Why do we sleep?

Exercise, Health, Lifestyle

sleeping problems

What is sleep?

Sleep is a state of altered consciousness of the mind and body which typically lasts for several hours every night. It involves the inactivity of the nervous system, relaxation of all the muscle of the body and is considered important for optimal health.

Sleep pattern

The normal sleep pattern involves the alternating REM (rapid eye movement) and NREM (non-rapid eye movement) sleep that occurs in a 90-minute interval cycle in a typical night’s sleep.

There are four phases:

Stage 1: Light sleep – between being awake and sleeping

Stage 2: Initiating sleep, drop in the body temperature, regular heart rate and breathing.

Stage 3 and 4: The deepest form of sleep when the breathing slows down and the blood supply to all the organs increases, the repair process begin, muscles are relaxed, the blood pressure goes down, various hormones like growth hormone are released.

What is the importance of REM and NREM?

REM makes up about 25% of the night’s sleep: It first begins about 90 minutes after falling asleep. Lasts for some time and recurs about every 90 minutes. In the REM stage, the brain is more active, heart rate is raised and intense dreams can occur. At this stage, brain development occurs as the area of learning in the brain is stimulated.

Like deep NREM sleep, REM sleep also helps protein binding for growth.

During the NREM sleep, the body restores its functions of the brain, repairs and regrows tissues, promotes growth, and improves the immune system.

Benefits of sleep 

Normal Brain function and development: Sleep is essential for maintaining the normal levels of cognitive skills. ( This include speech, memory, innovative and focused thinking.)

Emotional well-being: Sleep can give you a feeling a sense of freshness, motivation and relaxation.

Physical health:

  • Sleep will help maintain hormonal balance in the body. For example, the hormones that regulate hunger and insulin regulation for blood sugar levels.
  • It is involved in the healing process of your heart and blood vessels.
  • It can support growth and development in children and teens by releasing hormones that builds muscle mass and helps the body repair.
  • It plays a role in puberty and fertility. 
  • It can improve immunity and help fight infections better.

Good physical performance levels:

  • Sleep can improve concentration, focus, awareness and general activeness of your body. 
  • It improves your ability to perform skillful activities.

How much sleep is recommended?

Age Recommended Amount of Sleep
Newborn babies about 17 to 18 hours per day
Preschool children about 11 to 12 hours per day
School children Minimum 10 hours per day
Teenagers about 9 to 10 hours a day
Adults (including the elders) about 7 to 8 hours a day

Sleep deficit 

Sleep deficiency can increase the risk for some chronic health problems.

  • Heart disease: Lack of sleep will keep the heart rate elevated leading to increased calcification (calcium deposits) in the blood vessels of the heart. There is also an increase in CRP (C-reactive protein), which is released with stress and inflammation that can lead to heart problems.
  • Obesity: Lack of sleep can interfere with appetite regulation due to imbalances in the hormones that regulate hunger. This can lead to eating at night when your body’s metabolism is low causing excessive fat storage leading to obesity.
  • Diabetes: Due to the increase in food intake and lack of rest, hormonal imbalances can affect the insulin response in the body. The metabolism of glucose is affected due to insulin resistant that can lead to type 2 Diabetes.
  • High blood pressure: With insufficient rest, the heart rate remains elevated. This raises the blood pressure which may cause hypertension.
  • Stroke or transient ischemic attack (mini-stroke):  It is related to elevated heart rate and hypertension that can lead to a reduction of blood supply to the brain leading to a stroke or mini-stroke.
  • Depression and attention-deficit hyperactivity disorder (ADHD): Due to lack of rest and interference in the brain function, lack of sleep can cause problems with thinking, mood swings, depression and hormonal imbalances that may lead to ADHD and depression.

Sleep Disorders – There can be about 81 disorders.

  • Insomnias (Sleeplessness): There can be difficulty at the beginning of sleep, maintaining sleep, abrupt waking from sleep, waking too early or poor quality sleep. This sleep difficulty can occur despite all attempts of trying hard to sleep.  This can be related to mental disorder, restless leg syndrome, sleep apnea or due to drug side-effects.
  • Sleep-related breathing disorders: Cheyne-Stokes breathing pattern is characterized by a gradual increase in the breathing followed by a gradual decrease and holding of breath for 5 to 50 seconds. This type of respiratory problem is also typically seen with other medical problems of the heart and kidney.
  • Sleep apnea: Irregular breathing pattern with disruption or episodes of breathlessness. It can be due to lack of sleep causing arterial oxygen desaturation (reduction in oxygen in the blood).
  • Hypersomnias (Narcolepsy): This involves daytime sleepiness and may be related to dysfunction in the brain due to increased lack of sleep at night or misaligned circadian rhythms (body clock).
  • Circadian rhythm sleep disorder: The “body clock” or the circadian rhythm is the 24-hour cycle that tells your body when to sleep and helps to regulate many other physiological processes. Disturbances can occur between the person’s sleep pattern and the pattern that is desired. For example, one cannot sleep when sleep is desired.
  • Parasomnias: The parasomnias consist of abnormal sleep-related movements, behaviors, emotions, perceptions or dreaming. It occurs while falling asleep, sleeping, between sleep stages, or during arousal from sleep. They are disorders that cause sudden waking up or a state of disturbed sleep.
  • Sleep-related movement disorders: Restless legs syndrome, sleep-related rhythmic movement disorder, large movements of the body or legs while sleeping can affect normal sleep pattern.

Other problems: 

Snoring is a sound produced by breathing. Snoring can also lead to impaired health as it can disturb the sleep of the individual and their sleeping partner. 

Sleep talking and sleep walking can be associated with REM sleep behavior disorder or sleep-related eating disorder. Usually, the person can get a sensation of falling, a sensory flash of walking to a place or a sleep-onset dream that can cause talking or walking. 

Who can be at risk of sleep disorders?

  • Working on odd timings/shifts:  Job timings that are against the internal body clock and working long hours.
  • Lifestyle problems: People who take medications to stay awake to complete tasks and studies. Other problems like alcohol or substance abuse.
  • Known or unknown medical condition: People who take medications that have side-effects that interfere with sleep. People with underlying unknown problems like stress and anxiety.

How is sleep problems diagnosed?

  • Blood Tests can be done to help find other underlying medical problems that can cause sleep problems.
  • Sleep studies (polysomnography): The electric activity in the brain (Electroencephalogram studies), behavior and other changes are observed while the person is asleep to study the problems associated.

How to get a good amount of sleep?

