is the time to take a step back and reflect on what we pump into our body every single day.

You can argue that with technological advancement, the medical space has found solutions to unknown ailments. Unlike in the past we now have treatments available for cancer, diabetes, tuberculosis, and even the common cold. So why bother monitoring your diet. After all, life was meant to be lived, not fretted over.

Nutrition doesn’t have to mean fancy, fitness-freaky food; all it means is a diet that consists of fresh and natural ingredients that fulfill your body’s dietary needs. A fresh salad with colorful vegetables, home-made lentils and rice and a grilled chicken sandwich (sans the mayonnaise) are all examples of nutritious meals.

A packaged granola health bar may contain high levels of sugar and saturated fats while home-cooked the plas and vegetables thrown on the grill can be an excellent way to get some lean protein and anti inflammatory spices like cumin, fenugreek, and turmeric into your body. Simply put, WHO’s philosophy that ‘good nutrition-an adequate, well-balanced diet combined with regular physical activity is a cornerstone of good health’ is a good credo to not lose sight of.

Consider the meals you eat. What is the major part of your main meals: breakfast, lunch, and dinner? Do you realize that most of the time your meal is mostly wheat chapatti/ bread or white rice, which is accompanied by whatever else is on the menu, sometimes it is dal or a vegetable, an added curd or chutney/achaar.

Most of the time we just eat as a matter of habit. Have we thought that the chapatti we eat is primarily carbohydrates and every portion of carbohydrates that we eat should have an appropriate portion of protein (dairy and pulses), fat (ghee and oils) and vitamins and minerals (dairy, vegetables, salads, and chutneys)? Unless all these nutrients are eaten in a definite proportion, you are not eating a balanced diet.

To understand this better, consider the ICMR guidelines. As per this, an Indian sedentary adult male needs this ratio:

Cereals and millets	30 gms
Pulses	30 gms
Milk and milk products	100 ml
Roots and Tubers	100 gms
Green vegetables	100 gms
Other vegetables	100 gms
Fruits	100 gms
Sugar	5 gms
Fat	2.5 gms

This guideline clearly shows that we need to eat equal amounts of cereals and pulses, lots of milk, fruits, and vegetables to meet our recommended daily requirement of proteins, vitamins, and minerals.

For every 1 roti/ chapatti (approx. 30 gms of wheat),

you should consume:

1 cup of dal

1/2 cup of milk as curd/paneer

½ cup of green vegetables (like spinach, methi, lauki, torai, tinda, pepper, karela, cucumber) 1/2 cup of other vegetables (like tomato, brinjal, beans, onions, garlic, lotus stem, cauliflower, cabbage, broccoli)

1/2 cup of roots and tubers (like potato, sweet potato, arbi, yam) tsp. of healthy oilseed oil/ghee

You need to know this:

The ‘multigrain’ term used in commercially packaged food means only that more than one grain is present and the primary ingredient is usually refined wheat flour.

The Confusion Surrounding Nutrition

There is no doubt that maintaining good health has become somewhat of an essential issue in the recent past. With lifestyle related diseases like diabetes and heart ailments affecting more and more people the profession of nutritionists and dietitians has boomed beyond imagination.

While nutritionists have helped a significant part of the world’s population get its life back on track, they have also complicated food for the significant other. We live in the Internet age, and that means everybody has access to a mine of conflicting information.

While the innocent potato and the somewhat comforting food group of fat have earned a bad reputation, various people have taken to adopting multiple diets, Right from the Paleo diet and Dukan diet to the Atkins and Keto diet, all everybody seems to want to do is lose weight.

Unfortunately, we have gotten all tangled up in this sticky web of specialty diets and healthy’ ingredients that promise to burn our pockets. The focus has shifted from eating healthy to losing weight, and that translates to the end justifies all means’ philosophy.

Teenagers and young adults choose to cut carbohydrates, dairy, and all kind of fat from their diet in the desperate attempt to lose weight, forgetting that in these formative years of their lives, they are eliminating essential micro nutrients required for bone formation and brain health.

Most fast-food is very high in sodium even items you might think are not. For example, the veggie burger has 900 milligrams, followed by the corn muffin-770 milligrams. The shake has nearly twice as much sodium as the fries.

You need to know this:

Tomato, cottage cheese (a firm white Indian cheese also known as paneer made from buffalo or cow milk) and avocado salad with warm homemade bread makes for a healthy meal.

An omelette with fresh herbs takes three minutes to prepare and two minutes to cook. Served with green salad or fresh vegetables and a wholemeal roll, it provides a perfectly balanced meal.

Beans, vegetable and ginger stir-fry with rice noodles take just ten minutes to prepare and provide a right balance of vital nutrients.

