Overuse Injuries in Orthopaedics practice

INTRODUCTION

Overuse injuries are injuries of the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression (pressing against hard surfaces), or sustained or awkward positions. It is also known as Repetitive Strain Injury or Cumulative Trauma Disorders. These are most commonly used to refer to patients in whom there is no discrete, objective, pathophysiology that corresponds with the pain complaints. Stress fracture is also a common overuse injury, which scientist already described it since 1855. Overuse injuries due to repetitive motion are common in occupational, recreational, habitual activities and elite athletes. [1] The examples of overuse injuries are Golfer's elbow, Tennis elbow, Baseball pitchers’ elbow, Javelin throwers’ elbow. These conditions have acquired names derived from activities in which they were encountered when they were first described.

PATHOPHYSIOLOGY
Normally, our tissues adapt to the stresses placed on them over time. Different types of stresses include shear, tension, compression, impingement, vibration, and contraction. Tendons, ligaments, neural tissue, and other soft tissues can undergo mechanical fatigue, resulting in characteristic changes depending on their individual properties. As a respond, the tissues attempt to adapt to the demands placed on them. In the process of adapting, they can incur injury unless they have appropriate time to heal. The rate of injury simply exceeds the rate of adaptation and healing in the tissue.
In stress fractures, it is resulted from recurrent and repetitive loading of bone. It differs from other types of fractures in that; most of them have no acute traumatic event preceding the symptoms. Usually, the patient has a history of an increase and/or change in the character of activity or athletic workouts, increase in frequency of doing activity, or change in posture during activity. Bones may be more prone to stress fractures if the bone is weakened, as in individuals with osteoporosis.
There are a lot of hypothesis as why does the injury happens in repetitive tasks. One of them is the depletion of adenosine 5’-triphosphate (ATP) in the muscle fibers, which leads to reduction of sarcoplasmic reuptake of Ca2+ resulting in high concentrations in the cytosol, allowing Ca2+ –dependent activation of phospholipase, the generation of free radicals, and damage to the muscle fibers involved. [1]
Other hypothesis involving Prostaglandin E2, which has been found to be present in high quantities in overuse tissues in rat and chicken models. [2] This mediator has been suggested to influence cell proliferation, increase collagenase, and decrease collagen synthesis. As the result of increasing loads on these tissues, nitric acid and prostaglandin amount are altered. However, a contradicting hypothesis based on rat-model observations shows that overuse of muscle may lead to an understimulation of tendon cells, rather than overstimulation.
In another study, alterations in regulation of genes within tendons undergoing overuse have been shown in the rat model, in which there is upregulation of genes associated with cartilage, and down-regulation of genes associated with tendon.[3] This might suggests that overuse may cause a morphologic alteration of tendon tissue, resulting in the cartilaginous changes in the tendons
From another point of view, psychosocial factors might play a role in overuse injuries for decades. This includes work satisfaction, perceived physical health, perceived mental health, coping mechanisms of the patient and his/her family, perception of work-readiness, and anxiety.
RISK FACTORS:
Risk factors for overuse injury are not only depends on the biomechanical changes of the action, but also intrinsic factor of the patient. Sex differences play a role in certain overuse injuries. For example, the incidence of carpal tunnel syndrome is higher among female compared to male. This has a variety of possible causes, including anatomical differences in the carpal tunnel, hormonal differences, differences in the activities performed by men and woman, biomechanical differences such as elbow carrying angles, Q-angles, femoral anteversion, and lean body mass. Stress fractures typically affect individuals who are more active, and the incidence probably increases with age due to age-related reduction in bone mineral density (BMD).
Although stress fractures result from repeated loading, some other causes such as menstrual disturbances and irregularities, lower dietary calcium intake, caloric restriction, less oral contraceptive use, muscle weakness, decreased testosterone level in male endurance athletes and leg-length differences are risk factors for stress fractures.[4] A study among military recruits has shown that recruits with stress fractures had significantly narrower tibiae and increased external rotation of the hip.
HISTORY:
It is important to obtaining complete information on the onset, timing, and frequency of symptoms; any associated symptoms; and alleviating and exacerbating factors. Information about specific activity or technique problem is also essential. Other relevant symptoms may include a history of popping, clicking, rubbing, erythema, or vascular phenomena. In athlete, specific attention must be paid to training details, equipment fit, and technique. The most salient historical feature in the diagnosis of stress fracture is the insidious onset of activity-related pain. In early stage, the pain is usually mild and felt toward the end of the inciting activity. As the disease progresses, the pain may worsen and occur earlier, limiting participation in sports activities. Rest may relief the pain in the early stages, but as the injury progresses, the pain may persist even after cessation of activity. Other than that, night pain is a frequent complaint. Usually, the patient has no recent history of trauma to the affected area.
Long-bone fractures usually lead to localized pain, while pain from injury of trabecular bone is more diffuse. Possible risk factors that precipitated or contributed to the injury should be identify. These include details of the athlete's training history both in terms of volume and intensity, intensive sustained muscular activity, muscle fatigue, structural malalignments, biomechanical inefficiencies, concurrent injury, or poor bone health status. Diagnosis is usually based on clinical findings and high index of suspicion because fracture site or new bone formation is visible on radiography maybe only after several weeks.
PHYSICAL EXAMINATION
The examination in case of overuse injury follows the basic method of orthopaedic examination; consist of inspection (including alignment and anatomical structure), palpation, and passive (including athlete's flexibility) and active range of motion (ROM). Usually, tenderness and guarding are present. During ROM examination, crepitus; painful or painless usually can be appreciated. On local examination, erythema, swelling, and anatomic derangement raise the possibility of an acute injury or infection, as well as the presence of an inflammatory disease. Some special test or maneuvers can be applied to help in making diagnosis, such as “Hop test” and “Fulcrum test”, or Tinel and Phalen tests at the wrist.[5] But, no single physical examination test is sufficiently sensitive and specific to permit the unequivocal diagnosis of a stress fracture. So, the doctor should correlate the history with examination, together with high clinical suspicion to consider the overuse injury as one of the possible diagnosis.