  • Sleep schedule should be kept the same every night. Avoid differences that may disturb your body clock.
  • Avoid strenuous exercise or doing work before bed as that will keep your brain active and delay sleep.
  • Avoid cigarettes (nicotine) and caffeine. Nicotine and caffeine are brain stimulants so both substances can interfere with sleep.
  • Getting enough fresh air and sun during the day can also help a good night’s sleep.
  • Learning relaxation techniques like breathing exercises can help.
  • Taking a warm shower before sleep can also relax the body. Keeping the bedroom cool and dark will also help prevent any disturbances.

If you have any type of sleep issues due to a shift-work schedule, it’s best to speak to your employer or consider visiting the experts to better understand your issues and eliminate the worry of any underlying medical condition.

Advertisements

The 5 Types of Hepatitis

Common conditions, Health, Lifestyle

Hepatitis liver

The liver is a vital organ located in the upper right part of your belly under the ribs.

Functions of the liver:

  • Making bile, a yellowish-green liquid that helps with digestion
  • Producing proteins and blood-clotting factors that the body needs
  • Regulating glucose (sugar) in the blood and stores extra sugar
  • Working with the stomach and intestines to digest food
  • Storing vitamins and minerals
  • Removing toxic (poisonous) substances from the blood

“Hepatitis” means inflammation of the liver. Hepatitis is also the name of a family of viral infections that affect the liver.

There are 5 types:

  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis E

The most common types of hepatitis disease are Hepatitis A, B and C. 

Causes of infection and types –

Hepatitis A: This is caused by consuming food or drinking water that is contaminated with faecal matter (human waste). As compared to other infections of hepatitis, hepatitis A usually improves without treatment.

Hepatitis B: It can be transmitted through sexual contact with an infected partner, through infected blood transfusions and dirty needles. Hepatitis B may scar the liver (cirrhosis) and lead to liver cancer.

Hepatitis C: This is the most common form of viral hepatitis. The exact cause is unknown, but it can happen through blood transfusion of infected blood and blood products, contaminated injections and through injection drug use.

Hepatitis D: Hepatitis D occurs in people with hepatitis B, increasing the severity of symptoms associated with hepatitis B.

Hepatitis E: Similar to hepatitis A, hepatitis E happens among people in countries with unhygienic living conditions where contaminated water and food consumption often leads to a spread of infection.

Which hepatitis is dangerous?

  • Types B and C have been reported more among people leading to a chronic (long-term) illness of liver disease. It is the most common cause of liver cirrhosis (liver tissue scarring) and cancer.
  • In addition, there are vaccines to prevent Hepatitis A and B. However, there is no known vaccine for Hepatitis C.

Period of illness with different types of hepatitis

Acute Hepatitis viral infection: This is a short-term illness that occurs within the first 6 months after someone is exposed to the hepatitis virus. Hepatitis A and E may not cause chronic hepatitis but for some with compromised immunity and delayed treatment, it may lead to chronic infection.

Chronic Hepatitis virus infection: Hepatitis viruses B and C can progress from acute to chronic episodes of illness after about 6months. It is long-term as the virus remains in a person’s body and continues to affect liver cells for years to an extent that there can be a complete liver failure.  

Pathophysiology of Hepatitis infection

Acute infection: The course of the virus is not completely understood but once it enters into the body, it multiplies and the infection persists due to weak immune responses which fails to control the viral spread of infection. Symptoms will appear and continue.

Chronic infection is established with the progression of infection. Liver lesions appear due to the immune responses and inflammation of the liver cells. It also triggers fibrogenesis in which the cells of the liver become hard, thickened and fibrous. This leads to scarring of the liver tissue known as cirrhosis. People with cirrhosis are then at high risk of developing end stage liver disease (ESLD) with hepatocellular carcinoma (cancer of the liver cells). 

Chronic hepatitis

Fig 1: Stages of liver infection with Hepatitis C virus(HCV)

Signs and Symptoms with all types of hepatitis

  • Fever due to infection.
  • Fatigue due to loss of appetite, nausea, and vomiting. Also, lead to long-term weight loss.
  • Abdominal pain due to build-up of fluid in the stomach due to inflammation. This occurs when the damaged liver doesn’t produce enough albumin, a substance that regulates the amount of fluid in cells. This may also lead to Pale colored stools, darker urine.
  • Joint pain: Pain and stiffness are early signs of inflammation caused by the body’s autoimmune response to the hepatitis virus.
  • Jaundice: Bilirubin present in the hemoglobin of the red blood cells can build up and cause your skin and the whites of your eyes to turn yellow. 
  • Brain problems: A build-up of toxins in the brain can cause personality changes. Advanced symptoms include abnormal shaking, agitation, disorientation, and slurred speech.
  • Diabetes: Liver is unable to store excess glucose and too much sugar is present in the bloodstream which may lead to insulin resistance or type 2 diabetes.

Who may be at risk of getting Hepatitis?

  • Infants born to infected mothers can get hepatitis B
  • Travelers to regions with high risk of Hepatitis infection most commonly reported in Asia, Africa, South America and the Caribbean.
  • Sexual contact with infected persons that cause viral transmission through body fluids.   
  • Household members, healthcare professionals and caregivers of infected persons through an accidental transmission.
  • Recipients of blood transfusions who may have accidentally received an infected blood.
  • Long-term hemodialysis patients through an accidental infected needle use or blood transmission.

Diagnosis of hepatitis

Blood tests for the antibodies can be helpful in diagnosing both acute and chronic hepatitis. Physical examination of the symptoms along with diagnostic studies such as ultrasound scan of the liver or a liver biopsy is also done to determine the severity of liver damage.

Prevention and Treatment of Hepatitis

Immunization :

  • Hepatitis A immunization of children (1-18 years of age) consists of 2-3 doses of the vaccine. Adults need a booster dose every 6-12 months following the initial dose of vaccine. The vaccine is thought to be effective for 15–20 years or more.
  • Hepatitis B vaccines provide protection against hepatitis B for 15 years and possibly much longer. All newborns and individuals up to 18 years of age and adult should be vaccinated. Three injections over a 6 to 12-month period are provided for full protection.

Safety Measures to Prevent Hepatitis

  • Hygiene: Wash your hands after going to the bathroom and before cooking or eating.
  • Protective sex: This may lower the risk of transmission. It’s always wise to know the history of your sexual partners, especially if they have an infection, you may run the risk of contracting the disease.
  • Drinking clean water: Avoid tap water when traveling to certain countries or regions.
  • Careful handling of drug needles and use of disposable drug needles only.
  • Avoid sharing personal items such as toothbrushes, razors and nail clippers.

