Dietary management, Exercise and Foot care in DM.

Dietary management

Goals of Medical nutrition therapy

1.       To achieve and maintain near normal glycemia

2.       To achieve and maintain optimal lipid profile , total cholestrol <150, triglyceride </= 120, HDL >50, LDL < 100

3.       To achieve and maintain normal blood pressure levels around 120-130 to 80-85 mmhg

4.       To adjust the nutrient intake to restore and maintain ideal body weight to avoid dyslipidemia, cardio vascular disease, hypertension and nephropathy. During childhood and pregnancy adjustment for growth should be provided

5.       For elderly patients, provision for proper nutrition and psychosocial needs

Diabetes Mellitus Type 2 – First step dietary management therapy + Exercise 50 % come under control.

Optimum daily intake needs in calorie intake per kg of desirable body weight.

                                          Sedentary           Moderate         Heavy

Obese                               20                           25                      30

Standard wt                      30                           35                      40

Underweight                     35                           40                      45

Total Calorie Intake :

Most important step while prescribing a diet

BMI( Basal Metabolic Index) = Weight in kg / Height in metre square

BMI between 22-25 ideal

Ideal body weight = Height in cm-100

Features of dietary management therapy :

-dietary management is not a reduction in diet , but modulation to suit particular need of individual . This concept will reduce psychological resistance against disease

-patient and spouse counselled together

-dietary articles prescribed in terms of weight

-better to prescribe foods in form of primary food articles like rice, meat, fish and others

-make understand reduction in food will not be beneficial

-quantity to diet and timing are important since other aspects of management such as medication and exercise are timed in relation to the diet

-vast majority of treatment failure can be avoided by proper dietary instructions

-need for strict adherence stressed during follow up

-patient should be involved in the formulation of the diet and such a participating instruction assures better compliance

-carbohydrates must make up 50-60% of the calories for good metabolic control, include more legumes, pulses, green leafy vegetables

-fats should make up 20-25% of total calories, saturated and mono & poly unsaturated fats should be equally distributed

-dietary cholestrol < 300 mg/day

-invisible fat : cereals, legumes, seeds, they contribute to 5 to 10 % of total energy intake

-milk & milk products 40 to 45 % of total fats

-milk fat is a saturated fat

-proteins 12-20%, must include lean meat and fish, strict protein restriction in renal failure

-dietary salt < 6gm/day, for hypertensives 3gm/day

-avoid smoking/alcohol completely

A SAMPLE DIETARY CHART ADVICED BY A DIABETES CLINIC

Morning 6 am : Tea / Coffee / Milk 200ml without fat and sugar.

Morning 8 am : Idli / Dosa / Chapathi / Upma / Pongal / Kichadi / Ada / Appam / Rice Puttu with Saambar 1 cup

Morning 11am : Butter milk / Coffee / Tea / Fat removed Milk 200ml + Marie biscuit / Dhal / Popcorn / Vada / Rusk / Cucumber salad- any one of these

Lunch 1 pm : Rice , with lots of vegetables and  green leafy vegetables, Sambar 1 cup, Rasam 1 cup, Butter Milk 1 cup

Non veggies : 100 gm fish or two pieces, 100gm chicken or two pieces, 100gm mutton or three pieces, egg white of one whole egg, only once in a week

Avoid : Egg yolk, fried fish, liver, brain, chest region of chicken, head of fish

Tea time 5pm : Coffee / Tea / Milk 200ml with Whole wheat mixed or Multi grain bread or same as said for 11 0’clock without sugar.

Night 8pm : same as breakfast or lunch

Night 10pm : 200ml of fat removed milk  without sugar.

Exercise therapy

Endocrine / Physiological responses during exercise

-suppression of insulin release directly as well as through epinephrine

-symphathetic system activation which inhibits insulin release and stimulates lipolysis

-non insulin dependant glucose uptake in periphery

Benefits of exercise

-lowers blood glucose concentration

-improves insulin sensitivity

-reduce triglycerides, increase HDL, reduce LDL

-reduce BP

-reduce body weight

-cardio vascular conditioning

-improves sense of well being and quality of life

Risks of unsupervised Exercise

-hypoglycemia may be caused due to over exercise, physical strain, untimely food, fasting, redcution in food as a part of dietary management etc

-symptoms of hypoglycemia are blurred vision, headache, confusion, giddiness, dizziness, increased craving for food, increased sweating, tremor, shivering

-hyperglycemia after very strenous exercise especially in poorly controlled patients

-precipitation or exacerbation of cardiovascular disease and acute cardiac events like arrythmias, sudden death and cardiac failure

-worsening of DM complications

Pre exercise check list for DM

-Duration and Intensity of the exercise must be planned with proper consultation of the diabetologist

