It is important to understand that the basic principles of strength training apply as they are for both sexes. However in the case of women some specific areas need to be addressed such as pregnancy, menopause, and others that arise due to structural and physiological differences. This is where strength training concepts need due modification with these specific needs in mind. The following guidelines for assessment and exercise prescription take into consideration these specific areas for designing and implementation of effective strength programs for women of all ages and varying fitness levels.
Various kinds of Strength:

For all practical purposes Strength can be defined as: The ability of a muscle or muscle group to exert Maximum Force. However the concept of strength is not all that simple when applied to working examples. This gives rise to various specific definitions of the strength. Let’s take time to understand some of them, in order to better our understanding of the concept.

• Anaerobic Strength:
• Aerobic Strength:
• Starting Strength:
• Explosive Strength:
• Absolute Strength:
• Relative Strength:
• Linear Strength Endurance
• Non-Linear Strength Endurance

Benefits of Strength Training (with * specific to women):

1) Functional Capacity
2) Disease Prevention
3) Stress Release*
4) Body Composition*
5) Bone Health*
6) Improved Sexual Function*
7) Reduction in symptoms of Menopause*
8) Easier, safer Pregnancy*
9) Easier Child Birth*
10)Healthier Infants*
11)Faster return to Pre-Pregnancy Wt*
12)Improved Hydration Status
13)Improved Thermoregulation
14)Improved Glucose Tolerance
15)Improved HDL levels
16)Reduced Triglycerides
17)Injury Prevention
18)Improved Sports Performance
19)Improved Balance*
20)Improved overall quality of life
21)Promotes Longevity and Vitality

Assessing Strength:
1 Repetition Maximum (1 RM): is the maximum weight that one can lift for any given movement in one single effort.

The 1 RM is the standard method used for measuring strength in most fitness and performance settings. Strength measurements are restricted to certain compound movements only due to the risk of injury involved in trying to test strength levels of smaller muscles. For all practical purposes the body can be divided into four basic segments to test strength. These are:

• Muscles of the anterior shoulder girdle: or the pushing muscles. These comprise of the pectoralis group, deltoids, serratus anterior, and triceps. The standard exercise used to test these muscles is the bench press.

• Muscles of the posterior shoulder girdle: or the pulling muscles. These comprise of the lattissimus dorsi, teres major, rhomboids, trapezius, biceps, and brachialis. The standard exercise used to test these muscles is either the bent row, or the lat pulldown.

• Muscles of the trunk: these act as the stabilizers and coordinate movements between the upper and lower body. These comprise of the abdominals, obliques, erector spinae, and the quadratus group. Generally strength testing is not done for these muscles, which are involved in flexion, extension, lateral flexion, and rotation of the spine. The reason being these are small and weak muscles, thus risk for injury is extremely high.

• Locomotors: as the term suggests these are the muscles that help us move around. The main muscles in this group are the gluteus group, quadriceps, and hamstring, namely the knee and hip extensors. The standard exercise used to test these muscles is the squat or the leg press.

Testing for 1 RM:
1. After a thorough warm up, perform a couple of sets with a light weight that can allow about 15 reps or so.
2. Now increase the weight so that 8 to 10 reps can be managed.
3. Then increase weight to allow about 5 to 6 reps.
4. At this point increase 2.5 to 5 lb per effort for bench press and bent rows, and 5 to 10 lbs for leg press and squats, till 1 RM is reached.
5. Allow full recovery between attempts (2 to 2.5 min).

Note: strength testing can also be performed for simple exercises if the muscle group involved is strong enough, such as the knee curl and extension. In the case of extremely strong individuals small muscles such as the biceps and abdominals can also be tested.

Inherent Problems with Strength Testing:

Strength Testing requires a maximal effort. This greatly increases the risk of injury even for highly trained athletes. To safely test unconditioned athletes we use:

Predicted 1 RM: this method is based on the fact that most individuals can manage a certain number of repetitions with a given percentage of their personal 1 RM value for a certain lift. The approximate corresponding repetitions for various percent values of 1 RM are given in the table below:

%1RM 100% 95% 90% 85% 80% 75% 70% 65% 60%
Reps 1 2 2-3 4-5 8 10 12 14 16

Testing for Predicted 1 RM:
1) Warm up the subject thoroughly.
2) Make her perform one set of a given movement with a very light weight eith which she can manage about 20 reps fairly easily.
3) After about 2 min rest, increase the weight slightly so that she can manage about 15 reps fairly easily.
4) Now for the third set increase the weight with which you feel that she should be able to barely manage 10 to 12 reps.
5) After a two minute rest interval make the subject squeeze out as many reps as is possible. Ensure strict form and full ROM.
6) Compare the results to the table given above.
7) If the subject manages less than 10 reps that is just fine.
8) But if she does more than 15 reps, the test is not valid. Let her rest for five minutes and re-test after increasing the resistance suitably.

General Guidelines for Strength Training:
1. Address all of the body’s energy systems.
2. Use mainly structural and compound movements.
3. But at the same time use various movements.
4. Train all major muscle groups.
5. Avoid imbalances between opposing muscle groups.
6. Use high intensity and low to moderate volumes.
7. Allow enough time for recovery.
8. Provide optimum nutrition.
9. Use variation to avoid plateaus.
10. Have a progressive periodized approach for safe optimal results.

