Understanding Pain

By Dr. H. B. Jayasinghe (Family Physician), Founder Fellow of British Association of Medical Hypnosis

I was pleased to find the Health Watch Medical page in the Daily News back again after a lapse of several months.

The page with its medical advisory panel of Prof. Colvin Gooneratne, Dr. Dennis Aloysius, Dr. D. P.

Atukorale, and others was contributing much in health education of the public on important issues.

Last week's lead article on 'Eating out' by the Doctors Wives Association President Mrs Chrissy Aloysius was commendable as it is a much needed area today for proper advice and guidance of the public for better health when eating from out.

This week I thought of contributing this article on "Understanding Pain" as I feel this is another important area, not cared for most in the medical profession as important for public guidance for better health even though it is really a key area in life, for that pain is really a friendly messenger who warns a person when something goes wrong somewhere in the body that it needs to get investigated, and attended to by a medical professional.

A living friend

If not for that friend the pain which most of you readers fear, dread and even detest you would not know when something goes wrong in your body, until it gets worse, and leads you to considerable suffering and even death ultimately. This is why understanding pain is very important in life. Pain is really a living friend and not a foe to be dreaded.

Although the word 'pain' comes from Latin 'poena', the same root as 'punishment' pain is an inevitable an essential part of being alive. Without pain we would have to pay attention consciously to everything we do, which would make life impossible sometimes.

Difficult to define

Even though pain is real, yet it is difficult to define it. It is subjective only the person in pain can describe it, although we have a poor vocabulary to do so considering how important it is.

No Imaginary pain

There is no instrument that a doctor can use to find out objectively how much pain you are in. At the same time there is no such thing as imaginary pain.

When does it become a problem?

Only when pain is constant and you cannot take any action to relieve it, does it become a problem rather than a friend you think.

Pain relief

When we think of pain relief, we usually think of drugs. Even endorphins, the substances we produce naturally to relieve pain, are called the body's natural pain killing drugs.

Place of drugs, fewer the better

Drugs do have an important place in treating pain. So why not use them? In fact the fewer pain killers you take the better for many reasons. The more you take them, the more habitual you become, and the less effective they will be. The less you take them, the more effective they will be when you really need them.

Cause untouched

When you use a pain-relieving drug, you may lose the pain, but the cause of the pain will be untouched.

Almost invariably pain is closely associated with fear, anxiety and increased muscle tension. In other words fear causes increased muscular tension which causes increased pain. Pain killers will not help to relieve this.

Hypnotic Relaxation in pain relief

In a tension headache a pain killer will relieve the ache, but does nothing for the fear or stressful situation and the muscular tension that is causing the headache. This could lead to more severe headaches, until pain killers do not work any more. Hypnotic relaxation on the other hand allays anxiety and fear, reduces muscle tension, and relieves the ache quite effectively.

In addition, the affectivity of analgesics or pain killing drugs can be enhanced and their use can be minimised, by employing the resources of the unconscious mind under hypnosis.

In certain instances of intractable pain that do not respond to conventional treatment with analgesics and sedatives, hypnosis remains to be the only form of effective therapy available to relieving the suffering.

BMA Approved Hypnosis for pain relief in 1955

The British Medical Association has approved the use of hypnosis as a therapeutic modality in pain relief on April 23rd 1955.

In Sri Lanka

The college of General Practitioners Sri Lanka has set up a department Clinical Hypnosis headed by Dr. H. B. Jayasinghe which conducts a one year training course for doctors on clinical hypnotism. At the moment there are 28 doctors in the country who are holding this diploma from the CGP.

What's the buzz about energy drinks?

Kelum Pelpola, Final year Medical student

"Energy drinks" seem to be the buzz word among a lot of young adults both internationally and locally. The web sites as well as advertisements in the mass media for these products are full of images of macho lifestyles. They promote beverages containing ingredients that sound scientific, but may be unfamiliar to many consumers.

While we all need an energy boost from time to time, an energy drink may not be the best way to get it, experts say. The FDA (Food and Drug Administration of the US-The US government agency responsible for ensuring the safety and effectiveness of all drugs, biologics, vaccines, and medical devices) does not define the term "energy drink"; that label is up to manufacturers' discretion.

