Nirupama Shankar, PT, MHS – Brain Blogger Health and Science Blog Covering Brain Topics Sat, 30 Dec 2017 16:30:10 +0000 en-US hourly 1 Breast Cancer – Catching it Early Tue, 21 Oct 2008 14:24:20 +0000 I write this article in honor of October being Breast Cancer Awareness month. Most of us know someone within our close social circle who has been through this terrible ordeal. This is not surprising, as the National Cancer Institute estimates that there were about 2.4 million women breast cancer survivors in 2004, with a 3.5% increase annually in the incidence of breast cancer. Unfortunately, this means more deaths in 2008 and 2009, unless women respond to the pleas for regular screening so that the disease may be detected early.

The easiest method of screening is, of course, self-examination. This is easy and can be performed in the privacy of one’s home. Many reliable medical websites provide information on the step-by-step process of the breast self-examination. A new tool called Cue is being released this month — this is a small device that may be placed in the shower. It is a small disc like instrument that reminds women of the best time in the month for breast exams, and also provides reminders when it is time for a mammogram.

The CDC recommends that women above 40 years of age schedule a mammogram every two years in addition to regular self-exams. A newer method of screening is the breast ultrasound, using the reflective properties of sonic waves to detect lumps and areas of calcification. When used as an adjunct to mammograms, more diagnoses of Cancer can be made. MRI is the most sensitive at detecting such potentially cancerous masses at much earlier stages of the disease. However, a MRI is recommended for women who are at a high risk (due to genetic, familial and environmental factors) of developing cancer. If lumps or masses are detected, a biopsy usually follows to check if the lump is malignant or benign.

Apart from these specific screening tools, a healthy daily lifestyle may also help decrease the risk of cancer. Foods high in beta-carotene and fiber such as carrots, legumes, squash, and whole grains may have anti-oxidant properties, lowering cancer risk. Foods high in saturated fats such as red meats, margarine, whole fat creams and cheeses may increase risk of all forms of cancer. Getting regular exercise and avoiding smoking and excessive alcohol consumption also contributes towards decreasing the risk of cancer.

Talking to friends and family to spread awareness is more important now than ever. Print, internet and broadcast media are doing an excellent job of promoting an understanding of this condition. Little steps can go a long way, and spreading awareness and encouraging everyone to do the same will help early detection and potentially save lives.


C. K. Kuhl (2005). Mammography, Breast Ultrasound, and Magnetic Resonance Imaging for Surveillance of Women at High Familial Risk for Breast Cancer Journal of Clinical Oncology, 23 (33), 8469-8476 DOI: 10.1200/JCO.2004.00.4960

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Medical Miscommunication Fri, 17 Oct 2008 14:15:14 +0000 Medical miscommunication is a very real problem in healthcare today. Miscommunication is essentially the failure to convey relevant medical information to key players in the medical team; resulting in minor errors or even malpractice. Ineffective communication may occur between patient and doctor or between physicians and experts.

In large hospital systems, medical notes are supposed to be transferred internally from department to department. But this often reaches the healthcare professional only after they have seen the patient. The transfer of medical records between two different hospital systems is almost non-existent, unless patients proactively demand it. Even then, there are numerous delays — a potentially dangerous and frustrating situation for the patient.

The Passage of TimeWhy is this happening more and more nowadays? One reason is definitely a time issue for physicians. Nowadays, one doctor manages a very high caseload and volume; they also have to spend a lot of time on documentation. As a result, they hardly spend 5-10 minutes one-on-one time with a patient. Needless to say, the stage is set for communication errors. Another interesting reason is the super-specialization trend. As more and more specialized fields emerge, patients are sometimes referred to many, many, specialists before a diagnosis is made, or a solution is presented. As a result, the team of professionals is constantly expanding. It is definitely more challenging to maintain very thorough communication inside a large team than a smaller one.

Miscommunication also occurs because one patient may be seeing too many different doctors — a form of doctor shopping. The patient is just trying to get the best possible opinion but, during that time, one doctor is unaware that another doctor is even treating the patient. I have heard of cases where the Primary care physicians sometimes do not even know that their patients are being treated by specialists for stroke or heart disease!

The effects of miscommunication may be minor such as a need for rescheduling an appointment, or a patient being prepped for surgery but the surgeon not being available at that time. On the other end of the spectrum, there could also be terrible results of miscommunication — over-medication, duplication of medication, duplication of services which increases healthcare costs, and surgeries on wrong areas of the body. Drug interactions are another big potential disaster; when patients do not communicate to the doctor what medications they are taking.

This is a scary and potentially life threatening situation, that may be avoided. When seeing a healthcare professional, we have a right to have all our questions answered, and we also have a responsibility to provide our medical history accurately and keep all our doctors on the same page by doing our part in communicating effectively with them. After all, we are the common link between all the medical professionals who treat us.

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Where Accessibility is a Dream – Disability Worldwide Thu, 16 Oct 2008 13:42:28 +0000 The Americans with Disabilities Act (ADA) of 1990 was officiated so that people with disabilities may continue to work, play and participate in day-to-day tasks and activities. It states that no employer may discriminate amongst or terminate employees based on a physical or mental impairment when they are capable of performing the job with or without reasonable modifications. Employers are responsible for maintaining the security of his employees’ job functions, and also for workspace modifications if they are within acceptable financial and location criteria.