By choosing foods carefully from fast-food menus, you can select a reasonably well-balanced meal, while limiting the intake of more harmful ingredients. For instance, choose small plain burgers as opposed to a giant burger with all the trimmings. Or skip the mayonnaise and melted cheese.

By leaving these out, 200 calories can be saved on a king-sized burger (also reduces your fat intake). Or order milk instead of a milkshake, or just plain water instead of a conventional cola drink. If you are having fries, choose a smaller portion and have a side salad.

And never be persuaded to eat massive helpings than you need. known as paneer made from buffalo or cow milk) and avocado salad with warm homemade bread makes for a healthy meal. An omelette with fresh herbs takes three minutes to prepare and two minutes to cook. Served with green salad or fresh vegetables and a wholemeal roll, it provides a perfectly balanced meal.

Beans, vegetable and ginger stir-fry with rice noodles take just ten minutes to prepare and provide a right balance of vital nutrients.

Diseases like infertility, diabetes, and obesity were mostly non-existent in cultures surviving on a native diet of unrefined foods. Unfortunately, in this age of readily available convenience foods like frozen cheesy snacks, frozen cuts of meat, and ready-to-eat meals, we tend to get busy with our careers and forget to take care of ourselves.

Fact is that convenience foods aren’t all that convenient for your health. Regular snacking on foods high in sodium, excess salt, and sugar has replaced family meals eaten fresh on the dining table.

Now is the time to take control of your lives, go ahead and have the nutrition conversation that can change your life. Clear your cupboards of instant noodles, sugar-laden biscuits, and the greasy packet of aloo bhujia; a new era of healthy, whole grain snacks is here to save the day. After all, whole food leads to entire health.

Try any of the meals given below when the munchies strike:

Switch the maida/refined flour for ragi or jowar flour the next time you make Sunday pancakes. The high amount of dietary fiber in ragi has shown to lower blood sugar levels and helps in weight loss.

Craving the greasy golden goodness of McDonald’s French fries? Make sweet potato oven-baked fries at home instead. Giving you the same crunch and satisfaction, this snack will provide you with twice the amount of fiber than regular white potatoes and is super rich in potassium.

The sweltering heat and sweet cravings giving you no rest? Refrigerate two bananas overnight and chuck them in a blender the next morning with some honey and blueberries. Voila, you get creamy, smooth ice cream that is rich in anti-oxidants and potassium.

Cannot resist the buttery call of salty, crunchy movie hall popcorn? No worries, get yourself a packet of fresh corn seeds from an organic store, pop in a vessel with butter and some garlic for a tastier, healthier alternative.

In this blog, I invite the reader to have a conversation about what defines good health and proper nutrition. In this blog, you will find information on growing prevalent diseases like diabetes, hypertension, and heart diseases that seem to have confounded doctors.

Goals

Eat right

Lose extra body fat

Read about food Change food habits

Sleep properly

Medical check-ups on time Wash and eat fruits and vegetables.

Eat cooked and

raw food

Avoid

sugar

white flour

Avoid processed,

packaged food

Have one healthy

morning ritual

Low back pain causes, symptoms, treatment

Low Back pain is an extremely common human phenomenon, a price mankind has to pay for their upright posture. According to one study, almost 80 per cent of persons in modern industrial society will experience back pain at some time during their life.

Fortunately, in 70 per cent of these, it subsides within a month. But, in as many as 70 per cent of these (in whom pain had subsided), the pain recurs.

Causes of Low back pain

The specific etiology of most back pains is not clear. Postural and traumatic back pains are among the commonest.

Back pain could be a feature of an extra-spinal disease like a genitourinary or gynecological disease. The following findings in the clinical examination are helpful in reaching a diagnosis.

Congenital causes

Spina bifida

Lumbar scoliosis

Spondylolysis

Spondylolisthesis

Transitional vertebra

Facet tropism

Traumatic causes

Sprain, strain

Vertebral fractures

Prolapsed disc

Inflammatory causes

Tuberculosis

Ankylosing spondylitis

Seronegative spond-arthritis (SSA)

Degenerative

Osteoarthritis

Neoplastic

Benign

– Osteoid osteoma

– Eosinophilic granuloma

Malignant

-Primary: Multiple myeloma, Lymphoma – Secondaries from other sites

Metabolic causes

Osteoporosis

Osteomalacia

Pain referred from viscera

 Genitourinary diseases

Gynaecological diseases

Miscellaneous causes

Functional back pain 

Postural back pain

– Protuberant abdomen

Occupational bad posture

– Habitual bad posture

HISTORY

Age: Some diseases are commoner at a particular age. Back pain is uncommon in children, but if present, it is often due to some organic disease. This is different from adults, in whom psycho logical factors play an important role in producing back pain. In adolescents, postural and traumatic back pain are commoner.