"There is scant scientific support for these ingredients to make the kind of claims manufacturers use in hyping their products," says Suzanne Farrell, MS, RD, a spokeswoman for the American Dietetic Association.

"Most of the energy from these drinks comes from the sugar and caffeine, not from the unnecessary extras."

She also points out these drinks contain plenty of calories from sugar, which can add up quickly if you drink a few cans. Aside from caffeine and sugar, some of the more common ingredients are taurine, ginseng, guarana, vitamins, and green tea.

"Most of the energy drinks contain high-tech-sounding ingredients that are not controlled substances, of no value, and potentially harmful" in large amounts, adds Cynthia Sass, MPH, MA, RD, specialist in sports dietetics, in USA. And trying to figure out exactly how much of each stimulant is contained in an energy drink can be difficult, she says.

"The amount of the stimulants is not always listed on the label, and even when the information is listed, it is hard for consumers to interpret because we are not familiar with these ingredients," says Sass.

One ingredient most people are familiar with is caffeine, and "what we do know is that large doses of caffeine can be very dehydrating," says Sass.

While one cup (8 ounces) of strong coffee has about 125-150 milligrams of caffeine and a 12-ounce can of ordinary cola has 35-38 milligrams, an 8.3-ounce can of energy drink may contain upto 280 milligrams. In general, caffeine consumption should be limited to about 200-300 milligrams per day, says Farrell.

Easy to Drink

One of the concerns about energy drinks is how easy it is to drink large quantities of these sweet beverages.

Energy drinks contain multiple stimulants that, when combined, can be dangerous and have a very powerful effect on the body. Most people know how much caffeine they can tolerate, but may not be familiar with the effects of some of the other ingredients.

Such possible symptoms are upset stomach, leg weakness, heart palpitations, being jittery, nervousness, and more.

Drink these energy drinks on an empty stomach and the effects can be magnified.

There will be an energy burst, but it could also lead to agitation, difficulty concentrating, hyperactivity, a problem sleeping, nausea, and affect blood pressure.

Fuel for Workouts?

Don't be misled into thinking energy drinks will power up your workouts, Sass says.

"If you take an energy drink before exercise, it could increase your blood pressure, overstimulate your heart or nervous system, resulting in a number of potential side effects on your body," she says. "You might think there would be no risk to drinking an energy drink, but some of these products have powerful, drug-like effects and should not be underestimated."

Her advice: "If you have any medical condition, hypertension, or heart disease, avoid all drinks that have multiple stimulants."

If you want to try an energy drink, she recommends trying a small amount the first time with a meal to see how your body reacts to it. She advises avoiding physical exertion during this trial period.

Need a Boost?

When you need a boost - whether to study for a test, prepare for a workout, or just get past an afternoon slump - there are healthier ways than energy drinks, the experts say.

Among the energy-boosters they recommend are a healthy diet, physical activity, and a good night's sleep.

And when you need a quick fix? "Energy drinks sound like they would be better than a latte, but a coffee drink made with skim or soy milk is a much better choice because we know more about the effects of caffeine," says Sass.

Screening for Type 2 Diabetes

by Dr. Bandula Wijesiriwardena and Chandrika Wijeyaratne

Recommendations for Sri Lanka

Though no direct evidence exists showing that screening for type 2 diabetes improves health outcomes or mortality rates, the following recommendations seem to be appropriate. Screen all adults with CVD, hypertension, dyslipidemia, or other CVD risk factors for diabetes mellitus. . There is insufficient evidence for diabetes screening in adults without CVD risk factors.

Screen adults 18 years or older with risk factors for type 2 diabetes (family history, obesity, gestational diabetes, polycystic ovary syndrome, high-risk ethnic group).

If under the age of 18, who to screen?

Although there is no direct evidence about screening intervals, expert panels have recommended screening every 3 years.

Use the FBG test to screen for diabetes because it has good specificity and is more reproducible than the 75-g OGTT to detect diabetes.

Consider performing a 75-g OGTT in individuals with an FBG of 100 to 126 mg/dL (5.6 to 7.0 mmol/L), as diabetes cannot be adequately confirmed or excluded with FBG values within that range.