Training Intensity:

Poor Fitness Extremely light resistance (< 50% 1 RM) or
simple free-hand weight supported movements.
Low Fitness Beginners 50 to 60% of 1 RM
Regular Exercisers 70 to 80% of 1 RM ( also for Hypertrophy)
High Fitness 85 to 100% of 1 RM (also for Strength and Power)

Volume:

Poor Fitness 2 sets per movement x 10 to 20 reps x
5 to 10 movements
Low Fitness Beginners 15 to 20 reps x 8 to 12 exercises x
1 to 3 circuits
Regular Exercisers 4 to 6 sets large muscle groups +
2 to 3 sets small muscles.
Hypertrophy Beginners 10 sets, intermediate 12 to 15 sets, and
advanced 20 to 25 sets per muscle group
High fitness & Strength Beginners 4 to 6 sets, Advanced 8 to 10
sets (only compound movements)

Recuperation (Acute & Chronic):

Acute Chronic
Poor Fitness 1 min 24 hours
Low Fitness Beginners 2 to 0 min bet circuits 48 hours
Regular Exercisers 1 min to 30 sec bet sets 72 to 96 hours
Hypertrophy 1 min to 30 sec bet sets 96 hours to 1 week
High fitness & Strength 2.5 to 5 min bet sets 96 hours to 1 week

Guidelines for Pregnant Women:
1) Reduce intensity to 60 to 70% due to slack muscles and tendons.
2) Avoid supine movements.
3) Avoid abdominal strengthening and use ab/back support.
4) Avoid impact.
5) Avoid dehydration and excess temperatures.
6) Make necessary dietary modifications to suffice exercise and fetal needs.

Guidelines for osteoporosis and arthritis:
1) Make sure to get correct nutrients for bone health (refer table below).
2) Moderation is the key word for injury prevention.
3) For arthritis, reduce intensity to 50 to 60 % and fol low the 4 hour pain rule.
4) Take enough antioxidants.

This table lists all the essential nutrients for a healthy skeletal system, how much of each do you require, anti-nutrients that inhibit their uptake, and the foods that are good sources of them:

Nutrient RDA* Inhibitors Best food sources - per 100 gm serving.

Calcium Child 600 mg
Adult 800 mg Lack of exercise, tea, coffee, alcohol, lack of hydrochloric acid in the stomach, hormonal imbalance.
Milk (120 mg), yogurt (149), Swiss cheese (925), Cheddar cheese (750), almonds(234), Brewer’s yeast (234), parsley, coriander, spinach (250), corn tortillas (200).

Vitamin D
Child 10 mcg
Adult 10 mcg
Lack of sunlight, fried foods.
Herrings (22.5mcg), mackerel (17.5), salmon (12.5), oysters (3), cheese (2), eggs (1.5).

Magnesium
Child 170 mg
Adult 300 mg
Large amts of Calcium from milk products, proteins, fats, oxalates, phytates.
Wheat germ (490 mg), almonds (270), cashew nuts (267), brewer’s yeast (231), buck wheat flour (229), peanuts (225), cooked beans (37), Garlic (36), raisins, green peas (35).
Phosphorus
Child 800 mg
Adult 800 mg
Too much iron, magnesium, aluminum.
Present in almost all foods.

Vitamin C
Child 35 mg
Adult 40 mg
Smoking, alcohol, pollution, stress, fried food, tea, coffee.
Peppers (100 mg), watercress (60),
Cabbage (60), broccoli (110), cauliflower (60), strawberries (60), lemons (80), kiwi fruit (85), oranges (50), tomatoes (60).

Zinc
Child 7 mg
Adult 15 mg
High calcium uptake, low protein uptake, copper, alcohol, excess sugar, phytates, oxalates.
Oysters (148 mg), ginger root (6.8), lamb (5.3), dry split peas (4.2), egg yolk (3.5), peanuts (3.2), almonds (3.1), whole wheat (3.2 mg)

What is the “Q” angle?

The “Q” angle is the angle at which the femur tapers inwards in females, due to broader pelvis. Over time weak muscles and chronic valgus stress can cause the knees to bend inward, causing severe pain and injury to the joint. It can be prevented through correct strength training at an early age.

Program Design & Periodization:

The benefits of a periodized program are:
1) Ensure steady progress.
2) Safety and injury prevention.
3) Avoid Chronic fatigue, chronic injury and burnout.
4) Provide variation and make training interesting.
5) Facilitate Adherence.
6) Successful achievement of long term goals.

FACTS

Leucoderma, the word literally means white skin. There is a pigment called melanin which gives our skin a uniform colour. Gradual loss of this pigment from the skin layer results in white patches.

Vitiligo usually starts with a small white spot(s) which gradually enlarges and develop into patch(es). These patches are pale in the beginning, but become whiter and whiter as time passes by due to loss of pigment. As the patches enlarge they merge together and form a very broad patch. In some cases most of the skin of the body may be covered by with white patches.

The course of vitiligo varies. With some it reaches a certain degree of development and then remains stationary for years; and in others it progresses indefinitely.

Cause of vitiligo is not yet clear but excessive mental tension seems to play a vital role. Injuries and burns do cause localized vitiligo. Heredity is also a well-recognized causative factor.

THE HOMEOPATHY APPROACH

The outward presentation of the internal imbalance is in the form of white patches on the skin. The constitutional homeopathic treatment is targeted to set this imbalance to normalcy, thereby producing normal skin and good health. That is why local application of any type is not advised and only oral homeopathic medication is used.

The aim of the constitutional treatment in homeopathy is to treat the patient as a whole so as to stimulate the body-mind system from within. The constitutional homeopathic treatment helps the body's own natural healing powers hence leading to a long lasting cure.

The duration of treatment can not be predicted as vitiligo is a chronic skin condition mostly resistant to treatment. The total duration of treatment varies from patient to patient, depending on various diverse factors such as:

(a) The duration of patches

(b) The extent, location and speed of spread of the patches

(c) Presence of other diseases.

(d) The overall general health of the patient.

