The burning question in minds of men and women during and immediately after a heart attack is, “Will I be able to go back to work?” “Will I be able to take care of my family?” It is difficult, if not impossible, for your doctor to tell you exactly what you will be able to do when you eventually leave the hospital, but if you understand the problem involved you may be able to help yourself.We must go back to the basic fact that your heart is a pump designed to pump blood. This muscular structure in a young adult has a phenomenal reserve capacity. On demand it may be able to pump seven or eight times as much blood per minute as it does when you are asleep. In other words, during extreme exercise your heart may be able to deliver 30 quarts of blood per minute to your body compared to the four quarts per minute that may be pumped during complete rest. As the years pass, the body ages and we are all aware that we no longer have, for example, the muscular strength that we had when we were twenty years old, nor at age sixty do we have the sense of sight or smell that we had when we were twenty years old.In a similar way the reserve capacity of your heart may be diminished by the process of aging. A person at age fifty may have a reserve capacity of five times, or possibly six times, the resting level of blood flow. We have stated previously that the result of a coronary thrombosis or myocardial infarction is the death of heart muscle. There is less heart muscle to pump the blood after a myocardial infarction than there was before the incident. The reserve capacity of the heart must, therefore, be diminished. This is the determining factor that will decide what you will or will not be able to do after your heart attack. If enough functioning muscle remains, you may be able to do practically the same things that you were able to do before your heart attack. This, of course, is particularly true if you had a large reserve capacity.The primary symptoms that you may recognize if you exceed your reserve capacity will probably be chest pain in the form of angina pectoris, fatigue, or shortness of breath on exertion. It is essential that the person who has recovered from a heart attack understand the factors that increase the demands upon the heart if he is to avoid difficulty and make the most of his physical impairment. The main factors that result in increased heart work are exercise, eating, emotional excitement, and extremes of temperature. Let us examine each of these in detail.When you exercise, as for example, taking a walk or hammering a nail, the muscles of your legs and arms are active and are doing work. This work demands increased food and oxygen to nourish the muscles of your legs and arms. Food and oxygen are carried to the muscles by blood that is pumped by your heart. Exercise, therefore, increases the work of the heart.The process of eating, and in particular digesting food, requires increased blood flow to the stomach and intestines. When food enters your stomach, the muscles of the stomach contract to mix the food with digestive juices and to propel the food to the intestinal tract. The intestinal tract also contracts to mix the food and to propel it further along. Great quantities of stomach acid and various digestive juices are poured into the intestinal tract to aid in digestion of the consumed food. These juices are produced by glands all of which depend upon blood for their raw materials. The production of digestive juices and the action of the intestinal muscles, therefore, require increased blood flow which must be supplied by the heart.A state of excitement or tension, anger, rage, or fear also results in increased heart work because these situations stimulate the adrenal glands, which produce adrenaline. The adrenaline circulates throughout the body and prepares the body for an emergency such as a fight or a flight (running away). The action of adrenaline upon the heart is to increase the rate of heart contraction and the work of the heart. A person who is frightened or angry, therefore, may have a heart that is working just as hard as if the man were actually running at full speed down the street.*12/309/5*


Meditation is frequently suggested as an aid in achieving and maintaining sobriety. Any number of approaches are available to those wishing to try it, and many treatment centers include an introduction to one or more. Although meditation has different goals depending on the type practiced, the process of reaching a meditative state is somewhat similar to relaxation. A fairly relaxed state is necessary before meditation can begin. Some schools of meditation use techniques quite similar to relaxation methods as a lead-in to the meditation period. In yoga, physical exercises are coupled with mental suggestions as a precursor. Studies have shown that altered physiological states accompany meditation or deep relaxation. Altered breathing patterns and different brain-wave patterns are examples. These changes are independent of the type of meditation practiced. The real physical response in part accounts for the feelings of well-being after meditation periods. Those who practice meditation find it, on the whole, a rewarding experience. Many also find in the experience some form of inspiration or spiritual help. Several highly advertised schools of meditation are receiving attention these days. You might investigate those that are available for clients who express an interest in meditation.A word of caution is needed here. Alcoholics tend to go overboard. Meditation should never be a substitute for their other prescribed treatment. Also, there are extremists in every area of life, and meditation is no exception to exploitation. That is why some personal knowledge of what is available, who is using it, and how it affects those who do use it is necessary before advising your alcoholic client to try it. Meditation is only helpful if it alleviates the alcoholic’s anxiety and allows him to continue learning how to function better in the world, not out of it.What is a meditation?Perhaps a meditation is a daydream, a daydream of the soul as the beloved and God, the lover, their meeting in the tryst of prayer, their yearning for one another after parting; a daydream of their being united again.Or perhaps a meditation is the becoming aware of the human soul of its loneliness and the anticipation of its being united with the One who transcends the All and is able to come past one’s own defenses.Or perhaps, again, it is a standing back with the whole of the cosmos before one’s mind’s eye as one’s heart is being filled with the sheer joy of seeing the balances of the All and one’s own self as part of it.Or perhaps a searching into one’s own motives, values, and wishes, with the light of the Torah against the background of the past.*142\331\2*