CAUSES

The primary factor leading to overuse injury is repetitive activity, although the specific type of force leads to different outcomes. Repetition is part of the definition of overuse injury. The concept is that overuse injury is associated with repeated challenge without sufficient recovery time. Another terms to describe repeated activities are cycles and fundamental cycles. While cycle is a large-scale activity that is repeated throughout the day, fundamental cycle is a small component of a cycle that may be repeated several times during the performance of a cycle. Repetitiveness and force exerted are features of a task that increase the risk of sustaining an overuse injury.

However, some studies have shown that cycle times and repetitive motions do not specifically lead to overuse injury in the upper extremity, but as possible causes for injury.[1] It is shown that vibration; especially over long periods is a factor in increasing the risk of many injuries such as lower back pain, intervertebral disk injury, and wrist injury. Apart from the above, malpositioning of limbs away from their neutral position increases the risk for overuse injury.


DIFFERENTIAL DIAGNOSIS
Differential diagnoses vary and depend on location, symptoms, history and physical examination.
o Shin splints (medial tibial stress syndrome) can mimic stress fractures ot the tibia. Shin splint pain tends to be present at the start of activity, while overuse injury at the end. Tenderness to palpation over a wide region of the tibia and the tibialis muscle, whereas the pain from stress fractures tends to be localized to a specific area on the tibia.
o True fractures can be differentiated from overuse injury by an obvious history, with a traumatic event being recalled by the patient with acute onset of pain.
• Muscle strains; may be acute or chronic. Chronic muscle strains can be differentiated from overuse injury by the location and by factors that exacerbate or worsen the injury.
• Costochondritis may mimic the pain seen in stress fractures of the ribs. Rib stress fractures should be suspected in athletes who participate in rowing sports, such as crew rowing. The pain of costochondritis may be more diffuse or widespread than the pain from stress fractures of the ribs. .[4]
• Nerve entrapment syndromes can also mimic overuse injury, but can be differentiated by presence of numbness in the former.[4]
• Popliteal artery entrapment syndrome is another cause of lower extremity pain. This also present with increased pain and/or swelling with exercise, which is more diffuse than the pain associated with stress fractures. Measurement of ankle blood pressures before and during exercise or an angiogram may help with the diagnosis.
DIAGNOSIS AND INVESTIGATIONS