In adults, ankylosing spondylitis and disc prolapse are common. In elderly persons, degenerative arthritis, osteoporosis and metastatic bone disease are usually the cause.

Sex: Back pain is commoner in women who have had several pregnancies. Lack of exercise leading to poor muscle tone, and nutritional osteomalacia are contributory factors in these patients. Some women put on a lot of weight during pregnancy, and later develop mechanical back pain.

Occupation: A history regarding the patient’s occupation may provide valuable clues to risk factors responsible for back pain. These are often not apparent to the patient, and could be a part of his ‘routine’. People in sedentary jobs are more vulnerable to back pain than those whose work involves varied activities. Back pain is common in surgeons, dentists, miners, truck drivers etc.

Past history: A past history of having suffered from spinal disease such as a traumatic or inflammatory disease may point to that as the possible cause of back pain.

Features of pain:

The following features are to noted:

Location: Pain may be located in the lower, middle or upper back. Disc prolapse and degenerative spondylitis occur in the lower lumbar spine; infection and trauma occur in the dorso-lumbar spine

Onset: Often, there is a history of significant trauma immediately preceding an episode of back pain, and may indicate a traumatic pathology such as a fracture, ligament sprain, muscle strain etc. A precipitating history is present in about 40 per cent cases of disc prolapse. The trauma may not particularly bea significant one.

It may be subtle, resulting from a routine activity such as twisting to pull something out of a drawer. Careful questioning regarding leisure activities and exercise is important because inconsistency in activity levels during work and leisure time can precipitate back pain.

Localisation of pain: Pain arising from a tendon or muscle injury is localised, whereas that i originating from deeper structure is diffuse. Often, pain referred to a dermatome of the lower limb, with associated neurological signs. pertaining to a particular root, points to nerve root entrapment.

Progress of the pain: In traumatic conditions, or in acute disc prolapse, pain is maximum at the onset, and then gradually. subsides over days or weeks. Back pain due to disc prolapse often has periods of remissions and exacerbation. An arthritic or spondylitic pain is more constant, and is aggravated by activity. Pain due to infection or tumour takes a progressive course, with nothing causing relief

Relieving and aggravating factors: Most back pains are worsened by activity and relieved by rest. Pain due to ankylosing spondylitis, and seronegative spond-arthritis (SSA) is typically worse after rest, and improves with activity. Severe back pain at night that responds to aspirin may indicate a benign tumour. Pain initiated on walking or standing and relieved by rest, is a feature of spinal stenosis. An increase in pain during menstruation may indicate al gynaecological pathology.

Associated symptoms: The following associated symptoms may point to the cause of back pai

Stiffness: It is associated with most painful backs, but it is a prominent symptom in pain due to ankylosing spondylitis, more so early in the morning. There may be an associated limitation of chest expansion.

Pain in other joints: In some rheumatic diseases, back pain may be the presenting feature, but on detailed questioning one may get a history of pain and swelling of other joints.

Neurological symptoms: Symptoms like paraesthesias, numbness or weakness may point to a lesion of the nervous tissue, or a lesion in close proximity to it (e.g., a disc prolapse).

Extra-skeletal symptoms: A history suggestive of abdominal complaints, urogenital complaints, or gynecological complaints may indicate an extra-skeletal cause of back pain.

Mental status of the patient must be judged to rule out any psychological cause of back pain (hysteria, malingering, etc.). A patient suffering from an organic disease may have an significant underlying psychological disturbance also.

posture and low back pain

PHYSICAL EXAMINATION

The patient should be stripped except undergarments, and examined in the standing and lying down positions:

Standing position: The following observations are made in the standing position:

Position: Normally a person stands erect with the centre of the occiput in the line with the natal cleft , the two shoulders are at the same level, the lumbar hollows are symmetrical and the pelvis is ‘square’. In a case with back pain, look for scoliosis, kyphosis, lordosis, pelvic tilt and forward flexion of the torso on the lower limbs.

Spasm: Muscle spasm may be present in acute back pain and can be discerned by the prominence of the para-vertebral muscles at rest, which stand out on slightest movement.

Tenderness: Localised tenderness may indicate ligament or muscle tear. There may be trigger points or tender nodules in cases of fibrositis (see page 304). Pain originating from the sacroiliac joint may have tenderness localised to the posterior superior iliac spine.

Swelling: A cold abscess may be indicating tuberculosis as the cause. 

Bending Forward

Range of movement: There is limitation of movement in organic diseases of the spine. One must carefully differentiate spinal movements from the patient’s ability to bend at the hips. 