-Review DM medications

-TMT/ Stress ECHO to rule out CAD and also to know individuals exercise tolerance capacity

-Ophthalmic fundoscopy to rule out proliferative retinopathy

-Biothesiometry to detect extent and severity of sensory loss

-Check blood glucose if < 100 mg/dl advice pre exercise snacks, 100-250 mg/dl can proceed with exercise, > 200 mg/dl check urinary ketones if positive, insulin should be started

For average middle aged DM patient

-walk 3km on level ground over a period of 45 mts

-swim for 30 mts at an average speed without cardiac distress

-cycle on level ground at 8 km/hr for 30 mts

Foot care in DM

-wash both the foot regularly in luke warm water with baby soap

-clean the foot clearly with bath towel making sure there is no water between the toes

-keep the toe nails clean, don’t allow them to get septic, cut the nails carefully

-always keep the moisture of the foot, don’t allow them to dry,apply suitable moisturising lotion and massage gently for some time, don’t allow moisture to stay between the toes

-always use suitable foot wears which are gentle and comfortable and clean, and use alwys clean socks

-when going outside don’t walk on naked foot especially around the fields and gardens, foot is a must every where

-check the foot wear for ant sand particles or thorn that may injure the foot

-walking around your house or garden with all vigour is necessary to maintain the blood circulation to the foot

-always keep your foot little higher than body level while at sleep to ensure suficient venous drainage

-while sitting for longer time don’t sit with putting legs over another legs

-immediately consult your doctor if you find any of these symptoms : numbness, prickling sensation, parasthesiae, tingling, oedema, foot crack, ulcers, corns, change in colour of skin and blisters

-if possible wear a different foot wear in morning and evening

-using canvas shoes with extra insole or MCR chappals are more helpful

-use always those shoes that are slightly bigger than you size

Also :

-Bath twice daily

-Over sweating areas apply talcum powder

-Dental hygiene is must

-Itching and skin diseases must be dealt with more seriosity

-If no proper control measures are taken DM might affect kidneys, heart, vessels and eyes.

 

    

   

   

    

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Experience, Listening, Clinics and Theory !

Experience, Listening, Clinics and Theory !

By Dr.Prasanth.K.P.

Not everybody is blessed with skills, like sachin or lata mangeshkar or messy, but these people are not the only successful people. The difference between them and other succesful people are talent, sheer talent. They posses such abundance of talent that nobody in the world cannot ignore them ! You people must very much be aware of the uproar created in the fb page of sharapova when she said that she did not know who sakhin was ? But keeping talent aside , its not the only factor that has given them the position that they are now, its also about some attitude that plays the key, its role is more than even hard work.

During a chat with my senior doc , who said when doing some arithmetics that even though I may be a good doctor (that which is he is aware of !) , I cant do certain things like writing it out, or do an extempore, he admits to have stage fear ! But I said its all about the doer –watcher phenomenon, when you are said to possess a talent at something you can be the doer and watcher at the same time, got my idea ? That is you can be aware of what you are doing, for example, even though Sachin may have a coach, from childhood, he needs no help of a coach ( an external watcher, observer, analytic supplement etc..) to correct his flaws or train, he can do without it,, its because of the cliché format followed that he “seems to have” a coach, he is in auto-pilot mode when on ! That part of the observation was proved by neuro scientists when they observed Neymar’s brain while on game, when they realised that he was literally on auto-pilot when on field. That’s the doer – watcher phenomenon I mentioned, being on auto pilot.

But that was my perception, my seniors take on that, pretty simplified, lay manly expalnation I say which every one would understand , is that , what you say the doer watcher , is nothing but the mistakes learned out of doing that helps you to get aware of what you do. It is impossible for any body of any quanta of talent to gain in confidence without experience. What ever type of genesis you may belong, as long as you are a theoritician, you cannot gain practise in the clinical field. That’s where I openly challenge the so called “purists” who demand a 100% ayurvedic system, to come out into the clinical arena. They are in their own cosy-comfotable field set up by their thoughts , that being in that gives them some sort of intoxication, they seldom venture into clinical side. What’s the use of such people ?