Once diagnosed with hepatitis, the treatment will depend on the type and stage of infection. Most adults recover completely from acute hepatitis A and B within six months period. Mild relapses may occur over time during the recovery of the disease. 

Early detection and treatment show excellent recovery from both hepatitis B and C. Further research development continues to provide a vaccine for hepatitis C.

 

Obesity – Adult vs Children

Common conditions, Food, Health, Lifestyle

Obesity

Obesity is the presence of excessive adipose tissue (fat) mass affecting the health status of any individual to an extent that it may lead to the risk of other serious health conditions. It is one of the most common global health problem replacing the more traditional public health issues.

Obesity in adults vs children

In order to classify an adult as obese, the body mass index (BMI) can be calculated that best classifies an individual according to his height and weight. 

BMI: It is the weight of the individuals body divided by the square of the body height ( expressed as kg/m2). The standard classification of an individual is given in table 1.

BMI good one

Note-BMI is not the best indicator for health as your excessive weight can also be due to healthy bulging muscles rather than fat storage. It does not give information on the fat storage distribution in the body especially in the waist region and cannot be used as a predictor for lifestyle changes and benefits.

Obesity in children  

In infants and children within 5 years of age, the obesity is determined according to the World Health Organization (WHO) “Child growth standards” and the WHO reference values for 5-19 years (body mass index-for-age).

WHO classification (birth to age 5)

  • Obese: Body mass index (BMI) > 3 standard deviations* above the WHO growth standard median*. 
  • Overweight: BMI > 2 standard deviations* above the WHO growth standard median*.

WHO classification (ages 5 to 19)

  • Obese: Body mass index (BMI) > 2 standard deviations* above the WHO growth standard median* (equivalent to BMI 30 kg/m2 at 19 years).
  • Overweight: BMI > 1 standard deviation* above the WHO growth standard median* (equivalent to BMI 25 kg/m2 at 19 years). 
*Growth Standard median: This is the standard of weight given for boys and girls by WHO according to the weight-for-length and weight-for-height of the children at a particular age.
*Standard Deviation: The weight difference of a child when compared to the mean (average) weight of the children belonging in the same age group.

Other classification for childhood obesity

  • Child is overweight: if BMI at or above the 85th percentile* and lower than the 95th percentile for children of the same age and sex.
  • Child is Obese: if BMI is at or above the 95th percentile* for children of the same age and sex.
*Percentile: It is a term used in statistics to give a value of a percentage of a child’s weight compared to the weights of the children of the same age group. For example, a test score that is greater than or equal to 75% of the scores of people who took the test is said to be at the 75th percentile rank.

Measuring Body fat in Adults

Waist Circumference: This method measures excessive fat around the waist and can be used as an additional measure in people who are obese or pre-obese according to the BMI.

For men, a waist circumference no more than 94cm and for women no more than 80cm is considered a safe range. Beyond which, one can develop obesity-related health problems.

Factors that lead to obesity

Genetic factors: The risk of obesity can be more if one or both parents are obese. This relationship of genes and obesity due to the environment and eating habits.

Age: With age, there can be a decrease in the metabolism of the body and loss of muscle mass. If physical inactivity ensues, coupled with bad eating habits, this can easily increase their ability to store fat in the body. Sometimes hormonal changescan also play a role leading to obesity. 

Gender differences: Women tend to gain weight during pregnancy due to hormonal changes.  Hormonal changes including estrogen, progesterone hormones can lead to weight gain. Imbalances in these hormones can also trigger insulin resistance, which in turn, leads to fat storage. In Men, imbalances in testosterone hormone can lead to weight gain. In general, it is observed that women are more at risk of weight gain compared to men also due to lifestyle differences.

Lifestyle:

  • Physical activity: With improvements in modern technology and conveniences, there is an increasing lack of physical activity. 
  • Food habits: Consuming foods with excessive fat, sugar and calorific foods. Increased snacking and overeating can lead to excessive fat storage.
  • Stress and lack of sleep: Both stress and lack of sleep can slow the body’s metabolism. Eating late at night can cause indigestion and leads to fat storage. 
  • Socio-Economic Status: Lack of resources, lack of access to healthy foods, unable to afford healthy foods or improper cooking habits, eating out too often can all lead to obesity.  
  • Side effects of medications: Certain pain medication, corticosteroids, antidepressants, thyroid medications taken by people with thyroid problems and other medicines can slow down metabolism and lead to fat storage. 
  • Known Medical Problem: Arthritis in the lower limb causing pain on weight bearing can reduce physical activity that leads to increasing fat storage.

Diseases such as stroke, kidney disease, Prader-Willi syndrome, Cushing’s syndrome and many others can prevent the person from engaging into physical activities due to pain or muscle/joint problems etc.  

Consequences of Obesity

obesity problems

Metabolic problems: 

The major metabolic risk factors resulting from obesity are

  • An increase in the total cholesterol concentrations especially triacylglycerol concentrations, and high-density lipoprotein (HDL) concentrations.
  • High blood pressure
  • Diabetes: Insulin resistance and glucose intolerance.

All this may lead to Metabolic syndrome that describes a group of risk factors that can increase the risk of developing a heart condition. 

Diabetes: Obesity can lead to deficiencies in sex-specific steroid hormones (estrogen, progestin etc) that causes insulin resistance and a decrease in glucose metabolism. 

Coronary Heart Disease (CHD): Metabolic syndrome and diabetes can lead to atherosclerosis and blocking of the major arteries of the heart leading to a heart condition.

Osteoarthritis: Osteoarthritis (OA) is an inflammatory condition that can be caused by obesity. Excessive weight gain can lead to wear-and-tear of the cartilage and bone leading to inflammatory joints. Other reasons underlying the relationship between obesity and osteoarthritis can be metabolic changes associated with increased fat storage. 

Pulmonary disease: Excessive weight gain in the upper body can increases breathlessness that will lead to CO2 retained in the body and a mismatch in the ventilation and blood flow that further worsens the respiratory system.

Hypertension: The exact cause is unknown, however, due to weight gain there is an increase in resistance to blood flow to and from the extremities. Increases in body mass index (BMI) can put an individual at a higher risk of developing hypertension. 

Gallbladder disease: Obesity is associated with increased secretion of cholesterol in the gallbladder that increases the risk of gallstones particularly cholesterol gallstones.

Hormonal disturbances: Increased obesity in women leads to increased male hormone (testosterone) production leading to hormonal imbalances. Upper body obesity is associated with an increase in testosterone that may be a major cause of problems related to menstruation. Obese men can also get hormonal problems that lead to erectile dysfunction. Childhood obesity can cause early puberty and hormonal problems later in adulthood.