Lying down position: In the supine position the following observations are made.

Straight leg raising test (SLRT): This is a test to detect nerve root compression (Annexure-III). 

Neurological examination: Sensation, motor power and reflexes of the lower limb a examined. This helps in localising the site of spine pathology.

Peripheral pulses: The peripheral pulses should be palpated to detect a vascular cause of low back pain, which may be due to vascular claudication.

The skin temperature in the affected leg may be lower.

Adjacent joints: Often, the pain originates from the hip joints or the sacro-iliac joints, hence the should be examined routinely.

Abdominal, rectal or per vaginal examination may be done wherever necessary. Chest expan sion should be measured in young adults with back pain.

INVESTIGATION

The diagnosis of back pain is essentially clinical. There is no use getting X-rays done in acute back pain less than 3 weeks duration, as it does not affect the treatment. On the contrary, X-ray examination is a must for back pain lasting more than 3 weeks; it is almost an extension of the clinical examination.

There are a number of other investigations like CT scan, MRI scan, bone scan, blood investigations etc. One has to be very thoughtful in ordering these investigations. Order only when you think it is going to change your line of action, or if the clinical diagnosis is doubtful.

Radiological examination: Routine X-rays of the lumbosacral spine (AP and lateral) and pelvis (AP) should be done in all cases. These are useful in diagnosing metabolic, inflammatory and neoplastic conditions. Though, X-rays are usually normal in non-specific back pain, these provide a base line. X-rays should be done after preparation of the bowel with laxatives and charcoal tablets.

CT scan has replaced more invasive techniques like myelography etc. It shows most bony and soft tissue problems around the spine and spinal canal.

MRI scan is an expensive investigation, now available in big cities. It delineates soft tissues extremely well, and may be needed in some cases.

Blood investigations: These should be carried out if one suspects malignancy, metabolic disorders, or chronic infection (please refer to their respective Chapters for details).

Electromyography: If nerve root compression is possibility, electromyography (EMG) may be appropriate.

Bone scan: It may be helpful if a benign or malignant bone tumour is suspected on clinical examinations but is not seen on plain X-rays.

Treatment

Principles of treatment: For specific pathologies,

treatment is discussed in respective chapters. Most back pains falling in the ‘non-specific’ category have a set programme of treatment, mostly conservative. It consists of rest, drugs, hot packs, spinal exercises, traction, corset and education regarding the prevention of back pain.

Rest: In the acute phase, absolute bed rest on a hard bed (a mattress is allowed) is advised. Bed rest for more than 2-3 weeks is of no use; rather, a gradual mobilisation using aids like brace is preferred.

Drugs: Mainly analgesic-anti-inflammatory drugs are required. In cases with a stiff spine, muscle relaxants are advised.

Physiotherapy: This consists of heat therapy (hot packs, short-wave diathermy, ultrasonic wave etc.). Gradually, a spinal exercises programme is started.

Traction: It is given to a patient with back pain with lot of muscle spasm. It also sometimes help in ‘forcing’ the patient to rest in the bed.

Use of corset: This is used as a temporary measure in treating acute back pain, in back pain due to lumbar spondylosis, etc.

Education: Patients must be taught what they can do to alleviate the pain and to avoid injury or re-injury to the back. This includes education to avoid straining the back in activities of daily living such as sitting, standing, lifting weight etc. ‘Back Schools’ are formalised approach to this education.

MAJOR CAUSES OF LOW BACK PAIN

CONGENITAL DISORDERS

Spina bifida: This and other minor congenital anomalies of the spine are present in about half the population, but are not necessarily the cause of back pain. Therefore, other pathological conditions should be ruled out before diagnosing this as the cause of symptoms. Treatment is as for non-specific back pain.

Transitional vertebrae: A transitional vertebra is the one at the junction of two segments of the spine, so that the characteristics of both segments is present in one vertebra. It is common in the lumbosacral region, either as lumbarisation (S, becoming L) or sacralisation (L, fused with the sacrum, either completely or partially).

TRAUMATIC DISORDERS

Back strain (acute or chronic): The terms back strain and back sprain are often used interchangeably. Most often this arises from a ‘trauma’ sustained in daily routine activities rather than from a definite injury.

People prone to back strain are athletes, tall and thin people, those in a job requiring standing for long hours and those working in bad postures. Sedentary workers and women after pregnancy are also frequent candidates for back strain.

Acute ligament sprain may occur while lifting a heavy weight, sudden straightening from bent position, pushing etc. Treatment is ‘non-specific as discussed earlier.