I share before you the difference that separates a person with a strong theoretical basis and one with a moderate theoretical basis but has got a strong base and is strong on the clinical side. Both of them say A and B, participates in a seminar on the application of takra dhara, that too presented before a scientific community of astronomers. A was a purist who knows nothing other than Ayurveda, he speaks only in Ayurvedic language, but B is a clinical person, who knows to speak the language of lay man ( other wise you are out in clinics !) . B knows about the value of A’s knowledge, which B lacks, so speaks for an hour or two with A, where A tells all about what he has prepared to present to B. B listened to it , and included majority of what A said in their conversation, but understood the practical side that the listeners were a scientific community, so presented in their language. But B clearly knows A was the better lot ! To his luck B got recognised by a scientific community and got the 1^st prize but A who got all the knowledge was ignored totally as the judges never heard of any tri dosas or ayurveda ! What a contardiction. The same is the case with our soceity. Nobody knows Ayurveda, but every body knows about a pain killer, an aspirin, an injection, a surgey, a by-pass, see how popular is allopathic medicine in the masses ? If you go on spitting slokas , you are gonna get alieanated from the soceity and the sience of life too ! DiD you get my point ? Here, as far as Tamil Nadu is concerned the Ayurveda IQ is literally zero, you say Dhara, Kizhi, they will scratch their heads ! You say aceclofenac gel, than they get you ! Such is the attitude of the patients. Be practical, speak the language of the patients, these Ayurvedic texts were not meant for students and researchers, but for the rogi’s or diseased persons !

Being a listener is one of the main traits in gaining knowledge. Know that empty vessels make more sound, was not a joke proverb ! Those who know, know that only while listening to others that they get to know, knowledge is in you, to such people and they do respect that knowldege.

So when you hear from the mouth of a vedanti, that “AHAM BRAHMASMI” or “TATTWAMASI”, don’t laugh, how I can be god ? It’s the knowledge present in you that they specify, not a stone sculpture holding a flute in his hand, bearing a peacock feather in his head. Don’t get disillusioned !

Good luck ye fellas !

Have a great day and an awesome weekend !! :) :) :)

The unpragmatic Ayurvedic Academia !

By Dr.Prasanth.K.P.

The biggest failure as far as Ayurvedic academia is concerned would be imitating the modern system right from the word go, the imitation has been pretty illogical one, done without any pragmatic approach. For anatomy you academics created a rachana sareera, and for physiology you created a kriya sareera, I doubt wether acharya says so, and in fact for all ye common masses,, there is no such thing as anatomy and physiology in ayurveda, its not a separatist approach, which I have been mentioning from the blog one, it’s a holistic one . Our very own Charaka, Susrutha and Vagbhata dedicates a section called Sareera Sthana, in which he describes about Obstetrics , Pregnanacy, Vital points, About the concept of Agni or digestive fire, About the inherent nature or prakruthi etc..Its beyond the perspective of anatomy and physiology. There is nothing such as a swasthavrittha mentioned in ayurvedics and there is no need for one, since allopaths study the preventive and social medicine, we for name sake study swasthavritha as two papers, which includes again soothrasthaana ( basics again ) in the second year also and a bit ( a tiny bit ) of yoga, which is injustice realising the importance of yoga, since the effect of pranayama on the body and breath controls is very vast as an ocean, its ridiculous, its bad. More importance should be given to Dravya Guna Vijnana, Yoga and Sutrasthaana must include both Soothra and Sareera. Anatomy and Physiology must be dealt with separate. That’s gonna be a hell of a challenge for the students, provided anatomy poses a nightmare for everyone alike !There is only one paper for Charaka, or is it needed ? Isn’t it a part of Kaya chikitsa ? Then why there was not a paper for Susrutha Samhita, its illogical ! Padartha vijnana and Sanskrit do good only provided all literatures are in Sanskrit and Sankhya philosophy forms the basement of all Ayurvedic thoughts. But that too must carefully be redacted, leaving out all those stories and things and Vaidyakeeya subhashita sahitya ! It does no good really ! Students may be introduced on a high note I say to the vedic philosophies and thoughts about sareera and atman, about the brahman etc which would be thought provoking and open their channels in the thought towards an Ayuvedic stream, an entirely Ayurvedic one. You cannot think of Ayurveda sans the vedas ! (any doubts on that ?) Second year is an empty one regarding an ayurvedic student , where the allopathic one scores highly , for the rest of his career, that’s what makes the real difference, the pathology and bio chemistry of the human body ! No Ayurvedic knowledge can equal its quanta of research and development. With quarter knowledge of human anatomy and physiology ayurvedic sub-consciously enters into an empty pool, then to go to the vast and wide ocean of chikitsa or treatment, he learns charaka, susrutha, astanga hrudaya ( that’s according to syllabus, while most of ‘em are satisfied with our popular A.H ) then all “relevant” points of commonly used MBBS texts, may be a 10 % just for the sake of passing out . How cann you treat a disease without knowing its pathology ? What do you know about pathology ? Ayurveda specifies a samprapti for every disease that is equal to pathology, but how much in use is that system ? How many of us know about nadi’s ? Well there’s plenty of topics to ponder and to debate ! 

