KNEE BRACES AND SPLINTING IN KNEE OSTEOARTHRITIS
Posted by on Friday, 22nd June 2012
KNEE BRACES AND SPLINTING IN KNEE OSTEOARTHRITIS
Introduction :
Knee brace can be used to stabilize the joint thus reducing further damage and pain. Methods of preventing and treating knee injuries have changed with the rapid development and refinement of knee braces. Prophylactic knee braces are designed to protect uninjured knees from valgus stresses that could damage the medial collateral ligaments1. However, no conclusive evidence supports their effectiveness, and they are not recommended for regular use. Functional knee braces are intended to stabilize knees during rotational and anteroposterior forces. They offer a useful adjunct to the treatment and rehabilitation of ligamentous knee injuries2.
Types of Knee Braces:
Functional Knee Braces
Functional knee braces are designed to substitute for damaged ligaments. For example, a patient who sustains an ACL tear may be offered a knee brace to wear in efforts to allow certain activities without surgery. Most patients who are concerned about knee braces already have a knee ligament injury. These patients would be interested in the functional knee braces. These functional knee braces are designed to compensate for a torn knee ligament1.
Prophylactic Knee Braces
Prophylactic knee braces are used to prevent knee injuries. Prophylactic knee braces are worn by athletes who participate in some high-risk sports in an effort to minimize their risk of sustaining a knee injury1.
How Knee Braces are useful Osteoarthritic Patients?
While nothing can cure osteoarthritis, this brace can help a person return to the type of activities he or she loves2,3.
The Knee Brace for osteoarthritis knee support works by:
Redistributing the weight and joint alignment. This is done by a process called off-loading which takes the direct weight off the joint. This allows the leg to move more naturally3,4.
Bi-Axial hinge gives the brace more flexibility and the ability to better fit the leg comfortably.
Load sensor helps the device to determine the forces being applied by the brace5.
With the relief from pain and better stability, the brace allows for an increase in leg functions, which leads to building up the muscles around the joint5.
More mobility reduces stiffness in the morning, allowing more activity during the day, and reduced pain when at rest4,5.
This knee brace is light weight and easily adjustable by the patient. It offers a 20 degree increase in range of motion and a 4-point dynamic leverage system. The knee support brace has many arthritis friendly features and is commended for its ease-of-use3,5.
An osteoarthritis patient should discuss using the brace or any other such appliance with his or her doctor first and understand what activities can be attempted before using such a device.7
What to expect from a Osteoarthritis (OA) knee brace?
Braces cannot cure OA and may not be right for everyone. However, it is a viable solution for many people. The ideal candidates are typically active people who are motivated to strengthen their muscles and willing to wear a brace to realize the benefits of this form of treatment8.
Discuss treatment goals with your doctor and others on your health care team before you get a brace5,7.
Dont expect a brace to feel good from the start. It may take from a week to a month to get used to how the brace feels on your leg. Be patient. It took a long time for your knee OA to develop9.
Bracing has come close to eliminating pain for some people with knee OA, while others experience moderate relief2,6.
The Appropriate Knee Brace for You
There are different kinds of knee braces and it's important for your doctor or a health professional to help decide which knee brace might be appropriate for you10. Three knee components to consider are:
medial (on the inside of the knee joint)
lateral (on the outside of the knee joint)
patellofemoral (behind the kneecap)
Usually knee braces are recommended for patients who have cartilage loss in one component of the knee, also known as unicompartmental knee damage. Osteoarthritis most commonly develops in the medial component8.
Types of Knee Braces Used in Knee OA
Single-piece sleeves made of neoprene, an elastic-rubbery material, are the most simple knee braces. The knee brace is pulled on over the foot of the affected leg and is placed over the knee where it provides compression, warmth, and support. This type of knee brace is for mild to moderate osteoarthritis and it is available over the counter in most drug stores. The fit should be snug9,10.
An unloader brace is a semi-rigid knee brace made from molded plastic and foam. Steel struts inserted on the sides limit lateral knee movement and add stability11. This brace is custom-fit to each individual patient for whom it is prescribed (usually patients with medial component osteoarthritis). Essentially, it relieves pain by transferring pressure from the inside to the outside part of the knee9.
The unloader knee brace can also be designed for patients with cartilage damage in the lateral component of the knee, as well as patients with severe osteoarthritis of the knee who are looking for temporary pain relief while they wait to have knee replacement surgery. To purchase an unloader knee brace, the patient must obtain a prescription from an orthopedic doctor, and the brace must be purchased at a store specializing in orthotics10.
Experts suggest that patients allow a week to one month to adjust to how the unloader brace feels. Right from the start, don't expect comfort. It takes a little time. Experts also warn patients about becoming too reliant on the unloader brace12. Take it off from time to time so you can exercise and strengthen muscles. It's also important to remember that a knee brace is just one part of a patient's treatment regimen. Don't disregard other aspects of your treatment regimen without first talking to your doctor
Splints in Knee Osteoarthritis..
The various types of knee splints differ in use, style, and complexity. The simplest knee brace is a neoprene sleeve. Neoprene sleeves are most useful if you have mild arthritis and your primary purpose is to reduce pain and swelling. This device does not provide alignment correction or structural support for the knee joint, although it may contribute some input to joint proprioception.
For realignment purposes, you can get several types of knee braces over the counter or custom fit by an orthotist. Custom fit braces are molded to your size and are usually of a higher quality; they are sometimes adjustable. Such braces are more expensive than over-the-counter braces, which have fewer options for adjusting fit11,13. Realignment goals vary because they are based on your personal biomechanics. They include bicompartment, patellofemoral, and tibiofemoral realignment 13.
For some people, the goal of using a knee brace may be ligament protection. I recommend that you see someone qualified to determine which type of brace meets your needs and to fit you properly11. Proper fit of a knee brace is essential, as an improper fit not only fails to realign the joint but also may lead to further joint damage. A gentleman I know used a brace for several years to reduce the pain in his knee during tennis, his preferred mode of exercise. Tennis puts lateral and torsional stresses on the knees, so a brace is a good way to reduce these stresses, which can damage arthritic knees7.