Radiography
Stress fractures may not show up on radiographs for the first 2-4 weeks after injury. The first radiographic finding may be a localized periosteal reaction or an endosteal cortical thickening. The low sensitivity of radiographs for stress fractures gives advantage to bone scanning, magnetic resonance imaging (MRI), and computed tomography (CT).
Magnetic resonance imaging (MRI)
MRI not only provides information about bone integrity and fracture orientation, but also can demonstrate focal tissue damage and edema.
Technetium-99m bone scanning
It took 72 hours for Technetium bone scan findings to be positive in the case of a stress fracture. However, a positive bone scan finding is nonspecific, and it may be indicative of another diagnosis, such as an infection or a neoplastic process. In a study which compare conventional radiography and bone scanning for the initial detection of stress fractures, positive findings were reported in 96% of bone scans, whereas only 42% positive findings were reported on radiographs.
Electrodiagnostic testing
Electrodiagnostic testing (such as EMG, nerve conduction studies) can be very useful in cases of peripheral nerve compression or injury; such testing can provide evidence of the location and severity of the injury. However, EMG and nerve conduction studies are not tests with high specificity, although they can provide much-needed information when vague symptoms are the chief complaint. They are also very useful for documenting work-related injuries.
Laboratory Tests
These tests are relevant if the individual is discovered to have metabolic bone disease or another comorbidity such as inadequate nutritional status.

TREATMENT
Physical Therapy
Patient should have rest, particularly avoidance of the inciting activity. Total bed rest is virtually never advisable for these patients. Instead, participation in a carefully planned physical therapy program is important. The physical therapy program also offers the patient the chance to see that movement will not lead to ongoing tissue damage, thus preventing significant "sick behaviors" or kinesophobia. Ill-fitting equipment, overtraining, or technique flaws commonly cause overuse injury in athletes. So, specialized fitted equipments hould be provided, while sports psychology is worthwhile in combating overtraining, and sport-specific coaching is often invaluable. Coaches, athletes, and physicians must work together to correct these problems.
Occupational Therapy
Occupational therapists can help to identify workplace modifications. In cases of individuals who develop overuse injuries as a result of the interface with adaptive equipment, occupational therapy may be of great benefit. Simple modifications in the manner in which the patient performs activities of daily living or modifications in the equipment itself can provide relief.


Surgical Intervention
Surgical intervention is required only if conservative approaches fail, or if the injury is amenable to surgery. Most common problems that lead to surgery in overuse injury are decompression of nerves and repair of lax or failed ligaments. Surgical procedures most typically involve open-reduction internal fixation and pinning of the associated fracture sites. Surgeries that are performed solely to relieve pain in the absence of objective findings are notorious for suboptimal outcomes.
Medication
Combined injection of corticosteroids and local anesthetics is quite helpful in persons with overuse injury.[1] Pain relief enables more effective participation in therapy, and it may help to limit the likelihood that the patient will develop a chronic pain syndrome. Usually, injections should be performed after less invasive measures fail. In some rare condition, immediate relief of pain may be necessary to allow participation in an athletic or performing arts event, and this can be achieved through injection therapy.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are mainstays in the treatment of overuse injuries. However, there are evidences that revealed that true inflammation is rarely a component of these disorders, especially tendinopathies. So, the use of simple analgesics has become more prevalent in the treatment of such disorders. Muscle relaxants, opiates, corticosteroids, tricyclic antidepressants, and sleep medications have a role in the specific treatment of individuals with overuse injury.