Generally, the treatment is long term. And desire for faster results frustrates the patient more than anything else and patient lands up with just change of Doctor. One should start the treatment with a positive attitude and must not rely on HIS EYES ONLY. Close photograph(s) of the involved area before starting the treatment and repeat photograph(s) every 3 months should be the ideal approach for assessment of changes. One may expect a definite change in about three to five months, depending on the duration, extent and speed of the spread of the vitiligo patches. The total duration of constitutional homeopathic treatment may be anything between six months to two years or even more.

The advantage of homeopathic treatment over other treatments e.g. steroids, puva etc are that
1. Homeopathy offers long-lasting cure instead of temporary relief.
2. It is absolutely harmless, safe and devoid of any toxicity.
3. There is no need for any local applications or sitting under sun or artificial light.

Overall health improvement is an added benefit.

Understanding cancer pain
Dr (Maj) Pankaj N Surange

Introduction
When you or a loved one receives a diagnosis of cancer, it isn't long before you begin to think of the pain many people associate with cancer. It can be a frightening time. What will the pain be like? What will it do to our lives? Many people with cancer eventually experience pain due to their condition. Approximately twenty percent of patients with newly diagnosed malignancies complain of pain. Thirty percent of patients undergoing cancer treatment complain of pain, and up to ninety percent of those with advanced cancer experience pain (Grossman 1994).
Pain associated with cancer can take many forms and is experienced differently by each patient. Pain can be sharp and severe, or it can be a dull constant ache. Regardless of the type of pain, a diagnosis of cancer does not mean you have to suffer with debilitating pain.
Today, most concerns about cancer-related pain can be relieved by understanding the facts about cancer pain, and learning about the help that is available for pain relief.
How pain happens?
Pain is transmitted through the body by the nervous system when our nerve endings detect damage to a part of the body. The nerves transmit the warning through defined nerve pathways to the brain, where the signals are interpreted as pain. Sometimes pain results when the nerve pathways themselves are injured. You feel pain when your brain receives the signal from your nerves that damage is occurring. All types of pain are transmitted this way, including cancer pain.
Pain can be acute or chronic: Acute pain usually starts suddenly, may be sharp, and often triggers visible bodily reactions such as sweating, an elevated blood pressure, and more. Acute pain is generally a signal of rapid-onset injury to the body, and it resolves when pain relief is given and/or the injury is treated.
Chronic pain lasts, and pain is considered chronic when it lasts beyond the normal time expected for an injury to heal or an illness to resolve. Chronic pain, sometimes called persistent pain, can be very stressful for both the body and the soul, and requires careful, ongoing attention to be appropriately treated.
Along with chronic cancer pain, sometimes people have acute flares of pain when not all pain is controlled by the medication or therapy. This pain, usually called breakthrough pain, can also be controlled by medications.
Cancer pain can be caused by many different sources. Pain can be experienced when a tumor presses on nerves or
expands inside a hollow organ. Pain also commonly originates from bone destructive lytic lesions. Bone marrow infiltration commonly cause bone pain that can be severe. Unfortunately, the radiation and chemotherapeutic treatments that are frequently used to treat cancer can also cause pain.
Assessment of your pain
The first step in getting your pain under control is talking honestly about it.
This means telling them:
• Where you have pain
• What it feels like (sharp, dull, throbbing, constant, burning, or shooting)
• How strong your pain is
• How long it lasts
• What lessens your pain or makes it worse
• When it happens (what time of day, what you're doing, and what's going on)
• If it gets in the way of daily activities
Your pain physician may ask you to describe your pain in a number of ways. A pain scale is the most common way. The scale uses the numbers 0 to 10, where 0 is no pain, and 10 is the worst. You can also use words to describe pain, like pinching, stinging, or aching. Some doctors show their patients a series of faces and ask them to point to the face that best describes how they feel.

Your Pain Control Plan
Only you know how much pain you have. Telling your doctor and nurse when you have pain is important. Not only is pain easier to treat when you first have it, but pain can be an early warning sign of the side effects of the cancer or the cancer treatment. You have a right to pain relief, and you should insist on it.
Cancer pain can almost always be relieved.
There are many different medicines and interventions available to control cancer pain. You should expect your doctor to seek all the information and resources necessary to make you as comfortable as possible. However, no one doctor can know everything about all medical problems. If you are in pain and your oncologist suggests no other options, ask to see a pain specialist or have your doctor consult with a pain specialist.
Controlling your cancer pain is part of the overall treatment for cancer.
Your pain physician wants and needs to hear about what works and what doesn’t work for your pain. Knowing about the pain will help your doctor better understand how the cancer and the treatment are affecting your body.
Preventing pain from starting or getting worse is the best way to control it.
Pain is best relieved when treated early. You may hear some people refer to this as “staying on top” of the pain. Do not try to hold off as long as possible between doses. Pain may get worse if you wait, and it may take longer, or require larger doses, for your medicine to give you relief.
You have a right to ask for pain relief.
Not everyone feels pain in the same way. There is no need to be “stoic” or “brave” if you have more pain than others with the same kind of cancer. In fact, as soon as you have any pain you should speak up.
People who take cancer pain medicines, as prescribed by the doctor, rarely become addicted to them.
Addiction is a common fear of people taking pain medicine. Such fear may prevent people from taking the medicine. Or it may cause family members to encourage you to “hold off” as long as possible between doses. Addiction is defined by many medical societies as uncontrollable drug craving, seeking, and use. When opioids (also known as narcotics) — the strongest pain relievers available — are taken for pain, they rarely cause addiction as defined here. When you are ready to stop taking opioids, your pain physician gradually lowers the amount of medicine you are taking. By the time you stop using it completely, the body has had time to adjust.
Treatment options
There is more than one way to treat pain. A simple, well-validated and effective method for assuring the rational titration of therapy for cancer pain has been devised by WHO. It has been shown to be effective in relieving pain for approximately 90 percent of patients with cancer and over 75 percent of cancer patients who are terminally ill. The World Health Organization (WHO) in 1986 established a stepladder approach for treatment of patients with cancer pain (fig.). The goal for this ladder was to provide treatment guidelines that healthcare practitioners could easily follow. The five essential concepts in the WHO approach to drug therapy of cancer pain are:
i) By the mouth. ii) By the clock. iii) By the ladder. iv) For the individual.
v) With attention to detail.
Medicines
Non opioids
Opioids
Adjuvants