Compression fractures: These fractures occur commonly in the thoraco-lumbar region. Treatment depends upon the severity of compression. It is important to be suspicious of any underlying pathology. Diseases such as early secondary deposits in an elderly, may produce a fracture spontaneously, in one or multiple vertebrae.

INFLAMMATORY DISORDERS

Tuberculosis: Spinal tuberculosis is a common cause of persistent back pain, especially in undernourished people living in unhygienic conditions. Early diagnosis and treatment is crucial for complete recovery.

Ankylosing spondylitis: This should be suspected in a young male presenting with back pain and stiffness. Symptoms are worst in the morning and are relieved on walking about. Spinal movements may be markedly limited along with limitation of chest expansion.

DEGENERATIVE DISORDERS

Osteoarthritis:

Prolapsed disc.

Spinal stenosis: Narrowing of the spinal canal may occur in the whole of the lumbar spine (e.g., achondroplasia), or more often, in a segment of the spine (commonly in the lumbo-sacral region). Stenosis may be in all parts of the canal or only in the lateral part; the latter is called as root canal stenosis. It may give rise to pressure or tension on the nerves of the cauda equina or lumbar nerve roots. Typically, the patient complains of pain radiating down the lower limbs on walking some distance, and is relieved on taking rest for a few minutes (neurological claudication). Diagnosis is confirmed by a CT scan or MRI. Treatment is by decompression of the spinal canal or root canal, as the case may be.

TUMOURS

Both benign and malignant tumours occur in the spine and the spinal canal. Tumours of the spinal canal, usually benign, are classified as extradural or intradural; the latter can be either intra-medullary or extra-medullary.

These tumours are usually diagnosed on myelogram or CT scan. Tumurs of the spine are mostly malignant, usually secolaries from some other primary tumours. Some commoner tumours of the spire as discussed below.

Benign tumours: These are uncommon. Osteoid osteoma is the commonest benign tumour of the spine. It causes severe back pain, especially at night. Typically the pain is relieved by aspirin. The tumour, usually the size of a pea, is found in the pedicle or lamina.

Haemangioma also occurs in the vertebral body. Meningioma is a common intradural, extra-medullary tumour which presents with back pain or radiating pain.

Malignant tumours: Multiple myeloma is the commonest primary malignancy of the spine. Metastatic deposits are extremely common in the spine because of its rich venous connections, especially with the vertebral venous plexus.

Pain often precedes X-ray evidence of a metastatic deposit. By the time a deposit is visible on X-ray, the tumour has replaced about 30 per cent of the bony content of the vertebra. A bone scan can detect the lesion earlier.

OTHER CAUSES

Metabolic disorders: Osteoporosis and osteomalacia are common causes of back pain.

degenerative Facet arthropathy and subtle Arthritis of the facet joints can result from a disease and mal-development of the facets (facet tropism).

The source of back pain is difficult to find because of variable factors. The aim is to identify the pathology that needs immediate treatment, such as an infection, neoplasm, disc prolapse etc. All other back pain are treated as ‘non-specific back pain’ with more or less common treatment programme.

While the patient is on this treatment programme, he is reviewed at regular intervals for any additional signs suggesting an organic illness. First establish whether the problem is acute (3 to 6 months) or chronic (longer than 6 months). If it is an acute pain, whether it is related to a definite episode of trauma or is spontaneous in onset.

The causes are accordingly worked out. In cases with chronic back pain, it is helpful to judge whether it is mechanical or inflammatory by asking the patient whether rest bring relief or makes the pain worse. According further sign s and symptoms helping diagnosis. Gives an outline of how to approach a patient with low back pain.

 

Cerebral Palsy, causes, Symptoms and treatment

Cerebral palsy defined as a non-progressive neuro-muscular disorder of cerebral origin. It includes a number of clinical disorders, mostly arising in childhood.

The essential features of all these disorders is a varying degree of upper motor neuron type of limb paralysis spasticity), together with difficulty in Coordination(ataxia) and purposeless movements.

Birth anoxia and injuries are the commonest cause of CP in developing countries. Causes can be divided into prenatal, natal and postnatal 

Causes of cerebral palsy

Prenatal causes

Defective development kernicterus

Natal causes

Birth anoxia Birth injury

Postnatal causes

Encephalitis Meningitis Head injury

Pathology: The pathology of this disorder is the degeneration of the cerebral cortex or basal ganglion, either because of their faulty development or because of damage caused by the various factor.

Clinical features of Cerebral Palsy

Presenting complaints: The clinical features vary according to the severity of the lesion, the site of the neurological deficit and the associated defect

Severity of lesion: The lesion may be mild in 20 per cent of cases, in which case the child may remain ambulatory without any help and may never require consultation.