PREVENTION
Nutritional measures: calcium supplementation
A study by Schwellnus and Jordaan found that there is no benefit with calcium supplementation (500 mg/d) beyond the usual dietary intake in male military recruits.[6]
Biomechanical measures: orthotics and shoe inserts
The use of orthotic devices and shoe inserts has been studied as a preventive measure for lower-extremity stress fractures. It is found that the incidence of lower-extremity stress fractures was lower in the group using semirigid orthoses (15.7%) or soft biomechanical orthoses (10.7%) than in the control group (27%). Additionally, the recruits better tolerated the soft biomechanical orthoses than the semirigid orthoses.[7]
In a prospective study of stress fractures, shock-absorbing orthotic device worn within military boots decreases the incidence of stress fractures. [8] There is a statistically significant decrease in the incidence of femoral stress fractures in the orthotic device group.
COMPLICATION
High-risk stress fractures
Even though nonunion of stress fractures is uncommon, but it can occur. To prevent this, stress injuries should be closely followed up for early surgical intervention. These include stress fractures of the neck of the femur, the anterior cortex of the tibia, the tarsal navicular, and the bases of the second and fifth metatarsals. Other high-risk stress fractures include stress fractures of the patella and medial malleolus.
Low-risk stress fractures
Low-risk stress fractures include most upper-extremity stress fractures, except for the fractures through the physis of the humeral head (little leaguer's shoulder) and fractures through the medial epicondyle (little leaguer's elbow), which may have complications due to the involvement of the growth plate.[9] Other low-risk stress fractures include stress fractures of the ribs, pelvis, femoral shaft, fibula, calcaneus, and the metatarsal shafts.














REFERENCES:
1. eMedicine. Scott R Laker, MD. Overuse Injury, Mar 12, 2008.

2. Flick J, Devkota A, Tsuzaki M, et al. Cyclic loading alters biomechanical properties and secretion of PGE2 and NO from tendon explants. Clin Biomech (Bristol, Avon). Jan 2006; 21(1): 99-106.

3. Archambault JM, Jelinsky SA, Lake SP, et al. Rat supraspinatus tendon expresses cartilage markers with overuse. J Orthop Res. May 2007; 25(5): 617-24.

4. eMedicine. John M Martinez, MD. Stress Fractures, Apr 17, 2008.

5. eMedicine. Vincent N Disabella, DO, FAOASM. Elbow and Forearm Overuse Injury, Feb 12, 2008.

6. Schwellnus MP, Jordaan G. Does calcium supplementation prevents bone stress injuries? A clinical trial. Int J Sport Nutr. Jun 1992; 2(2): 165-74.

7. Finestone A, Giladi M, Elad H. Prevention of stress fractures using custom biomechanical shoe orthoses. Clin Orthop. Mar 1999;360: 182-90

8. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles – A prospective study. Am J Sports Med. December 1990; 18:636-641.

9. Boden BP, Osbahr DC, Jimenez C. Low-risk stress fractures. Am J Sports Med. Jan-Feb 2001; 29(1): 100-11.


N.B. This article is excerpted from the Book : OVERUSE INJURIES IN ORTHOPEDIC PRACTICE: Diagnostic Enigma and Mananagement Principles