Medicines are prescribed based on the kind of pain you have and how severe it is. In studies, these medicines have been shown to help control cancer pain. Doctors use three main groups of drugs for pain: nonopioids, opioids, and other types
1. Nonopioids - for mild to moderate pain
Nonopioids are drugs used to treat mild to moderate pain, fever, and swelling. On a scale of 0 to 10, a nonopioid may be used if you rate your pain from 1 to 4. These medicines are stronger than most people realize. In many cases, they are all you'll need to relieve your pain. You just need to be sure to take them regularly.
You can buy most nonopioids without a prescription. But you still need to talk with your doctor before taking them. Some of them may have things added to them that you need to know about. And they do have side effects. Common ones, such as nausea, itching, or drowsiness, usually go away after a few days.
2. Opioids - for moderate to severe pain
If you're having moderate to severe pain, your doctor may recommend that you take stronger drugs called opioids. Opioids are also known as narcotics. You must have a doctor's prescription to take them. They are often taken with aspirin, ibuprofen, and acetaminophen. Getting relief with opioids
Over time, people who take opioids for pain sometimes find that they need to take larger doses to get relief. This is caused by more pain, the cancer getting worse, or medicine tolerance (see Medicine Tolerance and Addiction). When a medicine doesn't give you enough pain relief, your doctor may increase the dose and how often you take it. He or she can also prescribe a stronger drug. Both methods are safe and effective under your doctor's care. Do not increase the dose of medicine on your own.
3.Adjuvants
They can be used along with nonopioids and opioids. Some include:
Antidepressants. Some drugs can be used for more than one purpose. For example, antidepressants are used to treat depression, but they may also help relieve tingling and burning pain. Nerve damage from radiation, surgery, or chemotherapy can cause this type of pain.
Antiseizure medicines (anticonvulsants). Like antidepressants, anticonvulsants or antiseizure drugs can also be used to help control tingling or burning from nerve injury.
Steroids . Steroids are mainly used to treat pain caused by inflammation (swelling.)
Interventions
While opioids are the mainstay of cancer pain management, they have their limitations. Some patients may only tolerate moderate doses of opioids, manifesting side-effects such as sedation, confusion, and constipation. Another reason for opioid ineffectiveness may be the development of opioid-resistant pain. For these reasons, the search for analgesia has resulted in introduction of Interventions as fourth step in WHO’s ladder for chronic and cancer Pain management. A wide array of procedures exists (e.g., local anesthetic/steroid deposition, neurolysis by chemical or thermal means, or the implantation of spinal pumps to deliver medications not effective by the oral/transcutaneous route)
Sympathetic Blockade:- The sympathetic chain exists along the vertebral column, carries much nociceptive information, so blockade of sympathetic ganglia may improve visceral pain as well as sympathetically mediated pain. This may be considered an attractive and simple option for the diagnosis of pain and possible long-term pain relief.
Spinal Analgesia.:- Opioids, local anesthetics, spasmolytics, and alpha-2 agonists to both subarachnoid and epidural routes of administration. To provide chronic treatment, tunneled subcutaneous catheters are commonly connected to pumps with reservoirs.
Spinal Cord Stimulation:- The mechanism of analgesia produced by spinal cord stimulation (SCS) is still unclear. Some hypotheses involve antidromic activation of A-beta afferents (“gate control” theory), activation of central inhibitory mechanisms, increase in substance-P release, and actual block of transmission of electrochemical information anywhere in the dorsal spinothalamic tract. The attractiveness of SCS lies in the potential to provide analgesia to severe neuropathic states without the need for medication. Patients control the stimulation (on/off and intensity) with a small battery-operated control. SCS has a low incidence of infection since it is not accessed except for a battery change, which may be needed every 2 to 4 years, depending on the level and frequency of stimulation.
Neurolysis :- Injections of neurolytic agents to destroy nervesand interrupt pain pathways have been used for manyyears. Neurolysis is indicated inpatients with severe, intractable pain in whom lessaggressive maneuvers are ineffective or intolerable because of either poor physical condition or the development of side effects.
Managing and preventing side effects
Some pain medicines may cause:
Constipation (trouble passing stools) Opioids cause constipation to some degree in most people. Opioids cause the stool to move more slowly along the intestinal tract, thus allowing more time for water to be absorbed by the body. The stool then becomes hard. Constipation can often be prevented and/or controlled.
Drowsiness (feeling sleepy) At first, opioids cause drowsiness in some people, but this usually goes away after a few days. If your pain has kept you from sleeping, you may sleep more for a few days after beginning to take opioids while you “catch up” on your sleep. Drowsiness will also lessen as your body gets used to the medicine.
Nausea (upset stomach) and Vomiting (throwing up) Nausea and vomiting caused by opioids will usually disappear after a few days of taking the medicine. Some people think they are allergic to opioids if they cause nausea. Nausea and vomiting alone usually are not allergic responses. But a rash or itching along with nausea and vomiting may be an allergic reaction. If this occurs, stop taking the medicine and tell your doctor at once.
Medicine Tolerance and Addiction
When treating cancer pain, addiction is rarely a problem. Addiction is when people can't control their seeking or craving for something. They continue to do something even when it causes them harm. People with cancer often need strong medicine to help control their pain. Yet some people are so afraid of becoming addicted to pain medicine that they won't take it. Family members may also worry that their loved ones will get addicted to pain medicine. Therefore, they sometimes encourage loved ones to "hold off" between doses But even though they may mean well, it's best to take your medicine as prescribed.
People in pain get the most relief when they take their medicines on schedule. And don't be afraid to ask for larger doses if you need them. As mentioned in Opioids - for moderate to severe pain, developing a tolerance to pain medicine is common. But taking cancer pain medicine is not likely to cause addiction. If you're not a drug addict, you won't become one. Even if you have had an addiction problem before, you still deserve good pain management. Talk with your doctor or nurse about your concerns.
Tolerance to pain medicine sometimes happens.
Some people think that they have to save stronger medicines for later. They're afraid that their bodies will get used to the medicine and that it won't work anymore. But medicine doesn't stop working - it just doesn't work as well as it once did. As you keep taking a medicine over time, you may need a change in your pain control plan to get the same amount of pain relief.
This is called tolerance. Tolerance is a common issue in cancer pain treatment.
Newer developments
Intrathecal pumps
Only 2% to 5% cancer patients require interventions or the direct delivery of opioids to the central nervous system. Patients with unmanageable side effects may benefit from the epidural or intrathecal administration of opioids.
Approximately one tenth of the intravenous dose of an Opioid is needed when administered epidurally and one hundredth is needed when administered intrathecally. However, these procedures are expensive, and catheters and pumps are required to deliver the drug. To be cost effective, these devices should be used in a patient who has a life expectancy for longer than 3 months.
Radiofrequency ablation
This modality is becoming more popular in the present days. In this technique, the patient is sedated, an interventional radiologist uses a special needle to deliver radiofrequency current into the affected nerve, and destroys it. This procedure has fewer side effects and can provide pain relief for several weeks to months. It can also be repeated when necessary. It is used for ablation of intercostals nerves, trigeminal nerve, paravetebral nerves in the thorax and abdomen.
Vertebroplasty/Kyphoplasty
Used to treat painful vertebral body collapse/fracture caused by osteoporosis or tumor
Terminal stages: Palliative care
In the terminally ill cancer patients, conventional pharmacotherapy and even invasive analgesic therapy may not provide adequate relief of pain. In the very terminal phase, procedural options should be used relatively sparingly.
Options for the severe pain in this phase include subcutaneous infusions of opioids and/or sedatives.
Haloperidol and corticosteroids can be helpful symptom control adjuncts in the terminal phase. Comprehensive palliative programs for end-of-life care may be considered and can be inpatient or through home hospice. The physician should assess the needs of the patient and the family and fully discuss all care options. In addition to pain control, palliative care addresses the control of other symptoms associated with intractable cancer pain, including those relating to the physical, psychological, and religious or spiritual. Optimum quality of life is the primary goal of palliative care, which at the end of life is emotionally intense because of the multifactorial needs of the patient and family.
FAQ’s
Q. I'm afraid that if I use strong pain medicine now, there won't be anything left to treat my pain later, when it gets worse.
Pain medications don't work like this. Opioids used by themselves do NOT have a "ceiling" dose, meaning a level beyond which no more medication can be given. And if one opioid becomes less than satisfactory in providing pain relief, others may be used, as well as other medications and techniques for pain relief. There is ALWAYS more that can be done to ease your pain. Don't deprive yourself of your pain medication because you fear nothing can help later. It just isn't true.