In the majority (almost 50 per cent of cases), the child requires help with ambulation.

The usual presentation is a child less than one year old, in whom the parents have noticed a lack of control on the affected limb.

There is a delay in the developmental milestones such as sitting up, standing or walking. In about 30 per cent of cases, the involvement is severe, and the child is bed-ridden.

Pattern of involvement: The pyramidal tracts are involved in 65 per cent of cases, and they present with spasticity, exaggerated reflexes etc.

One or all the limbs may be involved. The commonest pattern is a symmetrical spastic paresis of the lower limbs, resulting in a tendency to flex and adduct the hips (scissoring), to keep the knees flexed and the feet in equinus.

Less commonly, it may present as monoplegia, hemiplegia or quadriplegia. In the upper limb, there is typical flexion of the wrist and fingers with adduction of the thumb and pronation of the forearm.

In 35 per cent of cases, extra-pyramidal symptoms such as ataxia, athetoid movements, dystonia predominate.

Associated defects: These consist of speech defect, sensory defect, epilepsy, occular defects and mental retardation.

About 50 per cent of the patients are severely mentally retarded, 25 per cent have moderate mental retardation and 25 per cent have borderline mental retardation.

Examination

On examination, there may be weakness of muscles, the distribution of which is variable.

This leads to marked muscle imbalance, resulting in deformities. The joints are stiff because of spasticity; hence when a steady pressure is applied, the muscle relaxes and the deformity is partially corrected.

As the pressure is released, the spasm returns immediately. The tendon reflexes are exaggerated, and clonus may be present.

The patient exhibits a lack of voluntary control when asked to hold an object.

As the patient tries to move a single group of muscles, other groups contract at the same time (athetoid movements).

Mental deficiency may be present. There may also be defective vision and impaired hearing.

Treatment

Principles of treatment: The aim of treatment is to maintain and develop whatever physical and mental capabilities the child has.

It consists of:

(i) orthopaedic treatment.

(ii) speech and occupational therapy.

Orthopaedic treatment consists of the prevention and correction of deformities, and keeping the spasticity under check. Methods of controlling the spasticity are:

(i) drugs-e.g., Diazepam, Beclofen

(ii) phenol nerve block

(iii) Neurectomy. Neurectomy may be required to control severe muscle spasm interfering with optimal rehabilitation.

Obturator neurectomy is performed for spasm of adductors of the thigh.

A number of other operative procedures may be necessary for improving selective functions.

Speech therapy and occupational therapy constitutes an important adjunct to the overall treatment of the child.

Mild cases can be looked after at home, but specialised residential schools are required for severely handicapped children.

Prognosis

Complete cure is impossible since an essential part of the brain is destroyed and cannot be repaired or replaced.

All that can be hoped for is improvement. Depending upon the severity of the underlying damage, a child can be made independent enough to earn his own living in due course.

A child formerly dependent on others for many daily activities may often become independent. This needs a great amount of patience and perseverance on the part of the parents and attendants of the child. In spite of all the treatment, there are a few in whom worthwhile improvement cannot be gained.

Cervical Spondylosis, symptoms, treatment

Cervical Spondylosis is a degenerative condition of the cervical spine found almost universally in persons over 50 years of age.

It occurs early in persons pursuing ‘white collar jobs’ or those susceptible to neck strain because of keeping the neck constantly in one position while reading, writing etc.

Pathology of Cervical Spondylosis

The pathology begins in the intervertebral discs. Degeneration of disc results in reduction of disc space and peripheral osteophyte formation.

The posterior intervertebral joints get secondarily involved and generate pain in the neck.

The osteophytes impinging on the nerve roots give rise to radicular pain in the upper limb. Exceptionally, the osteophytes may press on the spinal cord, giving rise to signs of cord compression.

Cervical spondylosis occurs most commonly in the lowest three cervical intervertebral joints (the commonest is at C₁-C₂).

Symptoms of cervical Spondylosis

Complaints are often vague. Following are the common presentations:

• Pain and stiffness: This is the commonest presenting symptom, initially intermittent but later persistent.

Occipital headache may occur if the upper-half of the cervical spine is affected.

• Radiating pain: Patient may present with pain radiating to the shoulder or downwards on the outer aspect of the forearm and hand.

There may be paraesthesia in the region of a nerve root, commonly over the base of the thumb (along the C6, nerve root). Muscle weakness is uncommon.

• Giddiness: Patient may present with an episode of giddiness because of vertebro-basilar syndrome.

Examination

There is loss of normal cervical lordosis and limitation in neck movements. There may be tenderness over the lower cervical spine or in the muscles of the para-vertebral region (myalgia).