Editorial Reviews
Product Description
Overuse injuries are injuries of the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions,vibrations,mechanical compression,or sustained or awkward positions.It is also known as Repetitive Strain Injury or Cumulative Trauma Disorders. These are most commonly used to refer to patients in whom there is no discrete,objective,pathophysiology that corresponds with the pain complaints.Physical activity is a great way for kids to build bone strength, prevent obesity and stay healthy,when paired with safety and prevention practices. With youth sports injuries rising at alarming rates,overuse injuries such as sore bones and muscles, and swollen or injured joints need prompt attention in child athletes to prevent chronic musculoskeletal problems later in life. Understanding overuse injuries can guide you to designing your training to reduce the risk of injury and help you to recognize and treat them as they inevitably occur.Overuse injuries can be defined as the product of "too much,too fast,too soon." The topics discussed in these chapters are conditions commonly seen by the author in his long stint as an orthopedic and sports medicine consultant.
About the Author
Prof Gourishankar Patnaik is internationally renowned orthopedic and Spinal surgeon. A topper throughout he has over two decades of teaching and research experience at various medical colleges in India, Oman, USA and Malaysia. A globe trotter he has authored many books. A gifted Surgeon his research interests include diabetes, Neurotrauma and E-learning.

CHEMOPREVENTIVE EFFECT OF
CURCUMIN IN COLORECTAL CANCER

INTRODUCTION
Colorectal cancer is main cause of cancer deaths in western countries. It accounts about to 15% of all cancers. Aetiology of colon cancer is multi-factorial and complex but diet is one of the important factors to cause and prevent cancers, like high animal fat consumption is associated with an increase in rate of colon cancer and frequent consumption of vegetables and fruits, due to presence of bioactive food components, decreases the risk of human cancers. This observation has led to research focused upon chemopreventive agents, especially those obtained from the diet. Recently researches have been focused on identifying, dietary phytochemicals that have the ability to inhibit the formation of cancer. Researches have shown that extracts of plants or their ingredients possess inhibitory effects against chemically induced carcinogenesis. Although, nutritional intervention may not be sufficient to protect/or reduce risk of colon cancer in high risk individuals. A complementary approach for secondary prevention would be to recognise and distinguish between chemopreventive agents. The effectiveness of these various chemopreventive agents, together with nutritional interventions in high-risk individuals should then be assessed. Medicinal plants or their crude extracts have been traditionally used in the prevention and/or treatment of several chronic diseases by various different ethnic cultures world wide. In India the incidence rate of large and small bowel cancers are low, but rectal cancer is more common in India as compared to colon cancer. This low incidence of colon cancer in Indians can be due to high intake of starch and the presence of natural antioxidants such as curcumin, found in spice turmeric which is exclusively used in Indian cooking.

Diferuloylmethane, a yellow pigment more commonly known as curcumin, is one of the active phytochemical found in plants of species of Zingiberaceae. Plants like ginger, saffron and turmeric are some of the plants that have plenty of curcumin. In the Indian subcontinent and Southeast Asia, turmeric has traditionally been used as a treatment for inflammation, skin wounds, and tumours. Turmeric is a significant ingredient in most commercial curry powders. It is also used to give a yellow colour to some prepared mustards, canned chicken broth, and other foods, and is also used as a fabric dye.

HISTORY OF CURCUMIN
Turmeric is known as the poor man's saffron, it is an ancient spice whose use dates back to the time of the Egyptian pharaohs. Highly prized by both Muslims and Indo-Europeans for its medicinal uses, it is just coming into its own as a powerful natural medicine in the West where research is beginning to confirm the potent roles it plays as an anti-inflammatory, anticancer, anti-mutagenic and antioxidant remedy. A traditional remedy in Ayurvedic medicine, an ancient Indian healing system that dates back over 5,000 years, it has been used through the ages as an "herbal aspirin" and "herbal cortisone" to relieve discomfort and inflammation associated with an extraordinary spectrum of infectious and autoimmune diseases. Indian Materia Medica, a standard Ayurvedic reference, cites dozens of conditions in which turmeric can be helpful as an adjunctive therapy including tissue injury or irritation, microbial infections, fevers, allergies, sinusitis, gastritis, colitis, hepatitis, kidney disease arthritis dermatitis, phlebitis, tuberculosis and autoimmune disorders. It is also cited as a remedy for liver disorders accompanied by jaundice. Topically, it can be used as a poultice to reduce inflammation and swelling due to sprains, cuts, bruises and superficial infections, including those of the eye -- which are treated with an eyewash containing turmeric that cools and soothes burning eyes. Another traditional use is to relieve congestion -- inhaling the fumes of burning turmeric directly into the nostrils is said to cause copious mucous discharge. Turmeric also is given to relieve diarrhoea and fevers, as well as vertigo, when applied directly to the scalp. Used for skin infections, colic, menstrual problems and congestion in China and Cambodia, the tuber also is used as a tonic, stimulant and diuretic in Madagascar. In Chinese traditional medicine it is known as "Jiang Huang," and used to eliminate flatulence; resolve liver and urinary problems, menstrual disorders, haemorrhage, and fever and chest pain; and prepared as a poultice for sores, wounds, bruises and infections. “There is also a vegetable which has all the properties of the true saffron, as well as the colour, and yet it is not really saffron” - Marco Polo, Thirteenth Century.