How Splinting Helps in Osteoarthritis KNEE ?
Many athletes wear braces or splints on their knee to help protect it from further injury. Wearing one may be all the knee needs, but only your ahead, a physical therapist can help you heal your knee and then teach you how to strengthen your knee after6,7,8.
Medications are an option that help many people. Your doctor may prescribe anti-inflammatories to reduce swelling inside the knee, reducing the irritation and pain. Analgesics, pain killers, may also be used. Depending on the injury, the knee may benefit from an injection of a corticosteroid directly into the joint6,7.
Immobilizing the knee is done in most traumatic knee injuries. By putting it in a splint, you cant injure it any further through movement and the knee has a chance to heal6,8.
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Hyaluronic acid in osteoarthritis
Posted by on Friday, 22nd June 2012
Hyaluronic acid in osteoarthritis
Osteoarthritis(OA) is a degenerative joint disease and is thought to be wear and tear of joint as part of an aging process.There are 2 types of OA,primary and secondary.Primary OA occurs in a joint de novo.It occurs in elderly and mostly in weight-bearing joints such as knee and hip.This is more common.Secondary OA occurs due to an underlying primary disease of the joint which leads to the degeneration of the joint.It can occur at any age and occurs commonly at the hip. Osteoarthritis is characterized by a loss of articular cartilage, which has a highly limited capacity to heal itself. Along with these cartilage changes, a reduction in the elastic and viscous properties of the synovial fluid occurs. The molecular weight and concentration of the naturally occurring hyaluronic acid decreases. Theoretically, this loss of elastoviscosity decreases the lubrication and protection of the joint tissues and is one postulated mechanism of pain production in osteoarthritis.1,2 Pharmacologic treatment generally consists of analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Physical therapy can be used, with exercises to maintain range of motion and strength. Intra-articular corticosteroid injections are often used for transient symptom relief. When conservative measures fail, surgical treatments limited to arthroscopic debridement, osteotomies to redistribute load and total joint replacements have been the only options until recently.
Intraarticular injections of hyaluronic acid is a viscosupplementation that is newly available options for patients with symptomatic knee osteoarthritis.The increase in viscoelasticity of the synovial fluid seems to play a role.The indications for viscosupplementation can be considered for use in patients who have significant residual symptoms despite traditional nonpharmacologic and pharmacologic treatments.Patients who are intolerant of traditional treatments can be considered these injections.
Viscosupplementation
The concept of viscosupplementation is based on pathologic changes of synovial fluid hyaluronic acid with its decrease molecular weight and supplementation.Two hyaluronic acid products are currently available in the United States: naturally occurring hyaluronan (Hyalgan) and synthetic hylan G-F 20 (Synvisc). Hylans are cross-linked hyaluronic acids, which gives them a higher molecular weight and increased elastoviscous properties. The higher molecular weight of hylan may make it more efficacious than hyaluronic acid because of its enhanced elastoviscous properties and its longer period of residence in the joint space (i.e., slower resorption)3. The exact mechanism of action of viscosupplementation is not well known. Although restoration of the elastoviscous properties of synovial fluid seems to be the most logical explanation, other mechanisms must exist. The actual period that the injected hyaluronic acid product stays within the joint space is on the order of hours to days, but the time of clinical efficacy is often on the order of months.4 Other possible mechanisms to explain the long-lasting effect of viscosupplementation include anti-inflammatory and antinociceptive properties, or stimulation of in vivo hyaluronic acid synthesis by the exogenously injected hyaluronic acid.5
Clinical studies of hyaluronan
Multiple studies have been conducted to assess the efficacy of intra-articular hyaluronan injections. Initial studies6-8 in the 1970s and 1980s demonstrated benefits for hyaluronan-injected knees. More recently, Dahlberg and colleagues,9 and Henderson and coworkers,10 in randomized, double-blind placebo-controlled trials found no benefit from intra-articular hyaluronan over placebo. Lohmander and associates11 similarly found no significant differences between overall treatment and placebo groups; however, a subgroup analysis of patients more than 60 years of age with more severe symptoms revealed beneficial effects from the hyaluronan injections. In contrast to these recent trials, which demonstrated no or minimal beneficial effects from intra-articular hyaluronan, other randomized controlled studies12-14 suggest overall beneficial effects of hyaluronan over placebo. Another study15 demonstrated efficacy of hyaluronan in a randomized blinded trial, with the treatment group showing more improvement than the placebo group and a group taking oral naproxen.
Clinical studies of cross-linked hylan
A summary of four clinical trials performed in Germany using cross-linked hylan16 demonstrated excellent results in 71 percent of hylan-treated patients, compared with 29 percent of placebo-treated patients. After six months, 53 percent of hylan-treated patients still reported excellent pain relief, compared with 22 percent of the placebo-treated patients. In a double-blind, randomized placebo-controlled trial using hylan,17 it was found that 39 to 71 percent of hylan-treated patients were symptom free at 26 weeks compared with 13 to 45 percent of placebo-treated patients. Another study18 compared intra-articular hylan with NSAID therapy in a randomized blinded trial. Hylan was found to be as effective as NSAID therapy at 12 weeks and was superior to NSAID therapy at 26 weeks. In addition, findings from a clinical practice19 showed that 80 percent of 458 knees injected with hylan had a positive response, and the average duration of efficacy was 8.2 months.
Adverse effects of intraarticular hyaluronic acid
Rates of adverse reaction has been low.The most frequent adverse reaction to this treatment is transient localised pain or effusion which is resolved within one to three days.There were no systemic effects attributed to hyaluronic acid.There are also reports on cases of induced pseudogout20.No long term side effects have been reported21.
Indications
Intra-articular hyaluronic acid injections should be considered in patients with significantly symptomatic osteoarthritis who have not responded adequately to standard nonpharmacologic and pharmacologic treatments or are intolerant of these therapies (e.g., gastrointestinal problems related to anti-inflammatory medications).2,14,15 Patients who are not candidates for total knee replacement or who have failed previous knee surgery for their arthritis, such as arthroscopic debridement, may also be candidates for viscosupplementation. Total knee replacement in younger patients may be delayed with the use of hyaluronic acid22.