Some forms of cancer:  There is an increased risk of growth of cancer cells in various body tissue among obese people. 

Fatty liver: Nonalcoholic fatty liver disease, a condition in which fat storage is excessive in the liver that can cause inflammation of the liver tissue and scarring(Cirrhosis).

Various psychological problems: There has been increased links of obesity with depression and mood problems possibly due to underlying hormonal problems or other conditions.

Prevention and Treatment 

  • Realistic healthy weight loss goal

Comprehensive lifestyle changes: 

  • Dietary changes: Avoid calorific or sugary foods. Developing meal plans to track what you consume. Seeking advice from a specialist to know what nutrients you are lacking or how to go about the changes. 
  • Increasing physical activity
  • Exercise: 3-4 times per week for 30 minutes each. 
  • Group support: Joining a weight loss group can help psychologically and improve motivational level toward achieving your goals.
  • Relaxation and stress management

Adherence to a weight loss program is important to bring about changes and to prevent health problems due to obesity. For further detailed assessment and treatment, it is best to consult an expert for individualized weight loss programs.

The Controversy about Monosodium Glutamate (MSG).

Common conditions, Food, Health, Lifestyle

CRS

In the food industry, great interest has been garnered over the use of a particular ingredient which has caused great controversy overtime. That ingredient is Monosodium Glutamate (MSG). It’s often used as a flavour enhancer. Although additives can improve the taste of many foods, it does carry a threat of causing allergies, food intolerance and even certain conditions among some individuals. 

What exactly is MSG?

MSG is a crystallised water-soluble kind of sodium salt made up of the amino acid “glutamate”.

Glutamate is present in nature both in its free form and usually bound to peptides and proteins. The free form is used as additive and is responsible for the flavour enhancing properties. The bound form does not have any effect on taste and is considered an excitatory neurotransmitter (the ones that keep you alert and awake) as they mediate many signals in the brain and is involved in normal brain function such as cognition, memory and learning. 

Commercially, MSG is made by fermenting molasses, sugarcane, corn sugar or starch. MSG can also be obtained from natural protein-rich foods such as seaweeds. 

How does MSG work?

There are glutamate receptors present in many parts of our body like the brain, tongue and other peripheral tissues.  The MSG used in food stimulates the glutamate receptors of the tongue to give a “meat-like” or “umami” taste to foods. 

MSG – Chinese Restaurant Syndrome (CRS)

MSG consumption has been linked to the term “chinese restaurant syndrome” since 1968. This syndrome is caused due to body’s intolerance to MSG. Although the use of MSG in chinese food is well known, other cuisines, processed foods and many fast foods also contain it. 

It is still considered as a common type of food intolerance that may possibly affect many individuals.  

Who can be more susceptible to MSG Symptom complex?

  • People with Respiratory problems like Asthma.
  • People with known immunity problems with histamine that causes allergies to additives.
  • People with intestinal problems like Coeliac disease.
  • People with a sensitive stomach to additives.

Signs and Symptoms of CRS

The type of allergic reaction, severity and frequency of symptoms can vary from person to person. Sometimes multiple symptoms can occur at the same time.

  • Neurological system:  anxiety or panic attacks, blurred vision, depression, dizziness, excessive sweating, fatigue, hyperactivity, irritable, poor concentration, sleep disturbance, mild to severe headaches, migraines, tiredness and leg cramps, numbness of the upper body, head and neck.
  • Skin problems: eczema, hives (urticaria), tissue swelling, tongue/ throat swelling, atopic dermatitis, facial flushing and burning, and angioedema (quick swelling of tissue under the skin).
  • Gut related problems: bloating(gas trouble), burning mouth or tongue, constipation, diarrhoea, indigestion, mouth ulcers, nausea,  vomiting, abdominal pain, cramping and irritable bowel syndrome.
  •  Respiratory symptoms: wheeze, cough, blocked nose and sinuses, hay fever, sneezing, rhinitis (inflammation of mucosal membrane inside the nose), unstable asthma, and laryngeal oedema.

When should you seek medical care?

Mild symptoms usually subside without treatment, however if symptoms are severe such as excessive swelling of the throat and tongue, difficulty in breathing and raised heart rate. It is best to immediately seek medical care to prevent the complication of allergic shock which is also known as “Anaphylaxis”. It is a potentially life-threatening allergic reaction with excessively severe symptoms associated with the MSG intolerance.

Diagnosis of MSG intolerance?

  • Medical evaluation (clinical assessment) can determine if the symptoms are not due to some other identifiable cause or disease process.
  • Heart rate and ECG-Electrocardiogram may be recorded to check the normal heart rhythm.  
  • Respiratory status will be checked for bronchospasm (narrowing of the airways).
  • Skin prick tests (or RAST) are used as a standard way of detecting allergen-specific IgE (a type of antibody produced in the body).

Prevention and treatment of MSG intolerance

Drinking water: Water can help flush out any allergens from the body especially MSG. It can reduce the impact and delay the occurrence of the allergic reaction. 

Elimination Diet: You can be put on a diet that excludes natural salicylates, amines and glutamate, as well as additives such as preservatives, colourings and MSG. This is to see if your symptoms improve with time.

Medication: Medical care can involve the use of prescribed medications that can help reduce the symptoms of allergic reaction.

Although, a reasonable amounts of such foods can be eaten among mild symptomatic individuals. It is best to avoid it as much as possible to prevent further complications.   

Varicose and Spider Veins – What are they and How to avoid them.

anatomy, Common conditions, Exercise, Health

main pic veins

What are Varicose and Spider veins?

Varicose veins are abnormal, dilated blood vessels (veins) caused by a weakening in the vessel wall. They may appear as swollen, twisted clusters of blue or purple veins.

Varicose veins are sometimes surrounded by thin, red capillaries also known as spider veins.

(group of tiny blood vessels located close to the surface of the skin, also called telangiectasias) – Refer Fig 1.

varicose veins
Fig 1: Varicose vs Spider veins

Role of veins and formation of abnormal veins

Veins carry blood back to the heart and have one-way valves that prevent the blood from back-flowing. The calf muscles act as a pump by which the blood is pumped back from the legs towards the heart as shown in Fig 2.

Deep Leg Veins

Fig 2: Normal blood flow through Veins, Calf muscle pump

If those valves of the veins become weak from extended periods of increased pressure and swelling, the blood can back up and collect within the veins. This causes the vein walls to weaken and bulge with blood, causing the veins to appear swollen and twisted as shown in Fig 3.

deformed valves

Fig 3: Normal vs Abnormal blood flow

Who can get it and where does it happen?