TIMELINE
Although the chemical structure of this remarkable spice, food preservative and dye was identified in 1910 it was only in the 1970s and 1980s that its many, varied health-promoting properties were identified. Recent, research is confirming what traditional healers have known all along, that the fresh juice of the root reduces swelling in bruises, wounds and insect bites and the dried powder kills parasites, relieves head colds and arthritic aches and pains. Research is also beginning to show that turmeric may be a valuable anticancer agent.

The earliest scientific paper on curcumin was published in year 1976 Sharma O P proposed the antioxidant activity of curcumin and related compounds. Gupta B et al, (1980) published Mechanism of Curcumin induced gastric ulcer in rats. Role of curcumin as an anti-inflammatory was demonstrated by Rao T S et al in 1982 and Mukhopadhyay A et al in 1982. In early 1983 a paper by Jiang T L et al, demonstrated effects of curcumae species on human tumour stem cell assay, however curcumae were relatively ineffective on the human tumours tested by him. However two years later in 1985 Kuttan R et al, saw inhibition in ovary cells of Chinese Hamsters by curcumin. A new model for evaluating nonsteroidal anti-inflammatory drugs (NSAIDs) was described by Satoskar R R et al in 1986. In the end of year 1989 researchers from Amala Cancer Research Centre, India demonstrated inhibition of chemical carcinogenesis by curcumin. There was no looking back after this year, a decade of research work on curcumin and turmeric suggested it as a potent anti-cancer and chemo preventive phytochemical. Recent studies are also suggesting curcumin as potent herbal remedy to fight against breast, colon, hepatic, skin and other cancers of gastric tract. Newer studies have suggested that curcumin inhibits HIV replication by blocking the long-terminal repeat region on HIV's genes.

CONCLUSION
Mechanism of curcumin is poorly known and many varied theories have been suggested about its action. But from these studies we can infer that curcumin inhibits carcinogenesis in large bowels.

Dr Varsha B Patel
www.homeotouch.com

1. Folic acid should be taken at least 6 months before planning a pregnancy.
2. Take high fiber diet, will keep cholesterol levels and blood pressure in check.
3. To have healthy glowing skin drink at least 8-10 glasses of water and eat lots of fruits and vegetable.
4. Adequate protein intake and diet rich in minerals and vitamins is necessary for healthy, shiny, bouncy hair.
5. Avoid canned and processed food, they contain lots of preservatives that are harmful.
6. Kicking meat from diet helps cut the risk of heart disease, diabetes, obesity and cancer.
7. Instead of eating 3 meals a day, eat 4-5 small meals to regularize blood sugar levels.
8. Substitute soya for other high protein drinks, it contains phytoestrogens that help prevent breast and ovarian cancers.
9. Bananas are good for hypertensives, they are high in potassium and low in sodium also are rich in fibre and thus restores normal bowel movement.
10. Avoid too much fibre as that can cause bloating and flatulence, consume lots of water along with a high fibre diet as it helps in forming a bulk.
11. People often over-eat to overcome feelings of boredom, depression, anxiety. Exercise releases endorphins or feel-good hormones, thus helps to distress.
12. Aqua aerobics, swimming improves muscle tone and strengthens injured joints and muscles.
13. Breathe consciously to improve mental health. If you are confused, anxious take a few deep breaths and confidence will be regained.
14. Never starve your self in order to lose weight. In starvation body stores more fat. Instead eat healthy and in moderation.
15. Practice meditation regularly, helps relieve stress, rejuvenates you and helps to improve your focus.
16. 2 hours of regular out door sports is essential to promote mental and physical growth in children.
17. Do not wash your hair more then twice a week. It weakens the roots of the hair.
18. Sleep early and wake up early keeps you energetic and elevates your mood.
19. Fasting once a week gives rest to gastrointestinal tract and thus improves the digestive system.
20. Avoid kneeling and climbing stairs if you are suffering from arthritis of knee joint.