Injection technique
Hyalgan is supplied in 2-mL vials (one injection per vial) or prefilled syringes, and Synvisc is supplied in 2-mL prefilled syringes. The recommended injection schedule is one injection per week for five weeks for Hyalgan, and one injection per week for three weeks for Synvisc. Repeat courses of viscosupplementation can be performed after six months. A knee joint can be injected several ways. One approach is to have the patient lie supine on the examination table with the knee flexed 90 degrees. In this position, the anterior portions of the medial and lateral joint lines can easily be palpated as dimples just medial or lateral to the inferior pole of the patella. Often, the medial joint line is easier to palpate and define and can be chosen as the site of injection. Alternatively, the knee joint can be approached with the knee extended, again with the patient lying supin. Most commonly the superolateral edge of the patella is the site of injection, but other quadrants of the knee near the patellar edges can also be chosen. With this approach (knee in extended position), the needle is generally aimed under the patella.
Actual injection site can be marked with a fingernail imprint or the barrel of a pen. Next, sterile preparation with a povidone iodine preparation (Betadine) and alcohol can be performed. A 22- to 25-gauge needle can be used for the injection. Local anesthesia with lidocaine before the injection can be used, but with a small gauge needle this is not always necessary. Alternatively, an ethyl chloride spray can be used for local anesthesia. Following puncture through the skin and into the joint space, the injection is accomplished. If resistance is encountered, redirection of the needle may be necessary.
If effusion is present, aspiration of the joint is recommended before the injection to prevent dilution of the injected hyaluronic acid. The aspiration can be performed at the same site as the injection, as previously described. The same needle can be left in place and used for the aspiration and the injection. Aspiration may require a larger bore needle, such as an 18- or 20-gauge needle. Following local anesthesia with intradermal lidocaine or ethyl chloride spray, the needle can be placed into the joint for aspiration. When aspiration is completed, hemostat clamps can be used to grasp and stabilize the needle, while the aspiration syringe is detached from the needle. The syringe containing hyaluronic acid can then be attached to the same stabilized needle followed by injection. No excessive weight-bearing physical activity should take place for one to two days following injection.
References:
1. Marshall KW. Viscosupplementation for osteoarthritis: current status, unresolved issues and future directions. J Rheumatol 1998;25:2056-8.
2. George E. Intra-articular hyaluronan treatment for osteoarthritis. Ann Rheum Dis 1998;57:637-40.
3. Wobig M, Bach G, Beks P, Dickhut A, Runzheimer J, Schwieger G, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther 1999;21:1549-62.
4. Cohen MD. Hyaluronic acid treatment (viscosupplementation) for OA of the knee. Bull Rheum Dis 1998;47:4-7.
5. Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol 1993;20(suppl 39):3-9.
6. Peyron JG, Balazs EA. Preliminary clinical assessment of Na-hyaluronate injection into human arthritic joints. Pathol Biol [Paris] 1974;22:731-6.
7. Weiss C, Balazs EA, St. Onge R, Denlinger JL. Clinical studies of the intraarticular injection of HealonR (sodium hyaluronate) in the treatment of osteoarthritis of human knees. Osteoarthritis symposium. Palm Aire, Fla., October 20-22, 1980. Semin Arthritis Rheum. 1981;11(suppl 1):143-4.
8. Peyron JG. Intraarticular hyaluronan injections in the treatment of osteoarthritis: state-of-the-art review. J Rheumatol 1993;39(suppl):10-5.
9. Dahlberg L, Lohmander LS, Ryd L. Intraarticular injections of hyaluronan in patients with cartilage abnormalities and knee pain. A one-year double-blind, placebo-controlled study. Arthritis Rheum 1994;37:521-8.
10. Henderson EB, Smith EC, Pegley F, Blake DR. Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: a randomised single centre double-blind placebo-controlled trial of 91 patients demonstrating lack of efficacy. Ann Rheum Dis 1994;53:529-34.
11. Lohmander LS, Dalen N, Englund G, Hamalainen M, Jensen EM, Karlsson K, et al. Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan Mulicentre Trial Group. Ann Rheum Dis 1996;55:424-31.
12. Dougados M, Nguyen M, Listrat V, Amor B. High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial. Osteoarthritis Cart 1993;1:97-103.
13. Puhl W, Bernau A, Greiling H, Kopcke W, Pforringer W, Steck KJ, et al. Intraarticular sodium hyaluronate in osteoarthritis of the knee: a multicentre double-blind study. Osteoarthritis Cart 1993;1:233-41.
14. Listrat V, Ayral X, Paternello F, Bonvarlet JP, Simonnet J, Amor B, et al. Arthroscopic evaluation of potential structure modifying activity of hyaluronan (Hyalgan) in osteoarthritis of the knee. Osteoarthritis Cart 1997;5:153-60.
15. Altman RD, Moskowitz R. Intraarticular sodium hyaluronate (Hyalgan) in the treatment of patients with osteoarthritis of the knee: a randomized clinical trial. J Rheumatol 1998;25:2203-12 [Published erratum appears in J Rheumatol 1999;26:1216].
16. Adams ME. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheumatol (suppl) 1993;39:16-8.
17. Wobig M, Dickhut A, Maier R, Vetter G. Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee. Clin Ther 1998;20:410-23.
18. Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP, et al. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cart 1995;3:213-25.
19. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85.
20. Disla E, Infante R, Fahmy A, Karten I, Cuppari GG. Recurrent acute calcium pyrophosphate dihydrate arthritis following intraarticular hyaluronate injection. Arthritis Rheum 1999;42:1302-3.
21. Maheu E. Hyaluronan in knee osteoarthritis: a review of the clinical trials with hyalgan. Eur J Rheumatol Inflamm 1995;15:17-24.