Spinal Cord Injury Levels & Classification

When people are injured, they are often told that they have an injury at a given spinal cord level and are given a qualifier indicating the severity of injury, i.e. "complete" or "incomplete". They may also be told that they are classified according to the American Spinal Injury Association (ASIA) Classification, as a ASIA A, B, C, or D. They may also be told that they have a bony fracture or involvement of one or more spinal segments or vertebral levels. What most people do not know is doctors are frequently confused about the definition of spinal cord injury levels, the definition of complete and incomplete injury, and the classification of spinal cord injury. In the early 1990's, when I co-chaired the committee that helped define the currently accepted ASIA Classification, there was no single definition of level, completeness of injury, or classification. In this article, I will briefly address the issue of spinal cord injury levels, the definition of "complete" spinal cord injury, and the ASIA Classification approach towards spinal cord injury.

Vertebral vs. Cord Segmental Levels

The spinal cord is situated within the spine. The spine consists of a series of vertebral segments. The spinal cord itself has "neurological" segmental levels which are defined by the spinal roots that enter and exist the spinal column between each of the vertebral segments. As shown in the figure the spinal cord segmental levels do not necessarily correspond to the bony segments. The vertebral levels are indicated on the left side while the cord segmental levels are listed for the cervical (red), thoracic (green), lumbar (blue), and sacral (yellow) cord.

Vertebral segments. There are 7 cervical (neck), 12 thoracic (chest), 5 lumbar (back), and 5 sacral (tail) vertebrae. The thoracic vertebrae are defined by The spinal cord segments are not necessarily situated at the same vertebral levels. For example, while the C1 cord is located at the C1 vertebra, the C8 cord is situated at the C7 vertebra. While the T1 cord is situated at the T1 vertebra, the T12 cord is situated at the T8 vertebra. The lumbar cord is situated between T9 and T11 vertebrae. The sacral cord is situated between the T12 to L2 vertebrae.

Spinal Roots. The spinal roots for C1 exit the spinal column at the atlanto-occiput junction. The spinal roots for C2 exit the spinal column at the atlanto-axis. The C3 roots exit between C2 and C3. The C8 root exits between C7 and C8. The first thoracic root or T1 exits the spinal cord between T1 and T2 vertebral bodies. The T12 root exits the spinal cord between T1 and L1. The L1 root exits the spinal cord between L1 and L2 bodies. The L5 root exits the cord between L1 and S1 bodies.

The Cervical Cord. The first and second cervical segments are special because this is what holds the head. The lower back of the head is called the Occiput. The first cervical vertebra, upon which the head is perched is sometimes called Atlas, after the Greek mythological figure who held up earth. The second cervical vertebra is sometimes called the Axis, upon which Atlas pivots. The interface between the occiput and the atlas is therefore called the atlanto-occiput junction. The interface between the first and second vertebra is called the atlanto-axis junction. The C3 cord contains the phrenic nucleus. The cervical cord innervates the deltoids (C4), biceps (C4-5), wrist extensors (C6), triceps (C7), wrist extensors (C8), and hand muscles (C8-T1).

The Thoracic Cord. The thoracic vertebral segments are defined by those that have a rib. These vertebral segments are also very special because they form the back wall of the pulmonary cavity and the ribs. The spinal roots form the intercostal (between the ribs) nerves that run on the bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes.

The Lumbosacral Cord. The lumbosacral vertebra form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal regions.

The Cauda Equina. In human, the spinal cord ends at L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a spray of spinal roots that is frequently called the cauda equina or horse's tail. Injuries to T12 and L1 vertebra damage the lumbar cord. Injuries to L2 frequently damage the conus. Injuries below L2 usually involve the cauda equina and represent injuries to spinal roots rather than the spinal cord proper.

In summary, spinal vertebral and spinal cord segmental levels are not necessarily the same. In the upper spinal cord, the first two cervical cord segments roughly match the first two cervical vertebral levels. However, the C3 through C8 segments of the spinal cords are situated between C3 through C7 bony vertebral levels. Likewise, in the thoracic spinal cord, the first two thoracic cord segments roughly match first two thoracic vertebral levels. However, T3 through T12 cord segments are situated between T3 to T8. The lumbar cord segments are situated at the T9 through T11 levels while the sacral segments are situated from T12 to L1. The tip of the spinal cord or conus is situated at L2 vertebral level. Below L2, there is only spinal roots, called the cauda equina.

Sensory versus Motor Levels

A dermatome is a patch of skin that is innervated by a given spinal cord level. Figure 2 is taken from the ASIA classification manual, obtainable from the ASIA web site. Each dermatome has a specific point recommended for testing and shown in the figure. After injury, the dermatomes can expand or contract, depending on plasticity of the spinal cord.

C2 to C4. The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle (the horizontal bone that goes to the shoulder. C4 covers the area just below the clavicle.

C5 to T1. These dermatomes are all situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the lateral aspects of the hand, and T1 covers the medial side of the forearm.