Varicose veins and spider veins can occur both in men and women. However, women are known to be affected more than men due to their hormonal predisposition and changes during pregnancy that affect the veins. 

These abnormal veins can develop anywhere, but most often appear on the legs and in the pelvic area because as compared with other veins in the body. This is because, lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting at the same time. This pressure can be stronger than the one-way valves in the veins.

Most varicose veins are seen on the surface of the skin as the superficial veins get swollen with blood collected in it that get raised on the surface and at times above the surface of the skin.  

Signs and Symptoms

Some may not have any symptoms but may be concerned about the appearance of the veins. Symptoms usually worsen after prolonged standing or sitting as the blood pools or collects in the veins of the lower limbs. 

Print

Fig 4: Swelling, Skin changes and Ulcers due to varicose veins

If symptoms occur, they may include:

  • Tiredness, burning, throbbing, tingling or heaviness in the legs
  • Itching around the vein
  • Swollen legs (Refer Fig 4)
  • Muscle cramps, soreness or aching in the legs
  • Brown discoloration of the skin, especially around the ankles (Refer Fig 4)
  • Leg ulcers (Refer fig 4)
  • Rarely varicose veins can form a painful blood clot, referred to as superficial thrombophlebitis (inflammation of a vein).

Risk factors and causes of abnormal veins

Varicose veins are related to increased pressure in the leg veins or defective valves in the veins.

They can happen due to reasons:

  • Idiopathic: The exact cause of this problem is unknown.
  • Heredity: A family history of varicose veins can put a person at risk of developing abnormal veins.
  • Advancing age: With aging veins can lose elasticity causing them to stretch. The valves in your veins may become weak, allowing blood that should be moving toward your heart to back-flow.
  • Prolonged standing or sitting.
  • Being overweight puts extra pressure on your veins, which means damage to the valves, making them more prone to swell.
  • Pregnancy: Pregnancy increases the volume of blood in your body but decreases the flow of blood from your legs to your pelvis. This circulatory change is designed to support the growing foetus but it can produce an unfortunate side effect — enlarged veins in your legs.
  • Hormonal influences during pregnancy, postmenopausal hormonal replacement therapy and use of birth control pills can cause excessive swelling in the lower limbs that hampers blood flow through veins. 
  • Wearing tight clothes can put pressure on the veins which can cause abnormal blood flow.
  • Injury to the veins due to trauma or accidents.
  • Other health conditions that cause increased pressure in the abdomen including liver disease, fluid in the abdomen, previous groin surgery or heart failure.

How is Varicose and Spider veins diagnosed?

A physical examination of the body especially the legs while the person is standing is done. A Doppler ultrasound scan can also check the blood flow in the veins near the skin’s surface and the deep veins. 

When to seek medical care?

  • Walking or standing becomes painful.
  • Soreness develops on or near a varicose vein
  • Your feet or ankles swell up very frequently.

If immediate care is not taken, symptoms may worsen. Complications may develop if there is an underlying disease in the deep veins or in the perforating veins which connect the deep and superficial veins.

  • Chronic venous insufficiency: Untreated venous problems may progress to a chronic condition of abnormal blood flow through the veins.
  • Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
  • Fungal and bacterial infections may occur as the result of skin problems caused by the fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
  • Thrombophlebitis: Inflammation of the vein due to blood clot formation.
  • Venous hemorrhage: Bleeding through the veins due to micro-tears and ruptures.

How to prevent varicose veins and its complications?

Lifestyle modifications:

  • Losing weight if you are overweight
  • Exercising regularly (especially walking)
  • Avoiding prolonged periods of sitting or standing
  • Avoid wearing tight-fitting undergarments and clothing that constricts the waist, groin or legs.
  • Avoid crossing your legs while seated.
  • Elevating your legs while sitting and sleeping will help.
  • When you need to stand for long periods, take frequent breaks – sit down and elevate your feet.
  • Do ankle pump exercises as shown in Fig 5.

ankle pumps

If you still develop varicose or spider veins, it is best to seek medical attention to know more in details on exercises and lifestyle changes that can be personalized to your needs.  

Why is Deep Vein Thrombosis Dangerous?

Common conditions, Exercise, Health, Lifestyle

DVT What is thrombosis?

Thrombosis is a process by which there is clotting of the blood in a part of the circulatory system. This causes a partial or total obstruction thus preventing blood from flowing normally through the circulatory system. This clot is known as a thrombus. 

What is Deep Vein Thrombosis(DVT)? 

A blood clot (thrombus) in the deep venous system is known as DVT. These clots are formed in the deep veins which are a part of the circulatory system that helps bring deoxygenated blood back to the heart. These veins have one-way valves that function to transport blood from various parts of the body to the heart as shown in Fig 1.

veins of our body

Fig 1: Deep veins of the body

Which body part can be affected with DVT?

There is a greater risk of developing DVT in your lower limbs than upper body as the deep lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting on them at the same time. In addition, if there are other factors that increases the pressure exerted on the valves in the deep lower limb veins, there are more chances of blood collecting within the veins thus making the lower limbs deep veins more susceptible to DVT.

Why is DVT dangerous?

There is a risk of a partial or complete detachment of this thrombus formed in the deep veins. This allows the thrombus to move with the blood flow and block other blood vessels. This process is called as venous thromboembolism.

pulmonary embolism

Fig 1: Thromboembolism

As shown in Fig 1, the thrombus blocks the blood vessel and cuts off the circulation to a particular body part or organ. This will lead to a lack of oxygen to the tissue (ischemia) and a loss of tissue function. The clot can also reach other blood vessels that supply the vital organs of the body, putting the body at a dangerous risk of stroke, lung, heart problems and post-thrombotic syndrome (PTS).

Post-thrombotic syndrome is a chronic(long-term) problem that occurs with DVT and involves chronic leg pain, swelling, redness, and ulcers (sores).

How does a thrombus form in the deep veins?

Blood clotting is the transformation of liquid blood into a semi-solid gel. The blood has a protein called fibrin. Fibrin is usually in its inactive state but when tissues or blood vessels are damaged, it becomes active. This process is called coagulation. The main reason of thrombus formation can be explained by the Virchow’s triad as shown in fig 2.

cause of thrombus

Fig 2: Main causes of thrombus formation

Conditions of prolonged bed rest or immobility which could be lifestyle-related or due to other reasons may cause stasis of blood within the veins that may lead to clot formation. Also, if there is an imbalance of the coagulation and anti-coagulation factors in the blood which may be caused by an injury or acute/chronic inflammation to the blood vessel walls may cause blood clot formation.