The ADA opens up wonderful opportunities for people wanting to pursue their careers even after a severe medical condition. It also has several guidelines for accessibility of the community — from specifications of the height of water fountains and sinks to measurements on width of doorways and hallways. These regulations allow easy maneuvering of wheelchairs and other equipment, making the community completely accessible to everyone without discrimination.

Disabled signIt is extremely heartening to see children and adults with disabilities benefiting from these legal guidelines. Because of such regulations, families can attend local community events, travel, and even take long vacations together. Granted, it takes some additional planning and effort, but at least they have the option. Not all countries are so accessible or inviting to persons with disabilities. In some countries, a disability pretty much means the end of life as one knew it.

The terms “disability” and “handicap” take on a much more literal and ominous meaning in developing nations. A young boy with a complete spinal cord injury in the cervical area will be confined to bed; unless carried by his family member or an aide. An elderly gentleman with a stroke will remain restricted to mobility within his apartment because he cannot navigate stairs, and his multi-storey apartment does not have an elevator. The concept of wheelchairs is a luxury — available only to the really affluent who can afford to have equipment custom built or imported from other countries. Corrective bracing and artificial limbs for persons with muscle imbalance or amputations is available, but very rarely used effectively. This is due to many factors like cost, lack of awareness, poor education and social stigma.

One hopes that the trend will gradually change. More businesses in the USA are taking ownership for issues around the world. Some companies that manufacture limb prosthetics and braces work closely with patients and their families. They collect old braces that patients have outgrown and donate them to countries that require them. Other companies offer financial support to smaller businesses in poorer nations. The World Health Organization (WHO) also funds educational programs that spread awareness about issues such as these. They even provide specific training programs for bracing and prosthetics.

All of this will lead to a more global solution to the effects of disability and loss of function.

Online Resources

The Americans with Disabilities Act.

The World Health Organization.

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Stop Talking, You Might Get Cancer Sun, 12 Oct 2008 21:14:29 +0000 Ok, so what is the consensus? Is talking over the cell phone harmful or not really? There have been a lot of suggestions that heavy cell phone use has a strong correlation with brain cancer. However, there is no conclusive evidence to prove this link for sure. But on the other hand do we really need conclusive evidence about this issue? I would think even if there were a small chance that cell phone usage and brain cancer are linked, we need to take the matter seriously.

So why do experts think that cell phones might cause cancer? First, cell phones are instruments that receive and emit radiofrequency (RF) waves. These are low frequency radiations that could potentially penetrate body tissues and cause increase in cellular temperature. Second, traditional cell phone use forces us to hold the instrument in such close proximity to the head; it concentrates the radiation into the brain. It is not known for sure if these radiations cause mutations in DNA or ions in the body fluid. But at the same time, the long-term effects of the radiation on the body have not been studied.

In the 1980’s, there was a tremendous increase in the number of cell phone users. This trend continued over the next decade and into the next millennium. The number of cellular phone subscribers has more than doubled in the last 8 years (from 110 million in 2000 to 255 million in 2008). Cell phones are used so frequently and for such prolonged time periods that it is highly important to conduct studies that throw some light on the cumulative effect of radiation exposure. Another important area to focus on is children’s cell phones and their effects. Since the child’s nervous system is still growing and developing, the cells are more susceptible to changes in structure. This increases their risk of cancer.

Some of the other factors that determine cancer risk are size of the cellular phone, strength of connecting signal, proximity to the ear, and frequency of use. Some people are already genetically predisposed to getting cancer; and it is especially necessary for them to be extra cautious. The vice-president of the American Cancer Society advises using headsets while talking over cell phones, using text messaging and using the speaker phone tool to greatly decrease risk. The general consensus is also that extensive research that needs to be done on the long-term effects.

In today’s wireless world, human beings are islands in a sea of radiation from every possible type of electronic device — from laptop machines to the complex gaming systems and phones that let you do a million things other than just talk! In an environment such as this, do we really have to actually talk over the cell phone to tap into the radiations? Aren’t we already exposed to them radiations just by being outdoors, or near a satellite dish receiver or a digital recorder? We can eat foods that are rich in antioxidants; we can refrain from smoking and drinking. But what can we do about the millions of E-toxins flying around us in the form of lethal radiations?


Cellular Telephone Use and Cancer Risk. National Cancer Institute Factsheet.

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Preventative Care in Medicine Sun, 28 Sep 2008 21:43:24 +0000 Medicine and health care are classified into various categories based on different specifying criteria. One of the classifications is a distinction on the basis of preventative and curative care: primary, secondary and tertiary cares. Primary care occurs when lifestyle modification behaviors are taught and encouraged in order to maintain a state of good health before disease occurs. Secondary care is provided after a disease has occurred, with a view to prevent progression into a disability. Tertiary prevention occurs after a disability has occurred, to improve function through rehabilitation.

I believe that primary care is the most important of the three, because it tackles issues at a very early stage, and may actually decrease onset of certain diseases and also prevent disease progression. Primary care is also cheap and easy to implement. Costs are significantly less for community education programs than treatment through surgery and hospitalization. This approach to healthcare is more socially responsible and economically viable. It is particularly important in the USA because many diseases are a result of faulty lifestyle choices that may be modified with proper education and awareness. For example, diabetes, obesity, heart disease and stroke have a strong correlation with modifiable behavior such as smoking, heavy alcohol consumption, fatty diet and sedentary lifestyle.