The HbA1c test has good specificity but only moderate sensitivity to diagnose diabetes and it has not yet been standardized for diabetes screening purposes.

Base on ADA WHO and ACP
Recommendations

Road traffic accidents and fitness to drive

By Dr. K.N.K. Wijayawardhana (Ex-Deputy Director Colombo National Hospital)

Road traffic accidents are on the increase daily, and the number of people who die, and get injured seriously are also on the rise, costing billions of rupees in taxpayers, money to the country. It is estimated that in the year 2003 this amount was Rs. 15 billion not a small amount for a third World Country like ours.

In this scenario it is very relevant to go into the question of the fitness of the vehicle drivers who were involved in these accidents.

Medical Fitness to Drive

This is where, the allegation is made on some of the doctors too, whether they had properly carried out their duties in recommending the medical fitness of a person to drive.

Fitness to drive

This is where some doctors may also be at fault. Sometimes in recommending medical fitness to drive some doctors may not be very thorough and accurate.

A driver after a fatal accident should be produced before the nearest judicial medical officer and the discretion whether to produce him before a magistrate should be in the hands of the medical officer.

Among drivers unfit to drive, epilepsy, defective visions, and importantly psychological problems have been found to be causes. Fitness to drive should be reviewed periodically, say every five years. Seat belts were used in the nineties but now their use is hardly ever seen.

Fitness of vehicle

The M.O.T. certificate is now forgotten. Vehicles especially buses and lorries with defective brakes ply our roads.

I have observed containers with bald tyres on the roads. I know of a friend whose vehicle was crushed by a toppling container killing both him and his wife instantly.

Alcohol, drugs and sleeping at the wheel

In a survey at the National Hospital sometime ago (I think it was by Dr. Anil Jasinghe, Director Accident Service) it was found that 11% of RTAs were due to drunken driving. However, the Police must be commended now as they are tightening up on drunken driving especially at night.

In the UK nobody dares to drive after liquor and at parties the drive back is done by the wife or a non-drinking person.

Sleeping at the wheel by bus drivers may be the cause for early morning accidents in the outstations. No passenger vehicle driver who has not had a proper rest should be allowed to drive at night. Some private companies employ two drivers on long trips.

Road conditions

Badly maintained roads, potholes, badly designed roads, poorly lit roads and lack of traffic calming measure are all factors. In road designing consultation and collaboration between the local authorities and the Police is absolutely essential.

Also with potholes and other unfilled road excavations damage is caused to vehicles resulting in expenditure of foreign exchange as not a single motor spare part is made locally.

Motorists should be able to recognize Pedestrian Crossings (PC) at a distance, so that he can slow down. Now very often until he comes almost to the PC he does not know that a PC exists. Sometimes the yellow paint is faded and a PC cannot be recognized.

According to a study done by Prof. Amal Kumarage of the Moratuwa University and one of the country's foremost authorities on road matters, in 2003 131 people were knocked down at these PCs. It is a matter of sheer luck.

Especially at night the motorist is completely unaware that he is approaching a PC.

Fight cardiovascular disease using a healthy diet and lifestyle

D.P. Atukorale, Senior Consultant, Cardiologist

A healthy diet and lifestyle are the best weapons you have, to fight cardiovascular disease. It is not so hard as you think. I am suggesting a few simple steps below which will help your life for long-term benefits to your health and your heart.

Use up at least as many calories as you take in

Start by knowing how many calories you should be eating and drinking to maintain your weight. Don't eat more calories than you know you can burn up everyday and increase the amount and intensity of your physical activity to match the number of calories than you know you can burn up each day.

Exercise

Aim for at least 30 to 45 minutes of moderate physical activity for at least 5 days of the week. Regular exercise such as cycling, brisk walking, swimming and other outdoor exercises can help you to lose weight and help you to reach physical and cardiovascular fitness.

Regular exercises help you to improve your good cholesterol (H.D.L. cholesterol) level and decrease your bad cholesterol (L.D.L.) level, control your hypertension (if you are a case of hypertension), help to control your blood sugar level (if you are a case of diabetes) improve your pulmonary function, increase your coronary collaterals and reduce your stress (tension).