22. Red book. Montvale, N.J.: Medical Economics Data, 1999.
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Medial Compartment Arthritis
Posted by on Friday, 22nd June 2012
Medial Compartment Arthritis
Etiology
Osteoarthritis of the knee usually occurs secondary to mechanical factors, which include partial or complete meniscectomy, femoral osteonecrosis, lower extremity trauma, ligamentous laxity, obesity, and lower extremity malalignment.[1,2]
Pathophysiology
With removal of approximately one third of the meniscus, increased force is transferred directly to the tibial articular surface.[ 3]The joint also becomes less congruent and is not able to disperse the force across the joint. Both of these factors increase contact stresses, which can lead to articular cartilage damage and subsequent osteoarthritis.[3,4,5]
Results from multiple laboratory studies have shown that abnormal alignment also leads to abnormal contact stress. Ogata et al, Wu et al, and Reimann performed similar studies in which a varus stress was placed across the knee.[12] Each study documented degeneration of the articular cartilage in the medial compartment. The injury to the articular cartilage occurs in the deeper layers without any surface evidence of injury.[11,12]
Fractures of the tibial shaft and plateau may lead to subsequent lower extremity malalignment. Most clinicians accept less than 10° of angulation in tibial shaft fractures. For instance, residual varus angulation increases contact stresses across the medial compartment of the knee. Tibial plateau fractures also may lead to medial compartment osteoarthritis. The arthritis in this instance is due to direct articular cartilage damage caused by the intraarticular fracture.
Ligamentous laxity also is a cause of medial compartment osteoarthritis. Anterior cruciate and/or lateral collateral ligamentous laxity or incompetence has been implicated as causes for medial compartment osteoarthrosis. ACL-deficient knees allow for anterior subluxation of the tibia on the femur. This leads to increased shear force upon the articular cartilage, which leads to early degeneration of the articular surface.
Torsional deformities of the tibia and femur have a clinical association with the onset of medial compartment degenerative changes. The torsion may be present on the tibial or femoral side of the knee. This may lead to varus angulation and increased contact stresses across the articular cartilage of the medial joint space, which leads to accelerated medial compartment osteoarthritis.
Presentation
Patients generally present with a chief symptom of pain in the knee that has worsened over time. Patients state that the knee generally feels worse in the morning when they awaken and that the knee pain generally lessens with some activity. As their activity increases during the day, so does their pain. Patients may state that anti-inflammatory drugs help alleviate the pain. Patients frequently describe pain on the inside (genu varum) or outside (genu valgum) of the knee if unicompartmental arthritis is the cause of their symptoms.[9,10,11]
History and physical examination are crucial in making the diagnosis. It is important to ascertain whether trauma to the knee has occurred, indicating an old history of fracture, articular damage, and/or ligamentous injury and malalignment. A history of pain in other joints may alert the physician to an etiology of inflammatory arthritis or bilateral lower extremity malalignment.[9,10]
Physical examination may reveal varus or valgus alignment of the knee. Pain over the medial joint line may indicate a meniscus tear or degenerative changes within the medial compartment.[12] Patellar tendon tenderness also may indicate medial joint degeneration, as well as possible patellar tendon pathology. Patients may have crepitus in the knee. Range of motion (ROM) of the knee may be decreased compared to the opposite side. Fixed flexion contractures are uncommon but may occur in patients with tibiofemoral osteoarthritis. Evaluation of ligamentous stability is important. The integrity of the cruciate ligaments and collateral ligamentous stability may determine the feasible treatment options.[12,13,14,15]
Determining whether the patient with varus or valgus alignment of the knee can be passively corrected to neutral is of key importance.[14] Again, this aids in determining the surgical options for treatment of medial compartment disease.
Treatment Modalities
Multiple treatment options are available for isolated medial compartment osteoarthritis of the knee. Surgical intervention is indicated when conservative therapies have failed. Conservative therapies include nonsteroidal anti-inflammatory drugs (NSAIDs), joint viscosupplementation, unloading braces, and physical therapy.
Arthroscopy
The first operative procedure is knee arthroscopy. Arthroscopy is indicated for patients in whom conservative therapy has failed who want the most minimal surgical procedure available. Arthroscopy usually is used as a temporizing measure until definitive surgical treatment is undertaken. Knee arthroscopy sometimes is indicated as a diagnostic procedure to determine a treatment pathway or may be utilized in conjunction with a definitive procedure. Arthroscopy of the knee has not been shown to slow the course of osteoarthritis of the knee; however, it has been demonstrated to provide pain relief. The period of pain relief ranges from 6 months to a few years.[9 ]
Osteotomy
High tibial osteotomy (HTO) is indicated in patients younger than 60 years (ideally in their sixth decade of life) who are in labor-intensive fields and experience activity-related pain with a varus alignment of the knee. The arthritis in the medial compartment must be noninflammatory, and the patient should have no patellofemoral symptoms. Certain criteria regarding ligamentous stability and presence of minimal flexion contracture must be met. If this procedure is used alone, it should be considered a temporizing measure because joint resurfacing ultimately may be required.[5,13 ]
Arthroplasty
Unicompartmental knee arthroplasty is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacements.[8] Also, UKA may have a smaller incision because the implants may be smaller.[8] Unicompartmental knee arthroplasty (UKA) is indicated in patients who are older than 60 years who have sedentary lifestyles, and were also performed for patients with age less than 60years noninflammatory arthritis, and pain with weight bearing[19]. Patients may have patellofemoral disease but usually are asymptomatic in that compartment. Symptomatic patellofemoral disease is a contraindication to the procedure. Ligamentous stability, weight, and coronal deformity of less than 15° also are considered. TKA is indicated in patients older than 65 years who have somewhat sedentary lifestyles and symptomatic arthritis in 2 or 3 compartments. The arthritis may be posttraumatic, degenerative, or inflammatory.[8,10,14,15,16,17 ,18, 19]
ABOVE:X-ray taken before arthroplasty(AP view and Lateral View)
BELOW: X-ray taken after arthroplasty(AP view and Lateral View)
Partial Knee Resurfacing Implant compared to a Total Knee Replacement Implant
Citation:
1. Birmingham TB, Kramer JF, Kirkley A, et al. Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control. Rheumatology (Oxford). Mar 2001;40(3):285-9. [Medline].
2. Dearborn JT, Eakin CL, Skinner HB. Medial compartment arthrosis of the knee. Am J Orthop. Jan 1996;25(1):18-26. [Medline].