Who is at risk of developing DVT?

  • Anyone with vein trauma due to broken hip or leg fractures during accidents.
  • Long periods of air travel coupled with lack of movement in sitting position can cause excessive swelling in the legs and stagnation of blood flow leading to clot formation.
  • Bed bound individuals post-surgery, muscular paralysis from a spinal cord injury, pregnancy or having recently given birth, especially by C-section, causing swelling and lack of calf muscle strength that impair blood circulation in the legs.
  • People with inherited blood clotting disorder.
  • People who have cancer as tumors shed particles that contain procoagulant activity.
  • Smoking affects blood circulation and stiffens the blood vessel wall making a smoker at higher risk of DVT.
  • Side-effects with the use of hormone therapy, including that used for postmenopausal symptoms among women.
  • Individuals with varicose veins, which are swollen, twisted and painful may develop clots.
  • People with a history of heart attack, stroke or congestive heart failure have high levels of cholesterol in the blood that lead to inflammation and possibly clot formation.

Signs and Symptoms of DVT

  • Pain, swelling and tenderness in one of your legs (usually your calf)
  • Affected area can be very painful and heavy.
  • Warm skin in the area of the clot.
  • Redness of the skin, particularly at the back of your leg below the knee.

How is DVT diagnosed?

A physical examination may not be enough as there may be individuals with no possible signs of DVT. Diagnostic tests will be necessary to confirm the condition.

  • Doppler ultrasound scan:  A clot may be visible in the image. Sometimes a series of ultrasounds are done over several days to determine whether a blood clot is growing or to detect any formation or movement of a clot.
  • Blood test: An elevated level of a clot-dissolving substance called D dimer will be found in the blood.
  • Venography. A dye (contrast agent) is injected into a large vein in your foot or ankle. An X-ray procedure is then undertaken that creates an image of the veins in your legs and feet, to look for clots. 
  • CT or MRI scans. Both computerized tomography (CT) scan and magnetic resonance imaging (MRI) can provide visual images of your veins and may detect any clot formed. 

When to seek medical care?

  • If you get swelling, redness, and pain in your leg, it may indicate a blood clot and immediate medical attention should be given. Sometimes there may not be any signs or symptoms or these symptoms could be due to other inflammatory condition or infection, therefore, it is difficult to make the diagnosis without seeking medical advice.
  • If there is associated pain in the chest or breathlessness further concern exists that you may be at risk of a pulmonary embolus. This could be a potential danger hence if you are at risk its best to discuss with your doctor about taking medications for preventing clot formation.

How to prevent DVT?

  • Compression stockings for bed bound individuals.
  • Early ambulation Post-surgery – getting the individual out of bed walking to allow good circulation of blood. If not possible, use a continuous passive motion (CPM).
  • Low dose of anti-coagulants can also be prescribed by the doctor.
  • During long flights, it is recommended to move frequently and/or use compression stockings.
  • Ankle exercises can help pump the blood from the legs upwards to the heart.
  • Lifestyle modifications –  smoking cessation and increased exercise.

If in doubt or experiencing any of the symptoms, always seek medical advice immediately. When detected early, it’s much easier to deal with.

What is Torticollis – Congenital and Acquired

Common conditions, Health, Injury, Pain

MAIN WRY NECK

What is Torticollis?

Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”.  It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.

What happens in torticollis?

Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles. 

Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.

sternocleidomastoid FRONT VIEW

In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2. 

CT

Pathophysiology of torticollis

As shown in Fig 2, Torticollis can be of two types.

  • Congenital
  • Acquired

Congenital Torticollis

“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as, 

  • Intrauterine (inside uterus) malposition of the baby 
  • Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth. 
  • Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.

Acquired Torticollis

This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults. 

Reasons for Acquired Torticollis

  • Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion). 
  • Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
  • Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
  • Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
  • Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
  • Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
  • Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.  
  • Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region. 

Signs and Symptoms of Torticollis

  • Inability to move the neck with limited range of motion
  • Chin tilted to one side
  • Headaches
  • Head tremor
  • Neck muscle spasm and pain
  • One shoulder is higher than the other
  • Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
  • Stiffness of the neck muscles
  • Swelling of the neck muscles (possibly present at birth)
  • Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.

When to seek medical care?

Congenital torticollis can be easily identified after childbirth and determine  the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.  

How is torticollis diagnosed?

A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).  However, it’s unlikely that the exact cause of the muscle spasm can be isolated.

In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.

How can torticollis be treated?

Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent. 

Other problems with delayed treatment 

  • Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
  • Open mouth posture with the tongue pulled to one side or the other.
  • Suck/swallow may be affected leading to feeding issues.
  • A permanent trunk and facial asymmetry can occur.

 Chances of torticollis relapse

Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.

The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.

General goals for treatment,

  • Reducing pain, spasm and muscle strains of the neck.
  • Improving mobility and flexibility of the soft tissue structures affected.
  • Reducing stiffness in the neck and mobilizing the joints of the neck.
  • Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
  • Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
  • Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.

There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery. 

Pregnancy – Things to note

Exercise, Health, Lifestyle, Pregnancy

preg main

Pregnancy is a time when the mother undergoes many physical and physiological changes. These changes happen so that the mother’s womb can nurture and host the growing baby. However, there are other possible effects of these changes on the musculoskeletal, cardiovascular and respiratory system of the expectant mother. Therefore, it is important to be aware of these effects in order to help the expectant mother to cope with the challenges of pregnancy.

What are the effects of the hormonal and Physiological changes during pregnancy?

Hormonal changes: Progesterone and Relaxin are two hormones whose levels are extraordinarily high during pregnancy. 

  • They cause changes in the collagen fibres of the connective tissues of the joints and soft tissue structures.
  • Loosening of ligaments decreases the stability of the joints.

Weight gain: Excessive weight and gravity can slow down the circulation of blood and body fluids mainly in the lower limbs. 

  • This can cause excessive workload on the body with physical activity
  • Excessive fluid retention
  • Swelling in the limbs and even face.

Postural change: 

PregnancyPosturePositions
Fig 1: Improper postures and good posture

Improper postures as shown in Fig 1, due to increased weight gain and forward shift of the centre of gravity. It can also affect balance and gait.

Improper postures:

  • increased lower back curvature – lumbar lordosis,
  • compensatory curving of the upper back – kyphosis or scoliosis,
  • rounding of shoulders 
  • forward chin position

Muscular changes:  As the baby grows the mother’s abdominal muscles and ligaments get stretched.