T2 to T12. The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

L1 to L5. The cutaneous dermatome representating the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

S1 to S5. S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Ten muscle groups represent the motor innervation by the cervical and lumbosacral spinal cord. The ASIA system does not include the abdominal muscles (i.e. T10-11) because the thoracic levels are much easier to determine from sensory levels. It also excludes certain muscles (e.g. hamstrings) because the segmental levels that innervate them are already represented by other muscles.

Arm and hand muscles. C5 represents the elbow flexors (biceps), C6 the wrist extensors, C7 the elbow extensors (triceps), C8 the finger flexors, and T1 the little finger abductor (outward movement of the pinky finger).

Leg and foot muscles. The leg muscles represent the lumbar segments, i.e. L2 are the hip flexors (psoas), L3 the knee extensors (quadriceps), L4 the ankle dorsiflexors (anterior tibialis), L5 the long toe extensors (hallucis longus), S1 the ankle plantar flexors (gastrocnemius).

The anal sphincter is innervated by the S4-5 cord and represents the end of the spinal cord. The anal sphincter is a critical part of the spinal cord injury examination. If the person has any voluntary anal contraction, regardless of any other finding, that person is by definition a motor incomplete injury.

It is important to note that the muscle groups specified in the ASIA classifications represent a gross over simplication of the situation. Almost every muscle received innervation from two or more segments.

In summary, the spinal cord segment serve specific motor and sensory regions of the body. The sensory regions are called dermatomes with each segment of the spinal cord innervating a particularly area of skin. The distribution of these dermatomes are relatively straightforward except on the limbs. In the arms, the cervical dermatomes C5 to T1 are arrayed from proximal radial (C5) to distal (C6-8) and proximal medial (T1). In the legs, the L1 to L5 dermatomes cover the front of the leg from proximal to distal while the sacral dermatomes cover the back of the leg.
 

Spinal Cord Injury Levels

Differences between neurological and rehabilitation definitions of spinal cord injury levels. Doctors use two different definitions for spinal cord injury levels. Given the same neurological examination and findings, neurologists and physiatrists may not assign the same spinal cord injury level. In general, neurologists define the level of injury as the first spinal segmental level that shows abnormal neurological loss. Thus, for example, if a person has loss of biceps, the motor level of the injury is often said to be C4. In contrast, physiatrists or rehabilitation doctors tend to define level of injury as the lowest spinal segmental level that is normal. Thus, if a patient has normal C3 sensations and absent C4 sensation, a physiatrist would say the sensory level is C3 whereas a neurologist or neurosurgeon would call it a C4 injury level. Most orthopedic surgeons tend to refer to the bony level of injury as the level of injury.

EXAMPLE. The most common cervical spinal injuries involve C4 or C5. Take, for example, a person who has had a burst fracture of the C5 vertebral body. A burst fracture usually indicates severe trauma to vertebral body that typically injures the C6 spinal cord situated at the C5 vertebrae and also the C4 spinal roots that exits the spinal column between the C4 and C5 vertebra. Such an injury should cause a loss of sensations in C4 dermatome and weak deltoids (C4) due to injury to the C4 roots. Due to edema (swelling of the spinal cord), the biceps (C5) may be initially weak but should recover. The wrist extensors (C6), however, should remain weak and sensation at and below C6 should be severely compromised. A neurosurgeon or neurologist examining the above patient usually would conclude that there is a burst fracture at C5 from the x-rays, an initial sensory level at C4 (the first abnormal sensory dermatome) and the partial loss of deltoids and biceps would imply a motor level at C4 (the highest abnormal muscle level). Over time, as the patient recovers the C4 roots and the C5 spinal cord, both the sensory level and motor level should end up at C6. Such recovery is often attributed to "root" recovery. On the other hand, a physiatrist would conclude that the patient initially has a C3 sensory level, a C4 motor level, and a C5 vertebral injury level. If the patient recovers the C4 root and the C5 cord, the physiatrist would conclude that both the sensory and motor levels are C5.

Discrepant lower thoracic vertebral and cord levels. The spinal vertebral and cord segmental levels become increasingly discrepant further down the spinal column. For example, a T8 vertebral injury will result in a T12 spinal cord or neurological level. A T11 vertebral injury, in fact, will result in a L5 lumbar spinal cord level. Most patients and even many doctors do not understand how discrepant the vertebral and spinal cord levels can get in the lower spinal cord.

EXAMPLE. The most common thoracic spinal cord injury involves T11 and T12. A patient with a T11 vertebral injury may have or recover sensations in the L1 through L4 dermatomes which include the front of the leg down to the mid-shin level. In addition, such a patient should recover hip extensors, knee extensors, and even ankle dorsiflexion. However, the sacral functions, including bowel and bladder and many of the flexor functions of the leg may be absent or weak. As in the case of cervical and thoracic spinal cord injury, it is important to assess both sensory and motor function.