3. Grelsamer RP. Unicompartmental osteoarthrosis of the knee. J Bone Joint Surg Am. Feb 1995;77(2):278-92. [Medline].
4. Gross AE, McKee NH, Pritzker KP, Langer F. Reconstruction of skeletal deficits at the knee. A comprehensive osteochondral transplant program. Clin Orthop. Apr 1983;(174):96-106. [Medline].
5. Jackson RW. Surgical treatment. Osteotomy and unicompartmental arthroplasty. Am J Knee Surg. Winter 1998;11(1):55-7. [Medline].
6. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. Apr 1999;81(4):539-48. [Medline].
7. Lindenfeld TN, Hewett TE, Andriacchi TP. Joint loading with valgus bracing in patients with varus gonarthrosis. Clin Orthop. Nov 1997;(344):290-7. [Medline].
8. Borus T, Thornhill T (January 2008). "Unicompartmental knee arthroplasty". J Am Acad Orthop Surg 16 (1): 918. PMID 18180388
9. Marwin SE, Siegel JA. Unicompartmental Gonarthrosis of the Knee: The Role of Unicompartmental Knee Arthroplasty. Orthopedic Special Edition. 1999;5(2):57-60.
10. Moseley JB Jr, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am J Sports Med. Jan-Feb 1996;24(1):28-34. [Medline].
11. Squire MW, Callaghan JJ, Goetz DD, et al. Unicompartmental knee replacement. A minimum 15 year followup study. Clin Orthop. Oct 1999;(367):61-72. [Medline].
12. Bingham CO 3rd, Buckland-Wright JC, Garnero P, Cohen SB, Dougados M, Adami S, et al. Risedronate decreases biochemical markers of cartilage degradation but does not decrease symptoms or slow radiographic progression in patients with medial compartment osteoarthritis of the knee: results of the two-year multinational knee osteoarthritis structural arthritis study. Arthritis Rheum. Nov 2006;54(11):3494-507. [Medline].
13. Reimann I. Experimental osteoarthritis of the knee in rabbits induced by alteration of the load-bearing. Acta Orthop Scand. 1973;44(4):496-504. [Medline].
14. Niemeyer P, Koestler W, Kaehny C, Kreuz PC, Brooks CJ, Strohm PC, et al. Two-year results of open-wedge high tibial osteotomy with fixation by medial plate fixator for medial compartment arthritis with varus malalignment of the knee. Arthroscopy. Jul 2008;24(7):796-804. [Medline].
15. Bert JM. 10-year survivorship of metal-backed, unicompartmental arthroplasty. J Arthroplasty. Dec 1998;13(8):901-5. [Medline].
16. Fu FH, Harner CD, Vince KG. Knee surgery. Vol 2. Williams & Wilkins;1994:1061-255.
17. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am. Jan 1989;71(1):145-50. [Medline].
18. Emerson RH Jr, Higgins LL. Unicompartmental knee arthroplasty with the oxford prosthesis in patients with medial compartment arthritis. J Bone Joint Surg Am. Jan 2008;90(1):118-22. [Medline].
19. Frankowski JJ, Watkins-Castillo S, Sculco TP, et al.Primary total hip and total knee arthroplasty projectionfor the US population to the year 2030. AmericanAcademy of Orthopaedic Surgeons; John Wiley &Sons, Inc; 2002. Updated: Sep 12, 2008
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Glucosamine in Osteoarthritis and other Food Supplements
Posted by on Friday, 22nd June 2012
Glucosamine in Osteoarthritis and other Food Supplements
Introduction
Osteoarthritis (OA) is the commonest form of arthritis found worldwide that can affect the hands, hips, shoulders and knees. It is responsible for the largest burden of joint pain and is the single most important rheumatological cause of disability and handicap.1,2 In Osteoarthritis, the cartilage that protects the ends of the bones breaks down and causes pain and swelling. Drug and non-drug treatments are used to relieve pain and/or swelling. Osteoarthritis commonly affects the hands, feet, spine and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis. These are food supplements show promise for helping people with osteoarthritis, those are Glucosamine sulphate, Chondroitin sulphate, SAMe (s-adenosylmethionine), Vitamin C ( ascorbic acid), Beta Carotene3 and many more.
Glucosamine
Glucosamine is almost synonymous with osteoarthritis as it has benefits for osteoarthritis. It can be found naturally in the body and is used by the body as one of the building blocks of cartilage.Glucosamine is an amino sugar produced from the shells of shellfish (chitin) and it is a key component of cartilage. Glucosamine (C6H13NO5) is an amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids. Glucosamine is part of the structure of the polysaccharides chitosan and chitin, which compose the exoskeletons of crustaceans and other arthropods, cell walls in fungi and many higher organisms, glucosamine is one of the most abundant monosaccharides.3
Glucosamine is necessary for the construction of connective tissue and healthy cartilage. It is the critical building block of proteoglycans and other substances that form protective tissues. These proteoglycans are large protein molecules that act like a sponge to hold water giving connective tissues elasticity and cushioning effects. This also provides a buffering action to help protect against excessive wear and tear of the joints. Without glucosamine, our tendons, ligaments, skin, nails, bones, mucous membranes, and other body tissues can not form properly.
Glucosamine works to stimulate joint function and repair. Everyone produces a certain amount of glucosamine within their bodies. Normally we generate sufficient amounts of glucosamine in our bodies to form the various compounds needed to generate connective tissue and healthy cartilage. But gradually the rate at which our bodies use glucosamine begins to gradually change with our increased athletic activity, injuries, burns, arthritis and other inflammatory disorders, age and other chronic degeneration.3 In such situations our bodies may not be able to keep up with the demand for glucosamine, leading to a decrease in the amount of proteoglycans produced. This can lead to a decrease in the amount of protective lubricating substances like the synovial fluids, which cushion our joints, and protects them from damage. In a nutshell, more glucosamine is needed but less is produced.