Q. How should I take my pain medications? On regular scheduled basis or whenever required?
For cancer pain that is constant, or expected to recur; the best method of administration is to take the medication on an around-the-clock, scheduled way, such as a tablet every 6 hours. This means that you'll have a steady level of medication in your bloodstream.
If you are not experiencing constant or frequently-recurring pain, then it might be helpful to think about activities that appear to trigger your pain, such as walking or riding in a car, for example. If there is a link between the pain and something you do, then you can arrange to take the medication in sufficient time to have sufficient relief in place when you undertake the activity.

Q. I take my pain medications on an around-the-clock basis, but at times I have pain anyway. What can I do about this?
The pain you experience is called breakthrough pain, and you probably need a medication to handle that kind of pain, as well as the pain your around-the-clock medications are designed to ease. Breakthrough pain can occur for no obvious reason, or as the result of some activity that seems to trigger it, such as walking, coughing, etc. Regardless of the reason, it's likely that you'll need an additional medication to use during these times.
Q. Are these pain medications available freely?
Some pharmacies are reluctant to stock opioid medications, because of a variety of concerns. Speak with your health care provider or your hospital social worker or pharmacist to learn the names of pharmacies that stock the medication you need and arrange to have your prescriptions filled there.
Q. If I take strong pain medicines such as opioids early on, will I run out of options if my pain gets worse later?
Depending on need, opioids may be prescribed at any stage of treatment. There is no need to "tough it out" early in treatment out of concern that strong pain medicines won't be effective if needed later on. Some people, but not all, develop drug tolerance, which means their body has become accustomed to the medication. When a medication doesn't relieve pain as well as it did, the dose can be adjusted or another type of medication or treatment can be prescribed. Patients may receive increasing doses of opioids for years without becoming addicted, or psychologically dependent. When the need for pain relief subsides, physical dependence can usually be managed without withdrawal symptoms by tapering the opioid before discontinuing.
Q. What is palliative care -- is it the same thing as end-of-life care?
A major priority of Memorial Sloan-Kettering's Pain and Palliative Care Service is the incorporation of the principles of palliative care into the care of all patients with cancer from the time of diagnosis, not only in the setting of advanced or terminal disease.
Palliative care treatment:
• Affirms life and regards death as a normal process.
• Neither hastens nor postpones death.
• Provides relief from pain and other distressing symptoms.
• Integrates the psychological and spiritual aspects of patient care.
• Offers a support system to help patients live as actively as possible until death.
• Offers a support system to help the family cope during the patient's illness and in their bereavement.
Q. I take pain medications around the clock, and sometimes this means I have to wake myself up several times during the night to take a pill. Can this be handled differently?
Yes, very probably. It may be possible for your pain physician to switch you to a different form of your medication or to a different medication that is longer-lasting, one that will allow you to sleep through the night. Speak with your physician about ways to solve this. Your sleep is very important to all aspects of cancer management, including pain management.
References:
1. World Health Organization. Cancer Pain Relief. Albany, NY: WHO Publications Center; 1986.
2. Cancer Control. March/April 2000, Vol. 7, No.2
3. NCCN practice guidelines in oncology-v.1.2008
4. Cancer Pain Relief, Second Edition, with a guide to Opioid availability, World Health Organization, 1996.
5. Mercadante S, Fulfaro F. World Health Organization guidelines for cancer pain: a reappraisal. Ann Oncol 2005; 16(suppl 4):iv132-iv135.
6. Fine PG. The evolving and important role of anesthesiology in palliative care. Anesthesia Analgesia 2005; 100: 183-188.