HospitalBoth consumers and providers in the field of healthcare have a responsibility towards making healthcare delivery efficient and cost effective. As consumers we can make regular appointments for screening programs (such as physicals, dental work-up, eye-exams, cervical screening, etc.) that will facilitate early diagnosis and detection of disease (if present). As providers, we can hold more public health service workshops, screening programs, health education programs, and community based classes in varied settings to spread awareness about good health practices. This approach has been evaluated in many countries and literature suggests that it has been successful in decreasing smoking, encouraging women to get regular mammograms, and bringing about changes in diet and exercise levels.

It is heartening to see many professions (dentists, physical therapists, nurses) have already taken on these roles. Even as consumers we can encourage our friends and family to take this approach to healthcare — we will contribute to our own wellness and also make a difference in the big picture of healthcare.


McKenzie JF, Neiger BL, Smelter JL (2005). Planning, Implementing, and Evaluating Health Promotion Programs. 4th ed. San Francisco, CA: Pearson Benjamin Cummings.

J PROCHASKA, W VELICER, C REDDING, J ROSSI, M GOLDSTEIN, J DEPUE, G GREENE, S ROSSI, X SUN, J FAVA (2005). Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms Preventive Medicine, 41 (2), 406-416 DOI: 10.1016/j.ypmed.2004.09.050

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Craniosacral Therapy – Healing Through Touch Tue, 23 Sep 2008 16:20:59 +0000 The field of medicine and healing encompasses varied techniques that have a common goal — to alleviate suffering and facilitate healing. The last few years have seen a revival of ancient trends in healing — the traditional Chinese science of acupuncture, the holistic techniques of Ayurveda and Naturopathy. Many of the alternative medicine techniques provide an external stimulus to accelerate healing while tapping into and enhancing the body’s healing potential. One such technique is craniosacral therapy (CST) which may be utilized as an adjunct by chiropractors, physical and occupational therapists, and osteopaths. To an onlooker or to one who receives this therapy, it appears relatively simplistic –- the therapist places his or her hands on the patient’s body and begins to move the hands without excess pressure, in a seemingly random fashion. However, for the therapist, the process is complex and based completely on the dynamic messages that the patient’s body conveys (gauged perceptively through sensation of hand placement).

CST is based on the principle that the cranial bones, the vertebrae and sacrum share an intrinsic rhythm with the ligaments, muscles and fascia that surrounds them. This rhythm, when synchronized, facilitates smooth movement and circulation of the cerebrospinal fluid. This in turn maintains good lubrication within the intervertebral and facet joints of the spine, and contributes to good health and functionality of the spine and other body systems. This rhythm is termed as the “Breath of Life” and is similar to the concept of “Prana” in Eastern medicine. What craniosacral therapists aim to do is “read” or tap into this rhythm and move their hands in sync with the body to normalize the system. Certain key points on the body –- such as the base of the skull, the area over the sacrum and diaphragm are given special importance to release the soft tissue or bony blocks, so that movement and flow are optimized.

TouchAs a physical therapist, I am able to relate to the importance of touch and hand placement to elicit optimal neuromuscular response. The theory of embryonic maturation also supports the principles of CST. During embryogenesis, the same dermal layer (ectoderm) that differentiates to form the skin also develops into the brain and nerves. So in a manner of speaking when we place our hands on any part of a person’s body, we are indirectly communicating with the nervous system. I would love to explore this avenue of treatment further and add it to my “toolbox” of techniques. Currently one can attend hands-on workshops and short-term courses to learn this technique; there are no degrees or certifications possible in CST. CST also gets its share of flak from skeptics. They question the very existence of a craniosacral rhythm and its link to health, and argue that there is lack of evidence to confirm efficacy of the approach. The hugely subjective nature of the entire process, with limited or no objective measurement also takes away points from the technique.

Detractors argue that CST is unscientific, and that it just poses a feel good effect. But so what if patients feel better based merely on the relaxing atmosphere and their faith in the healing process of CST? Isn’t that the ultimate goal of all healers? To send the patient home relaxed and in less pain? In an ideal world, a relatively low-risk technique that is non-invasive and offers relief from symptoms (subjective reports from patients) would be encouraged, even lauded. However, in a world where healthcare costs are constantly being contained, and where third party payers dictate number of visits for treatments; a process that lacks hard, in-your-face evidence will surely be frowned upon. It is important not to completely disregard techniques such as CST based solely on the lack of evidence. Opening our minds to other treatment forms and alternative medicine can only obliterate the boundaries that we set for ourselves and help us expand — professionally and personally.

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Water – How Much is Too Much? Thu, 18 Sep 2008 23:04:16 +0000 A few years ago, my friend encouraged her father to drink large amounts of water through hot and sultry summer afternoons in India in a bid to sustain hydration in him — with solely good intentions. The next year, he was diagnosed with cardiomyopathy — which meant that his heart muscles were not pumping efficiently; leading to water retention and dilation of the heart. While the water drinking of the previous year did not cause the heart failure, co-existence of both events could have had a devastating effect on his health. Unfortunately, a woman from Sacramento, CA was not as lucky, and died as a result of consuming too much water. She voluntarily consumed about 8 ounces every 15 minutes for a whole day while controlling her bladder.

Water intoxication is a medical condition where the body is overhydrated, caused by consuming excessively large amounts of water. Water intoxication is also dependent on the rate of consumption of the water. When the body gets too much water too quickly, body fluids become to dilute, leading to electrolyte and mineral imbalances. The concentration of sodium, one of the most essential elements, especially decreases leading to hyponatremia. The water in the cells become too dilute due to which osmosis occurs, leading to an influx of water from the outside of the cells to the inside. When this happens, in theory cells might swell to the point of rupturing the cell walls. Other effects of water intoxication include water entering the lungs, pressure on the nerves and spinal cord, and swelling of the brain. Symptoms include mental confusion, fatigue, slurred speech, seizures and death.