As the age advances, body loses the capacity to make enough glucosamine. Having ample glucosamine in the body is essential to producing the nutrients needed to stimulate the production of synovial fluid, the fluid which lubricates cartilage and keeps the joints healthy. Without enough glucosamine, the cartilage in weight-bearing joints, such as the hips, knees, and hands deteriorates. The cartilage then hardens and forms bone spurs, deformed joints, and limited joint movement. This is how the debilitating disease of osteoarthritis develops.4
Therefore, in short, glucosamine is a major building block of proteoglycans needed to make glycosaminoglycans, proteins that bind water in the cartilage matrix which also acts as a source of nutrients for the synthesis of proteoglycans and glycosaminoglycans. It is also a stimulant to chondrocytes and playing key factor in determining how many proteoglycans are produced by the chondrocytes needed to spur chondrocytes to produce more collagen and proteoglycans acts as a regulator of cartilage metabolism which helps to keep cartilage from breaking down. 5
Glucosamine is the supplement most commonly used by patients with osteoarthritis. It is an endogenous amino sugar that is required for synthesis of glycoproteins and glycosaminoglycans, which are found in synovial fluid, ligaments, and other joint structures. Exogenous glucosamine is derived from marine exoskeletons or produced synthetically.
Exogenous glucosamine may have anti-inflammatory effects and is thought to stimulate metabolism of chondrocytes.
Glucosamine is available in multiple forms. The most common are glucosamine hydrochloride and glucosamine sulfate. Some products contain a blend of these, and many combine one of the forms with a variety of other ingredients. Glucosamine has been safely used in long-term clinical trials Overall, the evidence supports the use of glucosamine sulfate for modestly reducing osteoarthritis symptoms and possibly slowing disease progression.
Chondroitin
Chondroitin, an endogenous glycosaminoglycan, is a building block for the formation of the joint matrix structure. Chondroitin sulfate is a sulfated glycosaminoglycan (GAG) composed of a chain of alternating sugars (N-acetylgalactosamine and glucuronic acid). It is usually found attached to proteins as part of a proteoglycan.6 Chondroitin sulfate is an important structural component of cartilage and provides much of its resistance to compression. Along with glucosamine, chondroitin sulfate has become a widely used dietary supplement for treatment of osteoarthritis. Chondroitin is a molecule that occurs naturally in the body. It is a major component of cartilage,the tough, connective tissue that cushions the joints. Chondroitin helps to keep cartilage healthy by absorbing fluid (particularly water) into the connective tissue. It may also block enzymes that break down cartilage, and it provides the building blocks for the body to produce new cartilage.
Chondroitin sulphate Chondroitin is the most abundant glycosaminoglycan in cartilage and is responsible for the resiliency of cartilage and it has various effects in relieving symptoms of osteoarthritis and those are its anti-inflammatory activity, the stimulation of the synthesis of proteoglycans and hyaluronic acid, and the decrease in catabolic activity of chondrocytes inhibiting the synthesis of proteolytic enzymes, nitric oxide, and other substances that contribute to damage cartilage matrix and cause death of articular chondrocytes. chondroitin sulfate reduced the IL-1β-induced nuclear factor-kB (Nf-kB) translocation in chondrocytes. In addition, chondroitin sulfate has recently shown a positive effect on osteoarthritic structural changes occurred in the subchondral bone.7 A number of scientific studies suggest that chondroitin may be an effective treatment for osteoarthritis
Therefore, overall effects of chondroitin sulphate are; reduces osteoarthritis pain, improves functional status of people with hip or knee osteoarthritis, reduces joint swelling and stiffness and ultimately provides relief from osteoarthritis symptoms for up to 3 months after treatment is stopped
S-Adenosyl methionine
S-Adenosyl methionine (SAM, SAMe, SAM-e) is a dietary supplement that has been clinically shown to support and promote joint health, mobility and joint comfort.It is a compound produced by our bodies from methionine. Methionine is an amino acid found in protein-rich foods and a common co-substrate involved in methyl group transfers. SAM-e is critical in the manufacture of joint cartilage and in the maintenance of neural cell membrane function.8
Administration of SAMe exerts analgesic and antiphlogistic activities and stimulates the synthesis of proteoglycans by articular chondrocytes with minimal or absent side effects on the gastrointestinal tract and other organs and improving pain and stiffness related to osteoarthritis
Vitamin C( ascorbic acid)
Vitamin C( ascorbic acid) may help reduce the progression of osteoarthritis. Vitamin C is involved in the formation of both collagen and proteoglycans (two major components of cartilage, which cushions the joints). Vitamin C is also a powerful antioxidant that helps to counteract the effects of free radicals in the body, which can damage cartilage. Ascorbic acid(vitamin c) is a sugar acid with antioxidant properties. Its appearance is white to light-yellow crystals or powder, and it is water-soluble. One form of ascorbic acid is commonly known as vitamin C. In human plasma, ascorbate is the only antioxidant that can completely protect lipids from detectable peroxidative damage induced by aqueous peroxyl radicals. Ascorbate appears to trap virtually all peroxyl radicals in the aqueous phase before they diffuse into the plasma lipids. Ascorbate is a highly effective antioxidant, as it not only completely protects lipids from detectable peroxidative damage, but also spares alpha-tocopherol, urate, and bilirubin.Ascorbic acid stimulates collagen synthesis and modestly stimulates synthesis of aggrecan (a proteoglycan present in articular cartilage), Sulfated proteoglycan biosynthesis is significantly increased in the presence of ascorbic acid thus it may offer some protective effect against the super oxide and free radicals and limiting and delaying the osteoarthritis progression
Beta-carotene
. Beta-carotene belongs to a family of natural chemicals known as carotenoids. Widely found in plants, carotenoids along with another group of chemicals, bioflavonoids, give color to fruits, vegetables, and other plants.
Beta-carotene is another antioxidant that also seems to help reduce the risk of osteoarthritis progression. Beta-carotene is a particularly important carotenoid from a nutritional standpoint, because the body easily transforms it to vitamin A. While vitamin A supplements themselves can be toxic when taken to excess, it is believed (although not proven) that the body will make only as much vitamin A out of beta-carotene as it needs. Assuming this is true, this built-in safety feature makes beta-carotene the best way to get your vitamin A. A high dietary intake of beta-carotene is associated with a significantly slower progression of osteoarthritis, according to a study in which researchers followed 640 individuals over a period of 8 to 10 years .10
Conclusion
In conclusion,there are nutrients and foods that may help to halt the progression osteoarthritis before it becomes severe as well as helping to reduce the pain and inflammation associated with it.