Dr Varsha B Patel
www.homeotouch.com

While colorectal cancer remains one of the most deadly cancers, researchers are making steady progress against this disease. For people living with advanced colorectal cancer and their loved ones, small improvements make a huge difference. We are seeing many patients with metastatic cancer responding well to treatment and living for a longer time. For decades, medications to colorectal cancer were limited to two drugs: 5-Flurouracil and Leucovorin. But in 2004, doctors began to use targeted therapies also. Avastin and Erbitux are mono-clonal antibodies, new generation cancer drugs that can specifically target cancer tumors. The problem with traditional chemotherapy is that it can't be focused--the drug affects both cancer cells and healthy cells alike. Targeted therapies affect the specific mechanisms that allow cancer cells to grow. As a result, they have fewer side effects. Avastin blocks the effect of a substance in the blood that helps tumors to grow new blood vessels. This substance is called Vascular Endothelial Growth Factor (VEGF). By preventing the creation of new blood vessels, the tumor is starved; thus slowing down the tumor growth. Erbitux blocks the effects of a different growth factor called Epidermal Growth Factor (EGF). But these drugs are only used for metastatic colorectal cancers in combination with 5-Flourouracil, Leucovorin and Camptosar. Another turning point in treating colorectal cancer is Adjuvant and Neoadjuvant therapy. Adjuvant therapy is where chemotherapy and radiation are used after surgery. Neoadjuvant therapy is an approach where the treatment is given before surgery to make the tumor smaller and easier to remove. This is more convenient and it gives better results. It is a trend that is gaining momentum around the world. With more drugs to use for colorectal cancers, doctors are now trying them in new combinations and sequences. While new drugs get most attention, surgery remains the standard treatment for people in the early stage of this cancer. People can have inflated ideas about keyhole surgeries, but it is found that for rectal cancer, laproscopic surgery has not shown to be as effective as open surgery. Although these treatment advances are a cause for enthusiasm, we need to keep it in perspective. There are two ways to look at it. You could say that it's great that over the last decade, we have doubled the life expectancy of a person with metastatic colon cancer. On the other hand, you could say that over the last ten years, all we managed to add was about twelve months. Both statements are true. Although the steps might be frustratingly small, we are still moving forward. They may not be flashy, but hopefully with time and research, all of these smaller steps may add up to something big.