This condition is mostly reported in athletes and babies. When athletes train for or run long marathons, they sweat, losing a lot of water. In addition to water, electrolytes are also eliminated via sweat. When athletes attempt to replenish this by consuming plain water, they are in theory further diluting their precious reserve of the salts in the body. To avoid this, experts recommend that they drink sport drinks that contain minerals and essential salts, and also consume foods high in salts during or after a very long run. Babies have low body mass as compared with adults, and so they require significantly less water than adults. They may suffer from water intoxication if they are given large quantities of extra-dilute formula or if they are given too many bottles in one day. People consuming certain psychiatric medications, or people who are on a liquid diet should also balance their fluid consumption and excretion with care.

If overhydration does occur, it may be reversed through:

  • Diuretics, which increase the rate of urination, thereby concentrating the blood
  • Intravenous infusion of saline solution
  • Other forms of palliative care and pharmacological intervention by medical professionals

Water intoxication is very rare and requires very specific sets of circumstances to build up. But it can occur. The general guidelines are to drink about 8-12 eight ounce glasses of water a day, unless one is in very dry weather, exercising, or taking certain medications affecting the heart and kidneys. Staying within these ranges will usually nourish the body without causing an overload on the cardiac and renal systems.


Irene Baldoni, Rosanna Cordiali, Mauro Jorini, Mohamad Maghnie, Fernando M. de Benedictis (2007). Case 1: An infant with water intoxication. Acta Paediatrica, 96 (6), 926-927 DOI: 10.1111/j.1651-2227.2007.00312.x

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Documentation in Rehabilitation Wed, 10 Sep 2008 23:15:03 +0000 It goes something like this… “Patient seen for initial physical therapy evaluation on Aug 7th 2008. Patient is a 65-year old male, who sustained a CVA on June 26th 2008. Patient was accompanied to the ER when complaints of…”. Documentation, commonly referred to as “notes” is often the bane of the rehabilitation professionals work day. It is common to hear therapists and nurses and physicians mention how much they enjoy interacting with their patients and treating them; but they often have less positive things to say about the documentation process.

In the USA, there has been growing emphasis on documentation and maintaining good health records in the field of healthcare over the past few years. As a rehabilitation professional, I used to find summarizing the activities of a one-hour session into a paragraph of words somewhat challenging. But over the years, one tends to accept medical notes as part of one’s work, gradually getting more efficient at it. Documentation is primarily viewed as a means to communicate episodes of care to third party payers for reimbursement purposes. However, detailed documentation and well-organized records also serve to benefit the healthcare professional and the consumer. Some of the benefits of good quality documentation are:

  • Maintaining records so that administrative operations may be evaluated based on the recommendations of accrediting and certifying organizations.
  • Maintaining privacy and security of personal healthcare records.
  • Maintaining records to keep up with the expectations of the educated consumer.
  • Legal record of all communication between professional and consumer in case of disputes.

FilingIn the field of therapy and rehabilitation, the typical evaluation form has a section for goal setting. Personally, I think this is invaluable, as it gives the professional a chance to ask patients and their families what their expectations from therapy are, thereby including them in the process from the beginning. This is the foundation of the Interdisciplinary model of healthcare delivery, which places the patient and family at the center of the planning process. When goals are set early on, the rehabilitation plan is better outlined and specific to the patients’ needs. Studies have indicated that efficient goal planning and documentation improve patient compliance and participation in the program. Studies also suggest that concise and systematic goal planning has a positive effect on patient outcome.

To increase efficiency and ease of storage, hospitals and clinics are moving form the traditional pen and paper documentation toward electronic medical records (EMR). The technology boom has certainly affected healthcare; now documentation may be done on word processing software, over the Internet, or telephonically via dictation systems.

“Working from home” — a concept alien in rehabilitation — is now becoming a possibility; the EMR gives therapists the choice of completing notes at home.

Studies suggested that EMR improved reporting capabilities, and provided a standardized system to analyze and measure therapy outcomes. Studies also showed that EMR enabled individualized treatment planning for clients. Other benefits of EMR included improved efficiency of patient admission processes, decreased length of rehabilitation stay, improved communication within the team, and reduced duplication of information. Another advantage of the EMR is maintaining continuum of care, as the records are available to the entire treatment team for reference and for planning treatment sessions.

Maintaining current and accurate medical records is the responsibility of every healthcare professional. There are more advantages than disadvantages to this and timeliness of documentation benefits the consumer, the providers and companies that bear healthcare costs.

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Are You Vegetarian? How Do You Get Enough Protein? Sun, 07 Sep 2008 21:01:21 +0000 If only I had a nickel each time I was asked this question! Well, I am vegetarian, and my meals are balanced and healthy. I have not been diagnosed with deficiencies or malnourishment yet. On the other hand, I feel light and healthy, eat 25% less fat (than meat eaters) on an average, and save significantly on grocery costs.

The main sources of protein for vegetarians are legumes, nuts, whole grain and dairy products. The protein content in these foods per serving portion is in fact comparable to that in meats, fish and poultry. For example, broad beans and fava beans have approximately 26.12 grams (gm) of protein per 100 gm, while salmon and some other fish have only 25.72 gm / 100 gm. Soy based products have 36.49 gm of protein per 100 gm and pork and ham have 30.94 gm / 100 gm. The vegetarian foods mentioned above are significantly higher in fiber and lower in cholesterol, all of which bumps up their overall nutritive value. A more detailed break up of individual nutritional value is provided in the USDA Nutrient guide website. In addition, almost all whole foods are rich in protein, and are great sources of essential minerals like potassium, iron, magnesium and zinc; making them a well rounded and healthier option.