Conus and Cauda Equina Injuries. Injuries to the spinal column at L2 or lower will damage the tip of the spinal cord, called the conus, or the spray of spinal roots that are descending to the appropriate spinal vertebral levels to exit the spinal canal or the caudal equina. Please note that the spinal roots for L2 through S5 all descend in the cauda equina and injury to these roots would disrupt sensory and motor fibers from these segments. Strictly speaking, the spinal roots are part of the peripheral nervous system as opposed to the spinal cord. Peripheral nerves are supposed to be able to regenerate to some extent. However, the spinal roots are different from peripheral nerves in two respects. First, the neurons from which sensory axons emanate are situated in the dorsal root ganglia (DRG) which are located just outside the spinal column. One branch of the DRG goes into the spinal cord (called the central branch) and the other is the peripheral branch.

Thus, a spinal root injury is damaging the central branch of the sensory nerve whereas peripheral nerve injury usually damages the peripheral branch. The sensory axon must grow back into the spinal cord in order to restore function and they generally will not do so because of axonal growth inhibitors in the spinal cord and particular at the so-called PNS-CNS junction at the dorsal root entry zone. Second, the cauda equina contains the ventral roots of the spinal cord, through which the motor axons of the spinal cord pass to innervate muscles. If the injury to the ventral root is close to the motoneurons that sent the axons, the injury may damage the motoneuron itself. Both of these factors significantly reduce the likelihood of neurological recovery in a cauda equina injury compared to a peripheral nerve injury.
 

Complete versus Incomplete Injury

Most clinicians commonly describe injuries as "complete" or "incomplete".

Traditionally, "complete" spinal cord injury means having no voluntary motor or conscious sensory function below the injury site. However, this definition is often difficult to apply. The following three example illustrate the weaknesses and ambiguity of the traditional definition. The ASIA committee considered these questions when it formulated the classification system for spinal cord injury in 1992.

• Zone of partial preservation. Some people have some function for several segments below the injury site but below which no motor and sensory function was present. This is in fact rather common. Many people have zones of partial preservation. Is such a person "complete" or "incomplete", and at what level?
• Lateral preservation. A person may have partial preservation of function on one side but not the other or at a different level. For example, if a person has a C4 level on one side and a T1 level on the other side, is the person complete and at what level?
• Recovery of function. A person may initially have no function below the injury level but recovers substantial motor or sensory function below the injury site. Was that person a "complete" spinal cord injury and became "complete"? This is not a trivial question because if one has a clinical trial that stipulates "complete" spinal cord injuries, a time must be stipulated for when the status was determined.

Most clinicians would regard a person as complete if the person has any level below which no function is present. The ASIA Committee decided to take this criterion to its logical limit, i.e. if the person has any spinal level below which there is no neurological function, that person would be classified as a "complete" injury. This translates into a simple definition of "complete" spinal cord injury: a person is a "complete" if they do not have motor and sensory function in the anal and perineal region representing the lowest sacral cord (S4-S5).

The decision to make the absence and presence of function at S4-5 the definition for "complete" injury not only resolved the problem of the zone of partial preservation but lateral preservation of function but it also resolved the issue of recovery of function. As it turns out, very few patients who have loss of S4/5 function recovered such function spontaneously. As shown in figure 3 below, while this simplifies the criterion for assessing whether an injury is "complete", the ASIA classification committee decided that both motor and sensory levels should be expressed on each side separately, as well as the zone of partial preservation.

In the end, the whole issue of "complete" versus "incomplete" injury may be a moot issue. The absence of motor and sensory function below the injury site does not necessarily mean that there are no axons that cross the injury site. Many clinicians equate a "complete" spinal cord injury with the lack of axons crossing the injury site. However, much animal and clinical data suggest that an animal or person with no function below the injury site can recover some function when the spinal cord is reperfused (in the case of an arteriovenous malformation causing ischemia to the cord), decompressed (in the case of a spinal cord that is chronically compressed), or treated with a drug such as 4-aminopyridine. The labeling of a person as being "complete" or "incomplete", in my opinion, should not be used to deny a person hope or therapy.

Classification of Spinal Cord Injury Severity

Clinicians have long used a clinical scale to grade severity of neurological loss. First devised at Stokes Manville before World War II and popularized by Frankel in the 1970's, the original scoring approach segregated patients into five categories, i.e. no function (A), sensory only (B), some sensory and motor preservation (C), useful motor function (D), and normal (E).