Healthy diet - eat variety of nutritious foods from all food groups

You may be eating plenty of food but your body may not be getting the nutrients it needs to be healthy. Nutrient - rich foods have vitamins, minerals, fibre, essential amino-acids, essential fatty acids and are low in calories. To get all the nutrients choose foods like fruits, vegetables, wholegrain products and fat free or low fat dairy products and small fish most often from the following groups of dietary items.

Vegetables and fruits

These are high in vitamins, minerals and fibre and low in calories. Eat a variety of fruits such as mangoes, guava, avocado, veralu, anoda, gal-siyambala, sepadilla, jambu, duriyan, bananas, pineapple, apples, and grapes. Eat legumes (such as beans, lima-beans, dambala, soya, lentils, and broad beans), green leaves (Keera) such as gotukola, kankun, niwithi, thampala, mukunuwenna, and these have plenty of vitamins, minerals (such as, iron, calcium and magnesium) fibre, antioxidants, good quality proteins and good quality fats.

Fruits and vegetables help you to control your weight and blood pressure and improve your cardiovascular system without increasing your blood cholesterol.

Unrefined whole grains

These contain fibre especially the soluble fibre (which helps you to lower your cholesterol) and contain carbohydrates and are low in fat and help you to manage your weight if you consume these in moderation.

Fish

Eat fish at least twice a week. It is advisable to eat small fish as recent research has shown that large fish such as tuna contains significant amounts of mercury which is injurious to the brain. Eating tuna during pregnancy can affect the kidneys and brain of the foetus. Eat fish which is rich in Omega 3 fatty acids.

Meat

Choose lean meat and Poultry without skin and prepare them without added vegetable oils (which contain trans-fats). If you use vegetable oil for frying don't use these more than once for frying, as dangerous ketones and aldehydes are formed during deep frying.

Coconut oil is a very safe oil and can be used for repeated frying without formation of transfats. Avoid consumption of red meat such as beef, pork and mutton as these are full of saturated fats which are converted to L.D.L. cholesterol in your liver. Select fat free or low fat dairy products.

Cholesterol

Cut back on foods high in dietary cholesterol (such as liver, kidney and brain) and aim should be to eat less than 300mg of cholesterol per day.

Partially Hydrogenated Fats

Cut down consumption of food containing partially hydrogenated vegetable oils such as cookies, crackers, cakes and French fries as the amount of trans-fats in your diet should be reduced to the minimum as trans-fats are injurious to your health and these artificial fats decrease the level of H.D.L., increase your L.D.L. level and increase your serum triglycerides.

Salt

Choose and prepare food with little or no salt especially if you are a case of hypertension. Aim is to eat less than 2300mg of sodium per day. It is advisable to limit consumption of ham, bacon, dry fish, sprats, lime pickle, various sauces, salted butter, cheese etc.

Alcohol

If you are used to taking alcohol in moderation (i.e. one drink per day for females and two drinks per day for males) you can continue to take alcohol in moderation under the supervision of your family physician. If you have never consumed alcohol it is advisable for you to be an abstainer as it is extremely difficult to know whether you possess the gene for alcoholism.

Smoking

Smoking of cigarettes, cigars, pipes and beedis and chewing of tobacco are injurious to your health and should be completely given up for good.

Cigarette smoke contains more than 4000 injurious chemicals and nicotine in the cigarette smoke increases your blood pressure and heart rate, decreases the level of H.D.L. cholesterol, increases the level of L.D.L. cholesterol, precipitates cardiac rhythm disturbances, and makes your platelets more sticky causing thrombosis. Passive smoking (second hand smoke) is well-known to cause cardiovascular disorders and should be avoided.

In conclusion, stop smoking, reduce alcohol consumption, reduce body weight if you are overweight, reduce oil and fatty food, take regular exercises, reduce salt intake, consume a healthy diet consisting of plenty of vegetables, fruits unrefined whole grains, small fish, lean meat and avoid trans-fatty acids. Regularly check up your blood pressure, relax yourself whenever possible and take medication as directed by your doctor.