VegetablesOf late, there has been a renewed interest in the vegetarian lifestyle, which includes exclusively fruits, vegetables, grains, cereal and legumes and soy products. The benefits of an exclusively vegetarian diet includes lower risk of cancer, lower overall Body Mass Index, lower risk for diabetes and heart disease. A recent study by Fu and associates suggested that vegetarians had statistically significant lower systolic and diastolic blood pressure, and lower serum total cholesterol, low-density lipoprotein cholesterol, triglycerides, fasting blood sugar, and hemoglobin levels compared with the non-vegetarians.

Being vegetarian is also better for the environment as a decrease in the demand for beef and poultry will eventually lead to fewer meat farms. Lower number of cattle and poultry reared will mean decreased depletion of grasslands and fields, which will ultimately free up more pastures for production of food for humans. There are increasing vegetarian options available at the market and in restaurants. Numerous recipes are also available and it is easy to modify some of the existing meat recipes to make it vegetarian. Ethnic cuisines like Thai, Indian and Chinese are especially easier to adapt to suit a vegetarian. If this is an option you were contemplating, I suggest that you give Vegetarianism a fair shot and observe how your body and mind feel after a sustained period of this lifestyle.


C FU, C YANG, C LIN, T KUO (2006). Effects of Long-Term Vegetarian Diets on Cardiovascular Autonomic Functions in Healthy Postmenopausal Women The American Journal of Cardiology, 97 (3), 380-383 DOI: 10.1016/j.amjcard.2005.08.057

Liliane Chatenoud, Alessandra Tavani, Carlo La Vecchia, David R. Jacobs, Eva Negri, Fabio Levi, Silvia Franceschi (1998). Whole grain food intake and cancer risk International Journal of Cancer, 77 (1), 24-28 DOI: 10.1002/(SICI)1097-0215(19980703)77:13.3.CO;2-0

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Putting an End to Medicare Fraud Tue, 19 Aug 2008 07:52:20 +0000 When Medicare was signed in to law by President Johnson in 1965, it was intended to serve as a central funding resource for persons over 65 years, and people with disabilities. Over the years millions of people have benefited from the financial medical pool that Medicare is — providing healthcare resources to innumerable people in need. There is no denying that the founders’ vision and efforts are truly commendable. However, every coin has two sides to it, and of late the ugly side of Medicare has been rearing its head. Fraudulent healthcare practices by healthcare companies and individuals abusing their benefits have contributed greatly to the depletion of Medicare reserves. Senate Republicans estimate that frauds cost Medicare and Medicaid approximately 60 billion dollars annually.

The face of the offender in Medicare crimes is diverse, ranging from the small time swindler to the highly qualified surgeon. Setting up pseudo healthcare companies, intentionally entering false claim codes, billing for time that was not spent with the patient, and billing for unnecessary equipment are all techniques that have been used in racketing schemes that request “reimbursement” from Medicare. Home health care is another venue where Medicare fraud may occur. I have heard casual, subjective reporting from patients of professionals spending only 10 minutes in actual patient care activities, and billing for the entire hour. The area of providing home medical equipment also may be targeted, vendors may request more accessories on a wheelchair than is medically necessary and claim costs from insurance, or recommend more than one assistive device.

WheelchairThe Centers for Medicaid and Medicare Services (CMS) have responded to this issue by initiating a revamped auditing system, by contracting out the auditing process to independent companies. The pilot project was spread over three years and three states, during which time about $980 million in overpayments were identified, and $13 million reclaimed. This auditing process has triggered off strong disapproval amongst physicians. They claim that the auditors are aggressive and tend to barge in during appointments. They also complain about the cost that they incur (in terms of phone calls and mailing costs) when they have to retrieve and resend paperwork to the CMS.

I used to shudder at the thought of completing documentation for Medicare — my boss even joked that understanding Medicare paperwork was comparable to reading a rocket science textbook. But I see the value standardizing the claims processes, and asking for comprehensive documentation. What might inconvenience a few healthcare professionals will ultimately contribute towards keeping the Medicare pool viable for the future generations.

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Sleep and Consciousness – A Dynamic State of Being Sun, 10 Aug 2008 16:41:11 +0000 One of the more intriguing aspects of human behavior comes packaged in an extremely natural and habitual act — sleep. Most of us take this routine of sleeping as part of the day, and slide in and out of it rhythmically, systematically. When we do, though, our bodies and minds enter this realm of unknown — theoretically, a passive state of rest for the body and mind. However, due to the many subtle and spontaneous reactions in physical and mental functioning, experts now term sleep as a dynamic rather than a passive state of being.

Sleep follows a circadian rhythm that is regulated by many factors such as light (in the external environment), fatigue and stress (within the body and mind) and the production of certain hormones such as adenosine and melatonin. During daytime, the presence of sunlight triggers production of hormones like cortisol and adenosine, which promote alertness and wakefulness. As recedes and darkness sets in, the eyes register the change in quality of light, transfer the message to the brain cortex — and this stimulates production of melatonin, which promotes drowsiness and tiredness. Interestingly, the optimal concentration of these hormones through the day and night varies significantly from person to person. This may explain why some people prefer to stay up and wake up late, while others prefer to sleep and wake early. Newborns usually spend 14-18 hours in a day sleeping, and this decreases to 8 hours a day in adulthood.