  • Weakness of the abdominal muscle 
  • Less support or bracing to the spine

Due to weight gain, improper posture and possibly lack of gait control, there will be an excessive strain to the muscles of the hips, knees and ankles.

Blood Pressure changes: Pregnancy hormones can suddenly affect the blood vessels by narrowing or expanding them, causing a drop or sudden increase in blood pressure. This if may affect the blood supply to the vital organs like the brain and in severe cases may also affect the growing baby. 

Low blood pressure may cause:

  • Dizziness 
  • Brief loss of consciousness (passing out)

High blood pressure in pregnancy is also known as pre-eclampsia which may worsen to a condition called eclampsia.

Symptoms of Eclampsia:

  • Severe headaches and convulsions.
  • Problems with your vision, such as blurred vision, flashing lights or spots in front of your eyes.
  • Tummy (abdominal) pain, vomiting later in your pregnancy (not the morning sickness of early pregnancy).
  • Sudden swelling or puffiness of your hands, face or feet.

Changes in the Respiratory system: As the uterus enlarges, the movement of the diaphragm (main breathing muscle) may be limited. The uterus moves upwards, it progressively obstructs the downward movement of the diaphragm as shown in fig 2.

diaphragm pushed up
Fig 2: Uterus and abdominal contents pushing the diaphragm

It can force the diaphragm upwards mostly towards the end stage of pregnancy causing:

  • Breathlessness: difficulting in breathing normally.
  • Painful ribs: Rising pressure pushes the rib cage out sideways and forwards, resulting in pain in the front of the lower ribs, also known as rib flare.

Increased Metabolic Rate: Basal or resting metabolic rate (RMR) is the amount of energy the body uses while at rest. Due to hormonal changes, this RMR increases significantly during pregnancy that may put the pregnant women at a higher risk of developing hypoglycemia or low blood sugar leading to light-headedness and fainting.

Risk of health conditions during Pregnancy 

  • Ligament and joint sprain: As the ligaments are lax due to hormonal changes, there is more risk of ligament and joint sprains especially in the ankle joint during pregnancy. Ligaments of the feet become lax and with the additional weight of pregnancy, results in flat feet and development of painful conditions like plantar fasciitis, Achilles tendonitis etc.
  • Supine hypotensive syndrome (Restriction of blood flow): The enlarging fetus compressing the aorta and inferior vena cava against the lumbar spine, restricting blood flow.
  • Painful joints: Incorrect posture causes abnormal curves like kyphoscoliosis and scoliosis which may cause issues for anesthesia during pregnancy and delivery. They also exert excessive strain and fatigue on the body, particularly in the spine, pelvis and other weight-bearing joints (i.e. knees). This results in aches and pains, such as lower back, with the pain spreading to the buttocks, thighs and down the legs.
  • Low back Pain: The extra weight of the baby coupled with the shift in weight distribution may strain the back muscles and can cause muscular spasms. Excessive pressure placed on the back may also cause low back disc herniation that may affect the spinal nerves.
  • Posterior pelvic pain (PPP): Lax ligaments of the body allows the pelvis to enlarge, in preparation for childbirth. Also, due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened. This affects the stability of the sacroiliac (SI) joints – the joints between the tail bone and the pelvic bones on either side at the lower back region as shown in Fig 2.
SI Joint
Fig 2: Sacroiliac joint
  • Diastasis recti: “Diastasis” means separation. “Recti” refers to your abdominal muscle called the “rectus abdominis.” The rectus abdominis muscle runs in the front of the stomach and is excessively stretched during pregnancy. Sometimes the pressure increase due to baby growth may be too much causing the muscle to separate as shown in Fig 3. 
Diastasis recti
Fig 3: Separation of Rectus abdominis muscle.

This separation in the abdominal muscles may lead to:

  • Low back pain: due to lack of bracing to the spine.
  • Hernia: a condition when the abdominal contents can protrude out due to increasing pressure from growing baby and lack of support by the abdominal muscles. Umbilical hernia as shown in Fig 3.
umblical hernia

Fig 3: Umbilical hernia

  • Pubic symphysis pain: The weight-bearing joints, such as the pelvis, is increasingly stressed and loaded during pregnancy. Coupled with the instability that relaxin causes, the pelvis is susceptible to pain and injury. Sometimes due to stress, the pubic symphysis may be separated causing a condition known as symphysis pubis diastasis as shown in Fig 4. This commonly occurs during delivery.
Pubic symphysis
Fig 4: Symphysis Pubis Diastasis
  • Transient osteoporosis: This is a bone condition that happens during pregnancy and symptoms disappear within weeks of labour. It has no known cause, although hormones, nutrient deficiency, and other causes have been proposed. There is a sudden drastic loss of bone mass and swelling in the affected portion during pregnancy. This causes weakness of the bones which may lead to fractures during delivery and other complications for the mother.
  • Gestational Diabetes: Due to hormonal changes in your body, your cells can become less responsive to insulin. When the body needs additional insulin, the pancreas dutifully secretes more of it. However as the cells are unable to respond to it, your blood glucose levels rises too high resulting in gestational diabetes. This may lead to excessive weight gain and development of diabetes post pregnancy.
  • Carpal tunnel syndrome: “Water retention” or swelling in ankles, feet and hands in late pregnancy may lead to joint stiffness and nerve compression syndromes, such as carpal tunnel syndrome.
  • Varicose veins: Varicose veins of the legs may occur during pregnancy or worsen during this period. This is due to a reduction in the vascular tone and changes in the collagen structure in the body (due to progesterone and relaxin) that affect the veins. 

How to prevent health conditions during pregnancy?

Always monitor your health status and evaluate the presence of any specific health condition at an initial stage.

It is important to understand your body in order to avoid conditions and the potential complications it may cause. Proper treatment planning is undertaken at an early stage to ensure the safety and health of both the expectant mother and the baby. 

 As most of these conditions can be prevented with lifestyle and dietary changes, it is best to consult with the experts to know more in details about how to manage and prevent them. 

Restless Legs Syndrome

Common conditions, Exercise, Foot, Health, Lifestyle

restless leg syndrome

What is restless legs syndrome?

Restless legs syndrome (RLS) is a neurological disorder that is characterized by an uncomfortable sensation in the legs and rarely the arms. This leads to an overwhelming urge to move them continuously.

These movements may,

  • happen to partially or totally relieve discomfort.
  • begin or worsen during periods of rest such as lying or sitting
  • worsen during sleep, causes time to time movements also known as “periodic leg movements”.

It has also been suggested that RLS would be called “Willis-Ekbom disease”, as an homage to the two pioneers Thomas Willis and Karl-Axel Ekbom who first reported this condition. 