The most common prescription for diabetes is Insulin and Insulin often causes damage to the small blood vessels of the body. This damage also impact the retina of the eye and result in loss of vision and slowing this damage is extended to the delicate blood vessels in the filters of the kidneys. Diabetes may also damage the nerves in the body including the bladder; it may be difficult to pass urine with infected bladder. The pressure from urine building up in the bladder can cause kidney damage.

Chances of a diabetic person developing a kidney disease are very high (more than 60%). If left untreated, this could lead to more kidney damage or kidney failure.

One can have serious kidney damage without being aware of it. There are usually no specific symptoms of kidney disease until the damage is severe. However, if you have diabetes, you should be tested once a year to see if diabetes has affected your kidneys. Your doctor can arrange a urine test for protein (a random urine test for “albumin to creatinine ratio”), and a blood test to check how well your kidneys are functioning (the “serum creatinine”).

Symptoms:

Early symptoms of kidney disease show high level of protein in the urine. Eventually excess loss of protein from the blood causes the water from the blood to move into the body tissues causing swelling (edema). Itchiness, breathlessness and tiredness may also occur before the kidney failure occurs.

Cause of kidney disease:

Kidney infection is another major cause of kidney failure. Diabetic patients show high level of sugar in their urine causing the growth of bacteria. People with diabetes must take special care to avoid infections and have them treated immediately.

Kidney failure:

When the kidneys are about to fail you might experience tiredness, nausea and vomiting. You could also retain salt and water, which could cause swelling of your feet and hands, and shortness of breath. You may also find that you need less insulin than usual. When the kidneys fail, wastes and fluids will accumulate in your body and you will need dialysis treatments or a kidney transplant. You may be referred to a nephrologist (a kidney specialist) if your doctor thinks the damage to your kidneys is severe.

What can you do to prevent kidney damage?

There are special treatments (including proper food choices and medications) which may help to delay kidney failure. It is necessary to start these treatments as soon as your doctor notices any of the early signs or risk factors.

There are many things you can do to help prevent kidney damage:

* Have your urine, blood and blood pressure checked regularly by your doctor
* Maintain good control of your blood sugar
* Control high blood pressure (less than 130/80* on most readings)
* Stop smoking
* Exercise regularly
* Make the proper food choices
* Avoid excess alcohol
* See your doctor if you think you have a bladder infection
* Get enough sleep

If you are suffering from kidney failure and would like more information on alternative medicine, please visit www.kundankidneycare.com

The World Health Organization (W.H.O.) has stressed on the need to counter the deteriorating mental health in society. Statistics show that the rate of psychological disturbances leading to Suicide, Homicide, Marital breakdown, Alcoholism, Drug abuse etc. are increasing at an alarming rate. Cases of depression, stress, nervous anxiety and psychosomatic disorders are on the rise.

According to the National Mental Health Program document, about 20-30 million Indians are in need of some form of mental health care. Every year 2,50,000 new cases are reported; but these figures do not include the thousands of others who may be suffering in silence without access to help. With timely intervention and proper care, at least 60 % of these disturbed people can recover completely and at least 70 % can avoid chronic illness and disability. Psychotherapy & Counselling has never been more needed than it is today. There is an urgent need to rescue toxic and failing relationships; the relationship of man with himself, relationships within the family, and relationships in the community.

Heart To Heart Counselling Centre run by the Heart To Heart Foundation is an active effort to fulfill this need of society through various training programs and other activities. The Heart to Heart Foundation is a registered social organization committed to the promotion of Mental Health and Emotional Well-being through Counselling Services, Training Programs, Counselling Courses, Self-help Workshops, Awareness programs, Research and Publishing related material.

Activities at the Heart to Heart Counselling Centre

• Facility for personal counselling, couple counselling and family therapy.
• Pre-Marriage counselling, guidance and complete pre-marital medical check up.
• Marriage & Relationship Counselling.
• Sex Counselling and Therapy - For all sexual and psychosexual problems.
• Teenage Guidance Clinic for teenagers and parents.
• Sex education programs for schools, colleges and the adult community.
• AIDS Counselling
• Training programs in Personal Counselling (Client Centered Therapy and Cognitive Behavior Therapy)
• Workshops in Rational Emotive Behavior Therapy (REBT) for those having prior training in counselling skills.
• Training Program to become a Sex Educator.
• Self-Help Workshops such as Self-Help Through Creative Writing, Secrets of a Healthy Marriage, Stress Management (Multimodal approach), Golden rules of Parenting, Art of Communication etc.