SleepSleep is mainly comprised of two stages — the non-rapid eye movement (NREM) and the rapid eye movement (REM) phases. The former is a state of lighter sleep, while the latter is a deeper state. The NREM phase is followed by the REM state, and this cyclical progression occurs about 4 or 5 times in each 8-hour sleep period. As the name suggests, there is no eye movement in the NREM phase, and the overall muscle tone is maintained. This is the stage that is achieved just before the act of falling asleep and also precedes the act of waking up. The REM phase is characterized by complete relaxation in muscle tone, and cessation of physical activity. However, the brain becomes much more active during the REM phase; the thalamus, reticular nuclei and hypothalamus in the brain especially show increased activity (as observed by studies recording an increase in blood flow to these areas). Dreams commonly occur at this stage of sleep.

This is where strict definitions do not hold good, where rigid theories don’t always hold true. When we are dreaming, there is a certain part of our mind and being which is aware and conscious, yet some other parts of the brain that are completely at rest. Experts suggest that various types of dreams exist, that range form the dreamer not being in his or her own dream (dreams of childhood) to one where the dreamer is actively reflecting upon the ongoing dream and making deductions and judgments on the events happening in the dream (lucid dreams). This is an interesting lead to the contemplation about the distinction between dreams and reality.

The more I ponder over this, the more baffled I get. The contrast in this state of sleep is amazing — while the body recharges, the mind is replete with huge amounts of activity. Mental activity, when it occurs during the day, tires and stresses the human mind. Yet, one wakes up refreshed even after a night of sleep filled with dreams. Advances in funded sleep studies, establishment of numerous sleep analysis centers across the country have revealed a tremendous amount of information about the state of sleeping; but many aspects of sleep still remain a mystery.

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The Trans Fat Ban – Is High-Fructose Corn Syrup Next? Fri, 01 Aug 2008 14:59:33 +0000 On July 25, 2008, Governor Schwarzenegger made it official — California would be the first state to ban trans fat. Food providers have been given a year after which the law requires them to replace hydrogenated oils with healthier, naturally occurring oils such as soya, palm, and vegetable oils. The ban was prompted after the link between consumption of trans fat and diseases such as obesity, diabetes, and high levels of cholesterol was confirmed. A similar, but less publicized dietary villain exists — High Fructose Corn Syrup (HFCS).

The name may be slightly misleading to some -– the word corn may lead the consumer to believe that it is a naturally occurring substance, and fructose may lead one to confuse the compound HFCS with the fructose that occurs naturally in fruits. On the contrary, it is an artificial substance that uses extract from corn merely as a base. Corn extract is milled to form cornstarch, processed to form corn syrup (mainly glucose) and then modified by the addition of enzymes (alpha- and gluco-amylase, and isomerases); that convert glucose to fructose. The production of this chemical also involves other complex steps, including genetic modification of the enzymes used to make them more stable at higher temperatures. Despite the highly synthetic nature of HFCS, many manufacturers are allowed to use “All Natural” or “100% Natural” labeling in products that contain HFCS.

Clowning AroundPublished literature has suggested a significant correlation between the consumption of foods containing HFCS and obesity, diabetes and high cholesterol. Fructose also interferes with the absorption of essential minerals like Copper, magnesium and iodine. After fructose is absorbed in the intestine, it metabolized in the liver. When the liver processes large amounts of fructose, byproducts such as triglycerides, carbon molecules and other precursors to lipid formation are released. These freely circulating triglycerides and lipid molecules aggregate over time and are ultimately converted to fat — which leads to weight gain and obesity. The by products of fructose metabolism also increase the risk of blood clots, high cholesterol and heart disease. Fructose (when consumed in high concentration) also limits the cells’ capability to absorb glucose by interfering with the insulin receptors. This causes high blood glucose levels, which may convert to diabetes.

Scientists agree that the evidence is not conclusive, and further research is necessary. However, it is also true that the consumption of HFCS has increased greater than 1000% from 1970 to 2007. The large consumption amount (USDA approximates 40 lbs per capita in 2007) is certainly alarming. Another disturbing aspect is the unexpected places where HFCS shows up. It is fairly common knowledge that juices and sodas are sweetened with it instead of sugar, but not everyone expects HCFS to be present in breads, soups and salad dressings!

Despite the indications that HFCS is potentially detrimental to health and may be responsible for obesity and heart disease, a ban is unlikely (read impossible) to come by anytime soon. HFCS is cheaper and easier to transport than sugar, may be used in solid or liquid form — so it can be used in a variety of food products. High tariff placed on sugar exported from other countries and active lobbying by the corn industry magnates will sustain and encourage the large-scale production of HFCS. Ultimately, it is up to us to control our personal health by choosing to eat healthier and by making informed choices. We can stay in touch with the literature and expert opinion, and then decide what we want to include in our diet.


Bray, G.A., Nielsen, S.J., Popkin, B.M. (2004). Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. American Journal of Clinical Nutrition, 79(4), 537-543.

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Virtual Reality – New Steps in Stroke Rehabilitation Sat, 19 Jul 2008 12:27:57 +0000 Cerebrovascular accident (CVA or stroke) is one of the leading causes of death and disability in the USA; each year about 700,000 people sustain a stroke across the country. Based on the location and size of the lesion, there may be severe and permanent loss of function. The most significant residual effects of a CVA are related to paralysis (hemiplegia), speech disabilities (apraxia, aphasia), and neglect of the affected side. Unilateral neglect is a condition where the patient is unable to identify or respond to any sensory on the affected side of the body; and is more common is a right-sided CVA.