The upper limb may have signs suggestive of nerve root compression – usually that of C6, root involvement.

Motor weakness is uncommon. The lower limbs must be examined for signs of early cord compression (e.g. a positive Babinski reflex etc.)

RADIOLOGICAL FINDINGS

X-rays of the cervical spine (AP and lateral) are sufficient in most cases. Following radiological features may be present. 

• Narrowing of intervertebral disc spaces most commonly between C5-C6).

 Osteophytes at the vertebral margins, anteriorly and posteriorly.

X-Ray of the cervical spine, lateral view showing cervical Spondylosis ( note the lipping of C5-C6 vertebrae.

• Narrowing of the intervertebral foramen in cases presenting with radicular symptoms, may be best seen on oblique views.

DIFFERENTIAL DIAGNOSIS

The diseases to be considered in differential diagnosis of cervical spondylosis are:

(i) other causes of neck pain such as infection, tumours and cervical disc prolapse.

(ii) other causes of upper limb pain like Pancoast tumour, cervical rib, spinal cord tumours, carpal tunnel syndrome etc.

TREATMENT

Principles of treatment: The symptoms of cervical spondylosis undergo spontaneous remissions and exacerbations.

Treatment is aimed at assisting the natural resolution of the temporarily inflamed soft tissues.

During the period of remission, the prevention of any further attacks is of utmost importance, and is done by advising the patient regarding the following:

a) Proper neck posture: Patient must avoid situations where he has to keep his neck in one position for a long time. Only a thin pillow should be used at night.

b) Neck muscle exercises: These help in improving the neck posture.

During an episode of acute exacerbation, the following treatment is required:

Analgesics.

Hot fomentation

Rest to the neck in a cervical collar 

Traction to the neck if there is stiffness

Anti-emetics, if there is giddiness

In an exceptional case, where the spinal cord is compressed by osteophytes, surgical decompression may be necessary.

Arthritis, Rheumatoid Arthritis, Causes, Symptoms, Treatment

Arthritis is an inflammation of joint. It is characterized by pain, swelling and limitation of joint movement.

The cause may be purely a local pathology such as pyogenic arthritis, or a more generalised illness such as Rheumatoid Arthritis.

Today we will discuss about Rheumatoid Arthritis.

Rheumatoid Arthritis

Rheumatoid Arthritis is a chronic non-suppurative inflammatory of the synovial joint diagnosed as per the criteria laid down by American Rheumatism Association in 1987.

Symptoms

Morning stiffness.                                              Swelling of three or more specified joints.    Swelling of joints in the hand and wrist.        Symmetrical swelling.                                        Rheumatoid  nodule.                                          Rheumatoid factor positive.                              X-Ray change-erosion or unequivocal peri-articular osteopenia.

Causes Of Rheumatoid Arthritis

The exact causes is not known. Following factors have been thought to play a role in causation of the disease.

If four or more of these are present, it is Rheumatoid Arthritis.

A genetic predisposition is strongly suspected because of certain histocompatibility markers associated with it (HLA-drw4/HLA-DRI).

Agent such as mycoplasma, clostridium and some viruses have been implicated in its etiology.

It is now belived that rheumatoid arthritis results from exposure of a genetically predisposed individual to some infection agent.

This leads to autoimmunity and formation of immune complexes with IgG antibodies in the serum.

These immune complexes are deposited in the synovial membrane and initiate a self perpetuating chronic granulomatous inflammation of the synovial membrane.

State of Rheumatoid Arthritis

1- Potentially reversible soft tissue proliferations- In this stage, the disease in limited to the synovium. 

No destructive change can be seen on x- ray.

2- Controllable but irrepressible- Soft tissue destruction and early cartilage erosion x-ray shows a reduction in the joint space, but outline of the articular surface maintained.

3- Irreversible soft tissue and bony change- The pannus ultimately destroys the articular cartilage and erodes the sabchondral bone.

The joint become ankylosed usually in a deformed position (fibrous ankylosis). It may be subluxation or dislocated.

Associated changes- In rheumatoid arthritis there is something evidence of diffuse vasculitis.

The most serious lesions occur in the arterial tree, which may be mild non- necrotising arteritis, or sever and fulminant arteritis anki. To polyarteritis nodosa. The latter is fatal.

Diagnosis

Clinical features- It occurs between the age of 20 to 50 years. Women are affected about 3 times more commonly than men. 

An acute, symmetrical polyarteritis- Pain and stiffness in multiple joints particularly in the morning, mark the beginning of the disease.

This may be followed by Frank symptoms of articular inflammation.

The joints affected most commonly are the metacarpophalangeal joints, particularly that of the index finger. 

Other- The onset may be with fever, the cause of which cannot be established (PUO), especially in children. 