The ASIA Impairment Scale is follows the Frankel scale but differs from the older scale in several important respects. First, instead of no function below the injury level, ASIA A is defined as a person with no motor or sensory function preserved in the sacral segments S4-S5. This definition is clear and unambiguous. ASIA B is essentially identical to Frankel B but adds the requirement of preserved sacral S4-S5 function. It should be noted that ASIA A and B classification depend entirely on a single observation, i.e. the preservation of motor and sensory function of S4-5.

The ASIA scale also added quantitive criteria for C and D. The original Frankel scale asked clinicians to evaluate the usefulness of lower limb function. This not only introduced a subjective element to the scale but ignored arm and hand function in patients with cervical spinal cord injury. To get around this problem, ASIA stipulated that a patient would be an ASIA C if more than half of the muscles evaluated had a grade of less than 3/5. If not, the person was assigned to ASIA D.

ASIA E is of interest because it implies that somebody can have spinal cord injury without having any neurological deficits at least detectable on a neurological examination of this type. Also, the ASIA motor and sensory scoring may not be sensitive to subtle weakness, presence of spasticity, pain, and certain forms of dyesthesia that could be a result of spinal cord injury. Note that such a person would be categorized as an ASIA E.

These changes in the ASIA scale significantly improved the reliability and consistency of the classification. Although it was more logical, the new definition of "complete" injury does not necessarily mean that it better reflects injury severity. For example, is there any situation where a person could be an ASIA B and better off the ASIA C or even ASIA D?

The new ASIA A categorization turns out to be more predictive of prognosis than the previous definition where the presence of function several segments below the injury site but the absence of function below a given level could be interpreted as an "incomplete" spinal cord injury.

The ASIA committee also classified incomplete spinal cord injuries into five types. A central cord syndrome is associated with greater loss of upper limb function compared to the lower limbs. The Brown-Sequard syndrome results from a hemisection lesion of the spinal cord. Anterior cord syndrome occurs when the injury affects the anterior spinal tracts, including the vestibulospnal tract. Conus medullaris and cauda equina syndromes occur with damage to the conus or spinal roots of the cord.

Conclusion

Much confusion surrounds the terminology associated with spinal cord injury levels, severity, and classification. The American Spinal Injury Association tried to sort some of these issues and standardize the language that is used to describe spinal cord injury. The ASIA Spinal Cord Injury Classification approach has now been adopted by almost every major organization associated with spinal cord injury. This has resulted in more consistent terminology being used to /describe the findings in spinal cord injury around the world.
 

Unique idea of ayurveda in uniting person and his environs .

By Dr.Prasanth.K.P.
Ayurveda is an Indian contribution towards the medical science and like every traditional healing systems such as the Traditional chinese Medicine, its way of out look towards healing is in a different way to that of what we now call as the Modern medicine or Allopathy which is actually a westernised product adopted universally. Since traditional healing systems existed 2000 or 3000 years ago, much before the advent of Christ or Buddha, in an era where there were no MRI's or CT's or X-RAY's, the only possible way of any progress in what is called science was by three processes of pratyaksha(observation), anumana(inference) and aaptopadesa(whatever the scholar says!) .More than viewing through a naked eye , intution was depended on more frequently, with the doctors then being saints or sages, with lots of experience in spirituality and meditation, and the drugs available being raw and processed natural products, with heat being the only processing element. Since such is the history of traditional healing systems many of its philosophies and theories are controversial much like a blind person describing an elephant by touching its limb, tail, trunk and tusk. For example , charaka, susrutha and vagbhata all differ in their opinion about number of bones, arteries, nerves etc. But modern science has been succesful in developing a universal model of health system I say, that serves its purpose , in emergency life or death situations, whatever the critics , the ignorant ones , of the allopathic system may say. The ayurvedics especially the purist ones keep on stressing the essence of vedas and ayurvedic sayings, in an awfully freakish manner, that the patieny would consider the vaidya or the doctor as a control freak or maniac ! Apart from ayurveda depending on herbs for procuring medicines for diseases, its approach in treating a disease is holistic and entire, not like the particulate and separatist approach of allopathic stream. The treatment is given based on assessing ten factors called the "ten examinations" or the "dasa vidha pareeksha" which are the patients vitiated tissue, place of residence and place of affected part in body, immunity and persons strength, time and seasons, nature of mind, allergies and that which is congenial to him/her, digestive capacity, age, genetic nature, etc...inorder so that treatment be done considering or uniting several factors, yukti or logic is to be used, and for it to be applied all these numerous factors must be expressed in a same language, inculding disease and drugs ! So that element or factor that is missing may be added and that which is excess may be eliminated ! Pretty simple arithmetic isn't it ? But the failure of ayurveda is in the inherent impossibility in quantifying such factors or elements like a bio chemical report .It was this unifying concept of "advaita" philosophy that gave rise to the phenomena of "pancha bhoota theory" and "tri dosa theory", the former one for all that exists and the latter one for the living matter alone !
Certain set of qualities have been identified to distinguish the five elements of a panchabhoota and the three elements of a tri dosa, for example : 