What causes RLS?

  • Unknown cause
  • Genetic cause

RLS symptoms are related to hyperexcitability of the central nervous system- brain and spinal cord due to a possible deficiency of a chemical called dopamine. Dopamine plays a role in controlling muscle movement and may be responsible for the involuntary leg movements associated with RLS.

  • Disorder of the peripheral nervous system

The peripheral nervous system involves the nerves that carry signals from different parts of the body to the brain. The most likely possibility is the presence of hypoxia (lack of oxygen) caused by changes in blood flow or metabolism in the lower limbs that irritates the sensory nerves of the legs causing restlessness. 

  • Iron-deficiency anaemia – low levels of iron in the blood can lead to a drop in dopamine, triggering restless legs syndrome
  • Chronic (long-term) health conditions – such as chronic kidney disease, diabetes, Parkinson’s disease, rheumatoid arthritis, an underactive thyroid gland or fibromyalgia.
  • Radiculopathies: Radiculopathies are problems with the nerves and occur due to nerve compression at the spine caused by disc herniation and protrusion and/or disc degeneration. It is most commonly seen in the lower back regions (Lumbar spine). Nerve compression could cause referred pain and tingling sensations along the back of the leg to the feet that may be a secondary cause for RLS. 
  • Pregnancy – particularly from week 27 until birth; in most cases, the symptoms disappear within four weeks of giving birth
  • Side effects of certain medication: Antidepressants, Antipsychotic medicine, Lithium (used in the treatment of bipolar disorder), Calcium channel blockers (used in the treatment of high blood pressure), Antihistamines, Metoclopramide (used to relieve nausea). 
  • Lifestyle problems: Excessive smoking, caffeine/ alcohol, obesity, stress and lack of exercise.

Who can be affected with RLS?

  • Both the genders are affected but women are twice as likely to develop RLS than men which is still unknown and is suggested to be related to genetics, body functions or emotional differences. 
  • People of all ages can be affected but more commonly seen among middle-aged people secondary to other health conditions.

What are the signs and symptoms of RLS?

Signs and symptoms may vary from day to day, in severity and frequency from person to person during rest and most often during sleep. 

  • Abnormal sensations (Paresthesias)- pulling, creeping etc.
  • Unpleasant abnormal sensations (Dysesthesias)- the sensations range in severity from uncomfortable to irritating to painful example, tingling, burning, aching or like electric shocks.
  • Periodic leg movements during sleep
  • Typical movements like pacing and walking, jiggling the legs, stretching and bending, tossing and turning, rubbing the legs.
  • Inability to sleep leading to sleep disorders like insomnia (lack of sleep) due to increased urge to move or sudden waking up from sleep due to periodic leg movements.
  • Hyperactivity may be seen among children with RLS.
  • Fatigue/tiredness, lack of concentration, problems with cognitive function (related to thinking, attention and decision making) due to lack of sleep and excessive movements in the leg most often felt throughout the day.

How is RLS diagnosed?

There are no diagnostic tests that can diagnose RLS.

A thorough clinical assessment of the patient is necessary to be able to diagnose this condition. 

  • Clinical history: The history of the patient about signs and symptoms associated with RLS will be important for the diagnosis. The frequency, duration, and intensity of symptoms the aggravating and relieving factors as well as their tendency to occur during day and night time will be noted.
  • Family and Medical History: Family history and problems of other health conditions and the use of medications will be noted that may be the suggestive cause for RLS.
  • Neurological and physical examination: Examination of other underlying conditions related to muscle or nerve problems. 
  • Blood tests: blood test can be done to identify iron and vitamin deficiencies as well as other medical disorders associated with RLS.  
  • Sleep studies such as polysomnography (a test that records the individual’s brain waves, heartbeat, breathing, and leg movements during an entire night of sleep) may identify the presence of periodic leg movements and other problems of sleep.
  • RLS in children: This may be difficult since it may be hard for a child to describe any uncomfortable sensations in the leg and the urge for leg movements, when and how often the symptoms occur, and how long they last.
  • Misdiagnosis: RLS may be often misdiagnosed as “growing pains” or “Attention Deficit Hyperactivity disorder” (ADHD) in children and may be mistaken to be an onset of another neurological disease, such as Parkinson’s disease in adults.

How can this condition be treated?

  • Most symptoms can be treated by therapeutic treatments that improve the blood circulation of the legs, muscle flexibility and allow the nerves of the legs to relax. This can help diminish the uncomfortable sensations caused by restless legs syndrome.
  • Identification and treatment of other health problems are important to reduce the symptoms of RLS.  
  • Intake of diet rich in iron and vitamins will be beneficial.
  • Reducing smoking and alcohol consumption.
  • Stress management will help reduce symptoms and improve sleep.

Severe problems with RLS can be also be treated along with prescribed medications that improve the dopamine levels in the body. However, RLS may generally be a lifelong condition.There may be periods of no symptoms but may eventually reappear sooner or later. Adhering to the treatment methods can help reduce the symptoms at all times. 

Common Injuries of the Achilles Tendon

Ankle, Common conditions, Exercise, Foot, Injury, Lifestyle, Pain

Achilles tendon injury

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”. 

achilles Tendon main

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus).  Functions of the Achilles Tendon

  • Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.
  • Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.
  • Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.
  • Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon? The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

achilles Bursas

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”. 

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers. 

What causes an Achilles tendon injury?

  • Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs  more powerful movements such as lunges, jumps, or push off.

  • Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

  • Improper Footwear 
  • Side effects of certain medications  

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

  • Accidental trauma
  • Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

  • Genetic 

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in  ankle joints that lead to the wear and tear of the Achilles tendon. 

Achilles tendon injuries

achilles tendon injury locations

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon. 

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Achilles Tendon course of injury

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Tendonitis insertion

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Print

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear) Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Rupture complete

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

  • Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.
  • Thickening of the tendon
  • Bone spur formation at the insert of the tendon
  • Bruising and Swelling around the tendon area.
  • Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.
  • Restriction of Achilles tendon’s motion within the Achilles tendon sheath.
  • Bursitis: Inflammation of the bursas around the Achilles tendons.
  • Snapping or popping noise can indicate a tendon rupture.
  • Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)
  • A limp may be seen on weight bearing immediately after an Achilles tendon rupture
  • Ankle instability
  • Nerve or blood vessel damage: Signs include numbness, tingling, pins-and-needles sensation in your foot and bruised skin.

How is an Achilles tendon injury diagnosed? An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

achilles tendon rupture and normal

Fig 8: Achilles tendon rupture of the Left heel

 An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Complete tear MRI

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.