Some Question-Answers Related to Subjects we are dealing with

How important is mental health? What is the role of the family doctor in the area of mental health?
Ans: Man is obsessed with, and doing so much for increasing the longevity of mankind, but have we ever thought of the quality of life we lead? Physical well being and health is given the highest priority with newer drugs flooding the market everyday. Has anyone ever thought as much about emotional well being and mental health? The World Health Organization has declared that the emotional health of humanity is declining. Cases of depression, stress and nervous anxiety and psychosomatic disorders are on the rise and therefore family doctors are urged to look for signs in a patient which would indicate the need for counselling. In a society where going to the gym for physical fitness training and workouts is considered as the 'in' thing to do, it is sad to see that mental and emotional fitness and training is not accorded the same status. There is an invisible stigma attached to counselling, wherein general practitioners hesitate to refer cases for personal counselling fearing that the counsellees may take offense. Denial of the need for therapy only compounds the problem, for if there is anything worse than having a problem, it is denying that you have one. Timely intervention of counselling can avert many a disaster. For this, the support of general practitioners, social workers, other members of the helping profession and above all, the media, is extremely important. They are the ones who need to create awareness of the entity of counselling, the need for it and help in removing the stigma attached to it.
There is an urgent need for establishing meaningful human interaction between people. The fast-paced highly competitive urban world, the break up of the joint family system, more women working outside the house, single child norm etc. means that a 'friend in need' is even more required today. If we can increase the number of such 'friends' who DARE TO CARE, the rate of disturbed individuals becoming chronically ill and disabled will most definitely reduce. It needs to be mentioned that such caring not only benefits the receiver of care, but also benefits the care giver who gets in touch with his own human side, thus exerting him to be the best human being that he can be.

What is Counselling? How do counsellors help? What is their role?
Ans: Mental health is achieved when man is completely psychologically mature or self-actualized, and psychological disturbances, are nothing but a failure of such development.
A large number of disturbed people can be helped by establishing a caring human interaction which makes the disturbed individual open to explore and understand himself, and finally change something within himself to solve his problem. This is called counselling.
There are several misconceptions about the nature and intention of counselling and therapy. Many people believe that the purpose of therapy is to talk about their problems, rather than devising active means of solving these problems. It is not talk that is important, but action.
At this point it would be apt to understand briefly what personal counselling entails. For that, let us first understand what it is not. It is not offering interpretation, evaluation, support or advice; but it is in fact a human technology in which the counsellor through human interaction creates certain conditions in which the counsellee is provoked into a journey of self-exploration leading to self-understanding leading to action, so that the counsellee changes his/her thinking and behaviour, thus solving the problem and bettering his/her life. In short, it is not a 'handout' but instead a 'hand up'. He is helped to help himself.

Rapid long-lasting and meaningful improvements in psychological functioning call for at least two specific areas of intervention:
• We need to correct irrational thinking; and
• We need to overcome negative behaviors.
This is achieved by re-education and a systematic re-training of the mind by challenging long-standing self-defeating ideas, beliefs and behaviours, and replacing it with rational, realistic and appropriate beliefs and behaviours of life. The counsellee is also motivated to identify and reduce his stress levels on biological, psychological, sociological and spiritual levels and to increase his adjustive resources on all these levels.

What is the difference between Psychotherapy and Counselling?
Ans: Counselling and Psychotherapy are similar but vary in degree and intensity and in the goals to be achieved. In psychotherapy the goal is to bring about a deeper personality change which may take months and even years, however in counselling the goal is to achieve a better personal adjustment and growth in maturity and therefore the duration is just a few sessions.

Does your approach / methodology at the 'Heart to Heart Counselling Centre' differ in any way from the traditional approach used by psychiatrists & clinical psychologists?
Ans: We have done a great deal of research in exploring the Psychology of Resistance i.e. the dynamics behind a resistance to heal in the patient/counsellee and the study also suggests a methodology that can be adopted by therapists/counsellors to overcome this resistance. The methodology is a unique blend of the Western psychotherapeutic techniques (Client-centered therapy, Rational emotive behavior therapy, Cognitive therapy, Behaviour Therapy etc.) and Eastern psychotherapeutic techniques ('Abhidhamma' ~ the Buddhist psychology, Meditation, traditional Vedantic philosophy etc.)

Do you expect better results with your approach?
Ans: If therapists/counsellors equip themselves with the methodology mentioned above and adopt appropriate attitudes in the counselling process, there will be a higher success rate in the recovery of patients.
Do you use any medication during the process of psychotherapy / counselling?
Ans: No. We do not prescribe or dispense any medication at all during psychotherapy / counselling. We only establish an interpersonal relationship and stimulate the counsellee towards self-actualization.

Why is there an emphasis on 'Couple' therapy?
Ans: A couple is the smallest unit of community living, and how the couple functions as a unit sets the stage for the entire family. Thus, the beginning of the family whether functional or dysfunctional, starts with the couple. A family is known as dysfunctional when the desired goals of closeness, self-expression and meaning cannot be attained by the family members. When this happens, symptomatic behaviour takes place.
Thus, we understand how important it is for a couple to have a healthy and harmonious relationship with each other not only for themselves, but also for their child.
Since the emotional health of the couple directly affects the emotional health of the children and the family as a whole, it is high time that parents start focussing on their relationship as a couple and work towards strengthening it. The time and effort put into creating harmony with each other will reap rich dividends in the form of family health.
Happy couples create happy families, which in turn create happy communities, happy nations and a happy world.