Qualities of solid substances – (Parthiva Dravya Laksana)-Earth has – Guru (heaviness, heavy to digest), Sthula (bulky), Sthira (stable) and Gandha (smell) qualities.Hence, substances that have Earth as the predominant element (Parthiva Dravya) have Gaurava (heaviness), Sthairya (stability), Samghata (compactness) and well nourished qualities – 5Qualities of liquid substances (Apya Dravya Laksana) –Liquid element has Drava (liquidity), Sheeta (cold), Guru (Heavy to digest), Snigdha (unctuous, oily, moisture), Manda (dull), Sandra (thickness, dense) and rasa (taste) qualities.Substances containing liquid as predominant element (Apya Dravya) have Snehana (lubrication, moistness), Avishyanda (secretion, moisture, production), Kleda (wetness), Prahlada (satiation, contentment, satisfaction) and Bandhakrut (cohesion, binding, holding together) qualities. 6.Agneya Dravya Laksana – (qualities of Agneya substances) :-Agni has qualities such as Ruksa (dry), Teekshna (penetrating, sharp), Ushna (hot), Vishada (non-slimy), Sookshma (minute) and Rupa (appearance, showing, from)Substances that have fire as the main element causes Daha (burning sensation), Bha (luster), Varna (expression of colour) and Pachana ( digestion, process of transformation, putrefaction etc.) 7.Qualities of airy substances –  Vayaviya Dravya Laksana –Air has Rooksha (dry), Visada (non-slimy, clear), Laghu (lightness) and Sparsha (touch tactile sensation) qualitiesAiry substances posses qualities such as Ruksa (dry), it produces dryness, Laghava (lightness), Vaishadya (transparency, clarity), Vichara ( movements, different kinds of activities) and exhaustion 8.Qualities of ether dominant substances – Nabhasa Dravya Laksana:-Ether has Sukshma (minuteness), Vishada (transparence, clarity), Laghu (lightness) and Shabda (sound, hearing) qualities.Substances with ether dominance  produce cavitation (hollowness) and lightness (weightlessness) 9

The above are the qualities of the substances containing a dominant element. Similarly the three basic elements of life the vata, pitta and kapha has been assigned certain qualities or gunas by which we can identify their function in body.

So pancha bhoota and tri dosas are unifying factor of non living and living matter. How do they co relate ?Rasa or blood plasma contains more of kapha dosa and jala element, so any deficiency of rasa tissue would be treated with substances containing more of that particular element, jala in this case, for which the identifying qualities are given above. How do you express a persons place in terms of health ? That is a tricky question for ann allopath, he does not consider it all ! But according to ayurvedic principles, since tropical places are hot and dry, they are mainly vata pitta predominant, and hot is agni, dry is vayu and akasha so naturally subsatances from that land would be dry, hot , pungent, so vata pitta aggravaters or kapha pacifiers according to opposite qualities !So the treatment module is pretty much simple to express everything around in terms of life so that we can take what is necessary and avoid the harmful. That is the reason why our acharya says there is nothing present in this world that is not medicine, jagatyevam anoushadham naati jagathi kinjith !!! What an idea sir ji !!!Since the above process of elucidating a process and disease is as a result of long term careful onservations on a macroscopical plane, it is ought to be imperfect in its diagnosis though it may treat a disease and cure it. So at all times modern and ayurveda are going to be at logger heads and modern medicine is going to find out the loop holes in our understanding of the body and diseases, but ayurveda has survived the modern tsunami and is gaining certification world wide ! Since researches are ever increasing and ever productive about the better under standing of human body and process in the modern medical arena, it being progressed from the aspect of cells to genes to molecules, and since more  of modernised researches are being carried out by pharma companies in the area of herbal medicine, it is not far away, the allopathic system of medicine gets a new arm of herbal medicine not as a part of graduation curricula but as an entire speciality branch for rehabilitation and palliative care ! Ayuvedics are too lazy and too ignorant for this system to see the sun rise, they were not trained so ! If you take a person of same IQ an ayurvedic one will be much lazier and igmorant than the allopathic one ! We like things to stay as such, not takin gmuch of an effort to develop our rudimentary system, we take pride in being an ayurvedic but seldom practise it in our lives, we are worse than our patients in obeying ayurvedic restrictions , ayurveda is not a treatment its a life style, its a religion very much backed by philosophy, a sect, a culture for health, science may go deeper and deeper but upon touching the soul it gets reflected , then all tiny droplets unite into one whole ocean called Ayurveda !