REFERENCES
1) Clinical Practise Guidelines. Management of Osteoarthritis http://www.msr.org.my/html/Bookleta.pdf accessed on 13 February 2010
2) Cochrane Library. Glucosamine Therapy for Treating Osteoarthritis http://www.cochrane.org/reviews/en/ab002946.html accessed on 13 February 2010
3) Spark People Life. Dietary Supplement for Osteoarthritis
http://www.sparkpeople.com/resource/nutrition_articles.asp?id=865 accessed on
14 February
4) Horton D, Wander JD (1980). The Carbohydrates. Vol IB. New York: Academic
Press. pp. 727728.
5) Glucosamine and Osteoarthritis,How it works
http://www.arthritis-glucosamine.net/glucosamine-osteoarthritis.php accessed on
14 February 2010
6) Jamie G. Barnhill, Carol L. Fye, David W. Williams, Domenic J. Reda, Crystal L. Harris, and Daniel O. Clegg. Chondroitin Product Selection for the Glucosamine/Chondroitin Arthritis Intervention Trial. J Am Pharm Assoc. 2008; 46:1424.
7) Davidson EA, Meyer K (2007). "Chondroitin, a mucopolysaccharide". J Biol Chem 211 (2): 60511.
8) S-adenosyl methionine [SAMe]. Research Reports http://www.oralchelation.com/technical/SAM.htm accessed on 15 February 2010
9) McAlindon TE, Jacques P, Zhang Y, et al. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum. 1996;39:648-656.
10) iHerb. Com. Beta Carotene http://healthlibrary.epnet.com/GetContent.aspx?token=e0498803-7f62-4563-8d47-5fe33da65dd4&chunkiid=21547 accessed on 16 February 2010
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Should we become a Devotee? Teachings of swami Vivekananda
Posted by on Sunday, 18th December 2011
Should we become a Devotee? Teachings of swami Vivekananda
Prof Gourishankar Patnaik; Bhubaneswar
Swami Vivekananda became one of India's leading social reformers of the modern era and was a champion of humanitarianism and service to God through service to others. He is revered both in the East and West as a rejuvenator of mankind through the eternal truths of Hinduism. He spoke widely on Hinduism and its true meaning as written in the vedas and founded the Ramkrishna Mission, one of India's leading charitable institutions.
What is Life
Each soul is potentially divine. The goal is to manifest this divinity within by controlling nature, external and internal. Do this either by work, or worship, or psychic control, or philosophy---by one or more or all of these--and be free.
Pleasure is not the goal of man, but knowledge. Pleasure and happiness comes to an end. It is a mistake to suppose that pleasure is the goal. The cause of all the miseries we have in the world is that men foolishly think pleasure to be the ideal to strive for. After a time man finds that it is not happiness, but knowledge, towards which he is going, and that both pleasure and pain are great teachers; the ultimate goal of all mankind, the aim and end of all religions, is but one--reunion with God, or what amounts to the same, with the divinity which is every man's true nature.
The ideal of man is to see God in everything. But if you cannot see Him in everything, see Him in one thing, in that thing which you like best, and then see Him in another. So on you can go.
In this world of many, he who sees the One, in this ever-changing world, he who sees Him, who never changes, as the Soul of his own soul, as his own self, he is free, he is blessed, he has reached the goal.
Bhakti Yoga
Bhakti-Yoga is a real, genuine search after the Lord, a search beginning, continuing and ending in Love. One single moment of the madness of extreme love to God brings us eternal freedom. "Bhakti is intense love to God." "When a man gets it he loves all, hates none; he becomes satisfied forever." "This love cannot be reduced to any earthly benefit," because so long as worldly desires last that kind of love does not come. Bhakti-Yoga does not say "give up"; it only says "Love; love the Highest"; and everything low naturally falls off from him, the object of whose love is this Highest.
Purpose of Devotion
Bhakti is its own fruition, its own means and its own end. Those to whom the eternal interests of the soul are of much higher value than the fleeting interests of this mundane life, to whom the gratification of the senses is but like the thoughtless play of the baby, to them, God and the love of God form the highest and the only utility of human existence.
Bhakti admits no elements of fear, no being to be appeased or propitiated. There are even Bhaktas who worship God as their own child, so that there may remain no feeling even of awe or reverance. There can be no fear in true love, and so long as there is the least fear, Bhakti cannot even begin. In Bhakti there is also no place for begging or bargaining with God. The idea of asking God for anything is sacrilege to a Bhakta. He will not pray for health or wealth or even to go to heaven.
Advantages of Devotion
The peace of the Bhakta's calm resignation is a peace that passeth all understanding, and is of incomparable value. The great quality of Bhakti is that it cleanses the mind, and the firmly established Bhakti for the Supreme Lord is alone sufficient to purify the mind.
Of all renunciation, the most natural, so to say, is that of the Bhakti-Yoga. Here, there is no violence, nothing to give up, and nothing to tear off, as it were, from ourselves, nothing from which we have violently to separate ourselves; the Bhakta's renunciation is easy, smooth, flowing, and as natural as the things around us.
"Bhakti is greater than Karma, greater than Yoga, because these are intended for an object in view, while Bhakti is its own fruition, its own means and its own end." The one great advantage of Bhakti is that it is the easiest, and the most natural way to reach the great divine end in view; The path of devotion is natural and pleasant. Philosophy is taking the mountain stream back to its source by force. It is a quicker method but very hard. Philosophy says, "Check everything." Devotion says, "Give up all to the stream, have eternal self-surrender." It is a longer way, but easier and happier.
Bhakti-Yoga does not say "give up"; it only says "Love; love the Highest"; and everything low naturally falls off from him, the object of whose love is this Highest.
With love there is no painful reaction; love only brings a reaction of bliss; if it does not, it is not love; it is mistaking something else for love. When you have succeeded in loving your husband, your wife, your children, the whole world, the universe, in such a manner that there is no reaction of pain or jealousy, no selfish feeling, then you are in a fit state to be unattached.