Do children require personal counselling? What is the need for counselling at such a young age? What kind of problems do you come across in children these days? What are the typical parental responses to them?
Ans: Children of dysfunctional families do require counselling. However the success of such counselling depends on family therapy i.e. the involvement of parents and other members of the family. The child of psychologically immature parents feels like an emotional orphan, and when he cannot find emotional fulfillment at home, he starts looking for it elsewhere. Juvenile delinquency is the direct result of a dysfunctional family, and teenage pregnancies, alcoholism, substance abuse, association with terrorist outfits and anti-social groups is nothing but a desperate and misguided attempt at creating a world, a family for themselves.
Everyday young children and teenagers are brought by their parents to counsellors for 'treating' "bad behaviour" such as temper tantrums, rebellion, anti-social behaviour, disinterest in academics etc., and the counsellors are faced with the daunting task of gently but firmly confronting the parents about the toxic emotional environment at home. It is most of the time a Herculean task to get the defensive parents into therapy as a family, and more so as a couple.

What is the necessity of Pre-Marriage counselling and check-up?
Ans: Like Western countries, the divorce rate in our country is steadily on the rise. On going into details, invariably the cause is found to be either a physical incompatibility or emotional incongruity between the partners. In 90% cases the trauma of divorce can be avoided, if the couple undergoes a counselling session and certain medical investigations just before getting into matrimony.
As family physicians, very often doctors are expected to give guidance to those who are getting into matrimony. Parents find it difficult to explain everything to their sons or daughters about the new relationship they are entering into; either out of hesitation or lack of knowledge. Unlike more developed countries, sex education is still not widely advocated in schools or colleges in our country. At such occasions family doctors are invariably asked for help and are expected to oblige the parent community by doing the necessary briefing. In a busy practice, most of the doctors do not find adequate time to devote to Pre-Marriage Counselling, and are very often not too comfortable with counselling.
It is also very necessary to know about the physical well-being of both the partners before they marry, particularly about one’s reproductive ability and diseases that could be transmitted sexually. Our centre has this unique facility (Pre-Marriage Counselling & Check-up), in which both the partners can have all the concerned investigations done under one roof, and also get a healthy & complete understanding of all the aspects of the male-female relationship. We have a full-fledged Radiology, Sonography & Automated Pathology Laboratory set-up to meet every need in these cases.
In India, match making is still done on the basis of Horoscopes and the religious & financial backgrounds of the two families. It is high time that we start ascertaining the compatibility of the couple on more practical & realistic grounds by undergoing such medical check-ups & pre-marriage counselling.
Having done this, the youngsters will definitely be able to tie the nuptial knot with more confidence & self-esteem and start their new relationship on a more sound footing.

Besides providing the facility for 'Counselling & Psychotherapy' for individuals, couples & families, do you intend to extend your knowledge/ experience in any other manner?
Ans: We have already started conducting certificate courses in Personal Counselling based on humanistic psychotherapy for those in the helping profession e.g. psychiatrists, doctors, nurses, psychologists, counsellors, social workers, teachers, trainers, HRD personnel etc. through the 'Institute of Human Technology'. This 5-week certificate course in personal counselling, aims at meeting the need for continuing formation of professionals. We teach the Robert Carkhuff model of Personal Counselling in this course, which is an extension of Carl Rogers' Client-centred Therapy.

What is the Robert Carkhuff model? What is Client Centered Therapy?
Ans: Carl R. Rogers, a great pioneer in the United States, conducted a scientific research on the process of helping i.e. he tried to pinpoint the ingredients of the helping relationship (counsellor-counsellee) which, according to him, is the main factor in helping people with problems. He offered a blueprint for counselling in his book, Client-Centered Therapy. We owe much to Carl Rogers for bringing to the attention of counsellors the need to focus on the interpersonal relationship between counsellor and counsellee.
The American psychologist Robert Carkhuff, accepted all that Rogers had to offer and developed it further. Carkhuff concluded that the counsellor must function at a level higher than the counsellee's level of functioning; otherwise the counsellee will deteriorate. Later Robert Carkhuff presented a model of counselling (through his book Helping and Human Relations) which is both a recognition and an enriching extension of Rogers' model. We conduct training programs based on his latest and updated model.

What is Rational Emotive Behavior Therapy (REBT)?
Rational Emotive Behavior Therapy (REBT), founded by Albert Ellis is a “cognitive-behavioral” therapy. It was earlier known as Rational Emotive Therapy (RET). It is based on the concept that emotions and behaviors result from cognitive processes; and that it is possible for human beings to modify such processes to achieve different ways of feeling and behaving.
Rational Emotive Behavior Therapy (REBT) maintains that our emotional problems and counterproductive behavior are largely the result of ‘crooked’ unhelpful thinking. The basic premise of this approach to counselling and psychotherapy is that it is not events that cause our problems, but the way we think about them.
REBT believes that human disturbance is essentially ideologically or philosophically based, and so it strives for a thorough philosophic reorientation of a person's outlook to life. It uses the didactic approach i.e. teaching and re-educating the client in balanced and correct ways of thinking and behaving, and thus helping him acquire rational, realistic and appropriate beliefs of life.
Albert Ellis, founder of Rational Emotive Behavior Therapy (REBT) reasoned that therapy would progress faster if the focus was directly on the client’s self-defeating ideas, verbalizations and ‘beliefs’. He observed that client’s tended to get better when they changed their ways of thinking about themselves, their problems, and the world.
Albert Ellis calls our unhelpful thoughts “irrational beliefs” and says that they are at the core of much emotional disturbance. Rational beliefs on the other hand, are flexible, helpful ways of thinking and enable us to be psychologically healthy. In REBT the counsellor helps the client understand the role of such irrational "beliefs" and self-defeating value systems, in causing and maintaining problems in his life.
Rational Emotive Behavior Therapy (REBT) workshops help counsellors to develop knowledge and skills in this very effective, efficient and empowering method of personal change.