For a large part of the previous century, it was believed that people with stroke would have to lead a largely dependent life, confined to the wheelchair. They were even discouraged from moving their limbs or exercising. Over the years, rehabilitation for patients with stroke has come a long way. Focus has shifted from basic interventions utilizing strengthening exercises to more advance techniques based on the theories of motor learning and neuroplasticity. This included manual techniques by skilled clinicians as well as the use of equipment such as electrical stimulation modalities, and specialized bikes and treadmill systems — all aimed at optimizing function in patients with impairments. In the past few years, a major step for the field of rehabilitation has been the integration of fields such as assistive technology, robotics and computer sciences with the science of rehabilitation. The amalgam of the above has led to potentially powerful systems that will enhance the functional outcome in patients greatly. The latest entrant into the filed of rehabilitation is virtual reality (VR) systems for rehabilitation. Many of the systems have been tested, released and are now available to hospitals and clinics for use. Clinical trials are ongoing, for upgrading existing technology and for invention of new systems for recovery and rehabilitation.

Virtual realityIn 2002, the engineers at Rutgers University have created a VR system that included therapeutic activities aimed at recovery of function in patients with stroke. There are now many versions of this system available, and clinical trials are ongoing to evaluate the extent of efficacy of these systems in recovery of function. Like any VR gaming system, patients will see themselves in a simulated environment. Only, games will be replaced by targeted exercises that will work target various functional muscle groups in the arms and hands. Patients can complete fine motor tasks such as picking up objects, stacking objects, and gross motor tasks such as tapping balloons, catching objects and even reach for objects out of their base of support, thus encouraging balance retraining.

Of late, VR rehabilitation systems are also being evaluated for their use in decreasing neglect in patients with hemiplegia. This is achieved by the system providing visual cues from the affected side, to increase awareness and enhance adaptive relearning. A recent published case study (four participants) suggested that VR systems had the potential for decreasing neglect in patients with stroke. In addition to improvements on the objective tests that were administered, participants also subjectively reported that VR training sessions were helpful and enjoyable. VR systems can even simulate day-to-day situations like crossing a street, cooking, opening doors, etc. This will provide very specific learning of the tasks that are essential activities of daily living. The VR systems are effective as they emphasize active participation by the patient and provide varied environments for task practice while providing immediate feedback of quality. All of these fulfill the requirements of ideal motor practice and motor learning.

Stroke survivors, in my experience, are people who have the most enthusiasm to recover; their zest to go back to doing things they used to love serves as a wonderful motivator at rehabilitation sessions. Preserved cognition, high motivations levels, and a firm conviction to go back to their old routine makes patients with stroke ideal candidates for unique rehabilitation tools. I look forward to the day when these systems are available to most hospitals at an affordable price, with simpler user interfaces so that more and more patients will benefit from the systems.


Smith, J., Hebert, D., Reid, D. (2007). Exploring the effects of virtual reality on unilateral neglect caused by stroke: Four case studies. Technology and Disability, 19(1), 29-40.

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Living with Traumatic Brain Injury Mon, 14 Jul 2008 17:37:13 +0000 Living with a Brain Disorder CategoryA lady (let’s call her Carla) is driving down a street — it’s 10:00 pm on a Friday night. She thinks about her kids in bed, makes a mental note to check in on them before she goes to bed. She wonders what her boss has in store for her at the 8:00 a.m. meeting that was scheduled a week ago. Suddenly there is a blinding flash of light; a deafening crash, and her world goes black. Sound like a scene from a movie? I wish it were. According to the CDC, 1.4 million people in the USA sustain a traumatic brain injury (TBI) annually; 20% of these are caused by motor vehicle accidents (MVA). Fifty thousand of these traumatic brain injuries result in death each year. Carla might never be able to communicate with her children meaningfully. She certainly will not be able to get back to her work any time soon (if ever). Her social network will be disrupted; her schedule will be a series of medical appointments and consultations.

Brain MRIUnlike a fracture or an elective surgery, the ordeal does not end after the medical procedures are through. When a person sustains a TBI — in most cases families face some of their toughest challenges after the immediate palliative procedures are complete. The patient goes through acute care, an inpatient rehabilitation program, and then may be discharged to their home. In some cases, if they are medically unstable they are required to stay at post-acute settings and also receive outpatient rehabilitation. Some states in the USA also offer long-term care centers for those patients who might never be able to function safely and independently in their homes. These centers usually become permanent “homes” for these patients. Caregivers are often torn between running their homes and visiting their loved one; living their own life and accompanying their loved one to various medical appointments.

The residual physical impairments are only one aspect of the injury. Patients with TBI are prone to emotional disturbances, outbursts and attacks of a myriad of emotions ranging from depression to frustration to extreme rage. Anson and Ponsford studied 33 individuals with brain injury, and found that 51% of them had clinical levels of depression and anxiety (based on their scores on various scales that were administered. They also elaborated upon two styles of coping — non-productive coping (avoidance, self-blame, resorting to drug and alcohol use, etc) and adaptive coping (accepting the problem, and taking proactive steps, incorporating humor and enjoyable activities, etc). The results of their research study suggested that there was a statistically significant correlation between the type of coping mechanism used and ability to overcome the emotional problems.