Sometimes, visceral manifestation of the disease such as pneumonitis, rheumatoid nodules etc. May antedate the joint complaints.

On examination, one finds swollen boggy joints as a result of intra-articular effusion, synovial hypertrophy and oedema of the peri articular structures.

The joint may be deformed joint of the hand show typical deformities. There may be severe muscle spasm.

Range of motion of the joints may be limited. In later stage, the joint may be subluxated or dislocated.

There may be fever, rash and signs suggestive of systemic vasculitis. The rash in rheumatoid arthritis is typically non-pruritic and maculo- popular on the face, trunk and extremities.

Extra- articular manifestation of rheumatoid arthritis- Although, rheumatoid arthritis is primarily a chronic polyarthritis, extra articular manifestation are very common, and sometimes govern the prognosis of a case.

Investigations

Radiological examination- This consist of X- Ray  of both hand and of the affected joints.

Following features may be present

Reduces joint space

Erosion of articular margins

Subchondral cysts

Juxta- articular rarefaction

Soft tissue shadow at the level of the joint because of joint effusion or synovial hypertrophy.

Deformities if the hand and fingers.

Blood- It shows the following changes

Elevated ESR

Low haemoglobin value

Rheumatoid factor- This is an auto antibody directed directed against the fc fragments of immunoglobulin G (IgG).

RF can belong to any class of immunoglobulins that is IgG- RF, IgM-RF, IgA- RF, or IgE- RF, but commonly done test detect only the IgM type of RF.

It can be detected in the serum of the patient.

 

Hair fall after Covid-19 Recovery. After COVID recovery side effects

Hair fall is a comments problem after Covid-19  Recovery. Most of people suffering from excessive hair fall. Not only women facing this problem men also facing hair fall problem.

My own story

This is my own experience. I also had corona in the month of April and a few days after recovering from corona, I also started losing a lot of hair.

This my personal picture you can see my scap is clearly showing.

                 Hair lose after Covid recovery

I thought maybe for some reason my hair is falling so much, I did not have to suspect that this is a post covid side effect.

I thought the fall would stop on its own after some time but my hair started falling more and my scalp started showing a lot more.

As I have written in my introduction that I am a health worker and many co-workers with me also had covid.

Slowly all of them started having hair fall problem then I thought is this post covid side effect or not.

I saw following NDTV news. I realised this is post covid side effect

Causes of Hair fall

Hair fall is a normal thing after any illness and fever. Fever is the common symptoms of Covid.

As we all know Covid is a viral disease after any type of fever our hair goes into telogen phase this is a shedding phase.

This medical term known as Telogen effluvium. People with TE report hair loss that comes on suddenly.

Hair typically falls out in large clumps, often while brushing or showering.

Most of the people will also know that even when we have typhoid, we still have a lot of hair fall.

Most people see noticeable hair shedding two to three months after having a fever or illness.

Handfuls of hair can come out when you shower or brush your hair.

This hair shedding can last for six to nine months before it stops. 

Stress can causes a temporary hair shedding. Emotional stress can also force more hairs than normal into the shedding phase.

Diet plays a very important role in the growth of our hair and keeping it strong.

If you don’t have enough nutrition and diet your hair fall will started 

 After 2 month of treatment

Treatment  of Hair fall.

Vitamin D3 Deficiency. Lower Vitamin D 3 level is  most common cause of hair lose.

In Covid-19 disease every known about vitamin D3. Vitamin D3 also increase our immune system.

So check your vitamin D3 level if it is lower side you must have to take vitamins d3 doses. 

Recommended dose of vitamin D3 is 60k IU per week for 8 week. this is therapeutic dose.

Ferritin is a type of protein in your blood. It stores iron that your body can use when it needs it.

If you have low ferritin, this means that you also have an iron deficiency.

When you have lower ferritin level this also cause hair fall. You should take iron supplements.

Green vegetables, spanich and beetroot are full of iron so consume more.

If your hair lose is excessive so you can add some vitamin and minerals tables.

If you are not taking enough vitamins and minerals in your diet, then this can also be one of the main reasons for hair loss.

After being saved from covid, take care of your diet. Must be taken if supplement is required

If your hair lose has started, then you should consult your doctor at once.

If your hair is in the telogen phase, then your hair will not stop falling at any cost. It will stop naturally in three to four months. 

You can regrow your hair with medicine.

Minoxidil and Finasteride are common medicine for regrow your hair. It’s very helpful who has male pattern baldness and female pattern baldness. This medicine are very effective even if you have patches on your scalp.

I have been also using this serum since last two months and I have a big difference in my scalp.

Thank you

Hope this blog help you.