Disadvantages of Devotion
Its great disadvantage is that in its lower forms it oftentimes degenerates into hideous fanaticism. The fanatical crew in Hinduism, or Mohammedanism, or Christanity, have always been almost exclusively recruited from these worshippers on the lower planes of Bhakti.
That singleness of attachment to a loved object, without which no genuine love can grow, is very often also the cause of the denunciation of everything else. All the weak and undeveloped minds in every religion or country have only one way of loving their own ideal, i.e. by hating every other ideal. Herein is the explanation of why the same man who is so lovingly attached to his own ideal of God, so devoted to his own ideal of religion, becomes a howling fanatic as soon as he sees or hears anything of any other ideal.
Ways of Attaining Devotion
There is Bhakti within you, only a veil of lust-and-wealth covers it, and as soon as that is removed Bhakti will manifest by itself. In Bhakti-Yoga the first essential is to want God honestly and intensely. One way for attaining Bhakti is by repeating the name of God a number of times. Mantras have effect---the mere repetition of words...To obtain Bhakti, seek the company of holy men who have Bhakti, and read books like Gita and the Imitation of Christ; always think of the attributes of God.
But theorizing about God will not do; we must love and work. Give up the world and all worldly things, especially while the "plant" is tender. Day and night think of nothing else as far as possible. The daily necessary thoughts can all be thought through God. Eat to Him, drink to Him, sleep to Him, and see Him in all. Talk of God to others; this is most beneficial.
Get the mercy of God and of His greatest children; these are the two chief ways to God. The company of these children of Light is very hard to get; five minutes in their company will change a whole life, and if you really want it enough, one will come to you. The presence of those who love God makes a place holy, "such is the glory of the children of the Lord". They are He; and when they speak, their words are Scriptures. The place where they have been becomes filled with their vibrations, and those going there feel them and have a tendency to become holy also.
Stages of Devotion
We all have to begin as dualists in the religion of love. God is to us a separate Being, and we feel ourselves to be separate beings also. Love then comes in the middle, and man begins to approach God, and God also comes nearer and nearer to man. Man takes up all the various relationships of life, as father, as mother, as son, as friend, as master, as lover, and projects them on his ideal of love, on his God. To him God exists as all these, and the last point of his progress is reached when he feels that he has become absolutely merged in the object of his worship.
We all begin with love for ourselves and the unfair claims of the little self make even love selfish; at last, however, comes the full blaze of light, in which this little self is seen to have become one with the Infinite. Man himself is transfigured in the presence of this Light of Love, and he realizes at last the beautiful and inspiring truth that Love, the Lover, and the Beloved are one.
When the devotee has reached this point he is no more impelled to ask whether God can be demonstrated or not, whether He is omnipresent and omniscient, or not. To him He is only the God of Love; He is the highest ideal of love, and that is sufficient for all his purposes; He, as love, is self-evident; it requires no proof to demonstrate the existence of the beloved to the lover. The magistrate-Gods of other forms of religion may require a good deal of proof to prove them, but the Bhakta does not and cannot think of such Gods at all. To him God exists entirely as love. The perfected Bhakta no more goes to see God in temples and churches; he knows no place where he will not find Him. He finds Him in the temple as well as out of the temple; he finds Him in the saint's saintliness as well as in the wicked man's wickedness, because he has Him already seated in glory in his own heart, as the one Almighty, inextinguishable Light of Love, which is ever shining and eternally present.
The Bhakta at last comes to this that love itself is God and nothing else. Where should man go to prove the existence of God? Love was the most visible of all visible things. It was the force that was moving the sun, the moon and the stars, manifesting itself in men, women and in animals, everywhere and in everything. It was expressed in material forces as gravitation and so on. It was everywhere, in every atom, manifesting everywhere. It was that Infinite Love, the only motive power of this universe, visible everywhere, and this was God Himself.
"I may know that I am He, yet will I take myself away from Him and become different, so that I may enjoy the Beloved." That is what the Bhakta says.
Feelings of Devotee
If a man does not get food one day, he is troubled; if his son dies how agonising it is to him! The true Bhakta feels the same pangs in his heart when he yearns for God. The great quality of Bhakti is that it cleanses the mind, and the firmly established Bhakti for the Supreme Lord is alone sufficient to purify the mind. "Lord, they build high temples in your name; they make gifts in your name; I am poor; I have nothing; so I take this body of mine and place it at your feet. Do not give me up, O Lord." Such is the prayer proceeding out of the depths of the Bhakta's heart. To him who has experienced it, this eternal sacrifice of the self unto the Beloved Lord is higher by far than all wealth and power, than even all soaring thoughts of renown and enjoyment.
The peace of the Bhakta's calm resignation is a peace that passeth all understanding, and is of incomparable value. When the devotee has reached this point he is no more impelled to ask whether God can be demonstrated or not, whether He is omnipresent and omniscient, or not. To him He is only the God of Love; He is the highest ideal of love, and that is sufficient for all his purposes; He, as love, is self-evident; it requires no proof to demonstrate the existence of the beloved to the lover. The magistrate-Gods of other forms of religion may require a good deal of proof to prove them, but the Bhakta does not and cannot think of such Gods at all. To him God exists entirely as love. I know one whom the world used to call mad, and this was his answer: "My friends, the whole world is a lunatic asylum; some are mad after worldly love, some after name, some after fame, some after money, some after salvation and going to heaven. In this big lunatic asylum I am also mad, I am mad after God. You are mad; so am I. I think my madness is after all the best."
The true Bhakta's love is this burning madness, before which everything else vanishes for him. The whole universe is to him full of love and love alone; that is how it seems to the lover. So when a man has this love in him, he becomes eternally blessed, eternally happy; the blessed madness of divine love alone can cure for ever the disease of the world that is in us.
May we see the reflection of revered Swamiji in every Indian.
Prof Gourishankar patnaik is a consultant Orthopedic and spinal surgeon and social scientist based in Bhubaneswar. He can be contacted at drgsp66@yahoo.com and www.drgspatnaik.com
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