As a physical therapist, I have spent more than 10 hours a week with one patient and their families. This intense, one-on-one time gave me a glimpse into their current lives and a hint of how things were before this terrible episode dictated every aspect of their lives. I worked with moms who did not recognize their children, with professors who had completely lost the function of speech and teenage boys who would spend all of their adult lives confined to a wheelchair. I saw families attend session after session, hoping to find a fragment of the person they once knew and loved.

For families, living with someone they don’t recognize any more, being pushed suddenly into the role of a caregiver, and dealing with all the emotional ups and downs of the patient takes a physical and emotional toll. A recent literature review study that was published in the Journal of Clinical Nursing indicated that a family member’s cognitive, behavioral and psychological impairments of are greater stressors to the family than their physical disabilities after a TBI. The same study also suggested that partners of people with a TBI scored higher on stress indicator scales than parents; for the most part, women appeared to be more stressed than men.

For most people who have not been through these experiences, this information may be unfamiliar, and difficult to relate to. But the only way that people with TBI may be reintegrated into the community is increasing awareness about this complex disease. Understanding the intricate complexities in the lives of people living with brain injury will hopefully will make us more accepting of people. We can then do our part to assist patients reintegrate smoothly into the community. TBI is a disease that can be prevented by increasing awareness in the community and education with safety tips. The National Institute of Health and the Brain Injury Association are excellent resources for the entire spectrum of Brain Injury.


Verhaeghe, S., Defloor, T., Grypdonck, M. (2005). Stress and coping among families of patients with traumatic brain injury: a review of the literature. Journal of Clinical Nursing, 14(8), 1004-1012. DOI: 10.1111/j.1365-2702.2005.01126.x

Godfrey, H.P., Knight, R.G., Partridge, F.M. (1996). Emotional Adjustment Following Traumatic Brain Injury: A Stress- Appraisal-Coping Formulation. Journal of Head Trauma Rehabilitation, 11(6), 29-40. DOI: 10.1097/00001199-199612000-00006

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Vaccines – A Two-Edged Sword Mon, 30 Jun 2008 12:24:21 +0000 Recently, I accompanied my sister to a pediatrician’s office — for the first (of many) vaccination appointment for her twin 8-week old girls. Fortunately for my sister, the nightmare ended after a few pokes of the needle and a few throaty bawls of protest. Sadly, not every parent’s ordeal ends the same way. Each day, parents around the world take their children on this routine with faith that this will protect their children against deadly and potentially life threatening infections. But what if this very tool that is intended to protect becomes a lethal source of disability?

The most recent case of a 9-year old female child in Georgia refueled the debate about the link between vaccinations and the onset of neuro-developmental disorders. The child had a pre-existing, but non-symptomatic cellular disorder. However, after a round of vaccinations, she began to demonstrate classic behaviors associated with autistic spectrum disorder. The link between the vaccinations and exacerbation of the pre-existing condition was confirmed in this case. Over the years literature has suggested that the sudden surge of autism to near epidemic proportions may be linked to the high mercury content in some vaccine preparations. I make it a point to read ingredient lists in most of the packaged food products that I purchase (I am positive I am not the only one doing this!) Why then would we accept vials of liquid concoctions being injected into our bodies (or our children’s bodies) with no knowledge of ingredients? Here are some of the buffers, preservatives and fixers used in vaccines in addition to the attenuated virus:

Formaldehyde, Mercury, Aluminum, Antifreeze, Methanol, Phenol, Foreign DNA and even extracts from aborted human fetuses. All of these are certainly toxic, and many of these chemicals have no “minimum” levels that may be deemed “safe.” They are toxic to the human body, period.

In spite of the potential threat, pharmaceutical companies are only manufacturing newer vaccines, for all kinds of syndromes and diseases. The flu vaccine was introduced in 1976, and revived in the 1990’s. For teens, multiple vaccines are available for protection against meningitis, chicken pox, diphtheria — many of these are also available as combinations. The most recent entrant into the vaccine race is the Human Papilloma Virus (HPV) vaccine.

This vaccine, however, offers protection against only 4 strains of HPV viruses — types 16, 18, 6, 11. It should be also be known that the vaccine only may offer protection against viruses possibly causing cause only 70% of cervical cancers. Of course, this is being publicized as the only vaccine that protects against cancer, but the fact that even vaccinated persons may contract cervical cancer is left to the fine print. I would certainly not opt to be injected with those toxins in the vaccines for that kind of “probable protection.” Marketing for the vaccine also conveniently leaves out the fact that abstinence or practicing safe sex will also lead to the same level of protection. The indirect message that this vaccine sends to girls as young as 9 years of age (the recommended age for administering the HPV vaccine) is — hey you can go out and have unprotected sex now, and with the HPV vaccine, you will be protected.

I am not recommending scaring children off sex as an effective educational technique, but come on — tell it as it is. Having a group of happy looking girls say “We don’t want to be just one more statistic” and playing jump rope… seems to me to embellishing a hard truth with unnecessary niceties.

The debate about vaccination is certainly not new, it is an ongoing one; fervent discussions are sporadically sparked by incidents like the one cited earlier. Many communities are voting to not vaccinate their children at all, even in infancy. In all cases where the child has a compromised immune system, doctors do not vaccinate — as vaccination in these children may increase the risk of infection. In some states in the USA, doctors may even grant waivers to parents who refuse vaccination on religious or philosophical grounds. All said and done, as is the case with most issues — gather expert opinion, consider the positive as well as the negative implications of the matter, analyze for possible outcomes, and then make your own decision.

Image via deepspacedave / Shutterstock.

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