Being overweight is like three or more people riding a scooter or a two wheeler or three or four extra people are stuffed in a car. Both are going to break down either suddenly or gradually, that's sure. As both are carrying extra weight beyond their strength. Our knees are designed as per our height, to carry certain amount of weight. Weight is generally increased due to overeating & sitting idle or lack of activity. These days it's seen that people are working on computers for hours or watching television & having their food, is also one reason behind overeating. But lack of exercise, I feel is more responsible for being overweight. As exercise or physical activity is the process we burn the calories we acquired from food. But first of all you have to judge yourself & decide that you are going to fight for it. How to do it is not difficult.
There is one very simple method to understand whether one is obese or not. Just recollect out of memory the size of your waist line at the age of 18 or 20. If you don't, take help of your family members. If today, it's increased by around 15% than you can relax. Otherwise you should decide that you have to reduce that flab as soon as possible.
There is no need to press panic button. Here are some realistic tips to loose weight for all those interested in living happy & healthy life-long.
How to control excessive eating?
You have to carefully watch your dietary habits & eating pattern first. As crash dieting has corrosive effect & the lost weight bounces back more ruthlessly. So you have to carefully select the food items & might need to alter some of your habits related to it. We should always keep in mind that we must not loose essential nutrients while following dietary restrictions. So we will not discuss much about stop this or that thing type of restrictions.
- Be sure you are drinking lots of clean water throughout the day. This keeps the hunger suppressed & gives the feeling of fullness. Don't remain hungry as this will cause excessive eating at home. You can drink water if away from home or eating joint as it suppresses hunger for some time. At the time of meals drink a glass of water few minutes before joining the dining table. Sit comfortably & eat without hurry.
- As per Ayurvedic concepts, it suppresses "Jatharagni" (Digestive fire) & induces indigestion & constipation. It should ideally be consumed 20 - 20 minutes after meals for a good digestion. Not drinking water imparts a great effect on our digestive system as it helps essential nutrients to get digested. It is proven fact that drinking water during meals causes indigestion as it dilutes digestive juices & natural process of digesting the food properly. So, please stop drinking water, liquids & cold drinks with your meals or immediately after meals.
- Eat like a cow. Eating three big meals is not a good idea at least after forty. Eat five or six small meals is better option as it helps to keep regular flow of energy & keeps excessive hungry feeling away. Eating this way helps to maintain blood sugar levels within limits. Eat fresh vegetables & fruits with two main meals, with lunch & dinner to be precise. Dinner should be light as heavy will adversely affect your sleep.
- Have fruits between main meals so that you are filled with fibers. Having fruits 10 - 15 minutes before meals is always beneficial as it delays the absorption time & keeps you full for a longer time. Eating more fruits or vegetables is always beneficial as it reduces caloric intake.
- Control your craving for snacks, deserts & cold drinks just before, in between or after meals. You can have small sample quantities of these if it's irresistible, that too in initial stage. Otherwise better you forget these. These are the most serious threats to your weight reduction plans.
- It is a fact that we have 20% extra food always. The fact behind is that: it takes around 20 minutes for brain to register that food is on the way. In younger days we are not harmed as we are very active physically moreover need extra energy to grow. Gradually reduce 10% of your dietary intake & make it 20% within 2 - 3 months. If done slowly, you can do it definitely.
- Do try to be vegetarian, but slowly. Initially it will look difficult. Gradually start having vegetarian diet at least 3 - 4 times a week. You should limit animal protein consumption to control cholesterol levels to reduce possibility of landing into trap of cardiac disorders also. To keep protein intake high, start having legumes - peas, grams, lentils & other pulses. One more thing very simple is to avoid mixing animal proteins with starches like breads & potatoes. I'm sure you will gradually start relishing vegetarian delicacies.
How to add exercise to your lifestyle?
It is also one very important part of to achieving the goal of getting in shape. It's simpler than controlling the dietary habits. Here is how to do it gradually & without a pinch.
- Start walking while on a shopping spree. Leave your car at home if the market is within one kilometer or even if a mile. While in office you can walk & handover the document or message personally to your colleague, subordinate or boss.
- Use stairs instead of lift or escalator. Slowly you can add some exercise through this method.
- Brisk walking has numerous health benefits. One of them is reduction in weight apart from it being useful for joint health, cardiac health & immunity. Start walking at any point of time during the day as an when you are empty stomach since 3-4 hours. Go on tracking on weekends.
One final word:
Always keep in mind a law of nature "Human body has an incredible healing ability to repair, realign & recover naturally". It only needs a chance with serious attention, which we shall give. Wellbeing is always in our hands.