Tension headaches are caused by a tightening of the muscles at the back of the neck with consequent tension of the scalp. The pain can be felt at the back of the neck, over the top of the head, or over the forehead, and is often described as a ‘vice round the head’. The tension of the muscles is in itself painful, but associated constriction of the arteries to the muscles makes the pain considerably worse. The electromyograph (a machine which picks up electrical activity in muscle) can prove that active muscle contraction occurs during this form of headache.Patient G.H., a 45-year-old housewife, said:For the past nine months, I have suffered from almost continuous headaches. It is as if I have a heavy weight on the top of my head and I notice it as soon as I wake in the morning. It lasts all day but it does not keep me awake at night although it is there when I wake up in the morning. I do not feel sick and have no trouble with my eyes. Sometimes I feel a tight band around my head and usually the back of my neck feels stiff.This is a typical tension or muscle-contraction headache. In the case of G.H., direct questioning revealed that the headaches had started after her husband had told her he was contemplating divorce but had not yet decided to leave the conjugal home. These sorts of headaches could be due to depression, coupled as they were with feelings of lack of wanting to do anything, and early morning waking.Anxiety-depressive headaches are commoner than typical migraine but the two types often occur at different times in the same sufferer.

There is no doubt that smoking injures the health and it would be a wonderful world if nobody smoked: cleaner and safer. All the NHS money that now goes on smoking-related diseases could go into other areas of medicine. Smoking is a pernicious addiction because it both calms and stimulates the nervous system. It is possibly because of this, and also the masked allergy factor, that some people find giving up so difficult. (A hidden or masked allergy can happen with any substance which is taken into the body daily; when the body is denied the substance the symptoms appear. This is explained fully in A Little Bit of What You Fancy by Dr Richard Mackarness, published by Pan.)
Why Some People Fail Repeatedly
Some people give up smoking without any problems at all; they just stop. Others crave cigarettes and feel they don’t know what to do with their hands, but can distract themselves with a cup of coffee, eating sweets or doing something active. These two groups often scorn the person who fails again and again to give up the awful weed, and proclaim loudly that it is just a matter of will-power. Will-power certainly comes into it, and for those who do not suffer physical or psychological symptoms perhaps it is all that is needed to stop; but for the physically addicted/allergic smoker, there is a lot more to it – lack of will-power or weakness cannot be the cause of swollen joints, skin problems, and so on.
Morphine is the drug of choice for the management of severe pain in advanced cancer but opioids are frequently denied to patients who could benefit from them.
The belief that morphine should be only given when patients are dying is archaic. Morphine may be used for months or years and, correctly administered, is compatible with a normal life style. That morphine should be reserved for the ‘crescendo of pain’ which occasionally occurs before death is incorrect because the broad therapeutic range of morphine allows for increasing doses if need be.
Morphine will be ineffective in controlling pain if it is being incorrectly administered, used for morphine-insensitive pain or if matters of psychosocial concern have not been addressed. The correct dose of morphine is that which relieves the patient’s pain whilst causing acceptable side effects and must be individually titrated for each patient. Neuropathic pain is relatively
opioid-insensitive and may respond better to one of the adjuvant analgesics. Physical pain may be caused or aggravated by psychosocial problems and no amount of well prescribed analgesia will relieve this pain until the psychological and social concerns are addressed.
Side effects should not be severe. In patients with cancer, respiratory depression is very uncommon except in opioid naive patients who are commenced on parenteral therapy. Constipation occurs inevitably and requires explanation and advice about diet and laxative therapy. Patients should be warned of the possibility of somnolence and nausea and reassured that these usually improve after several days.
The most frequent reasons why morphine is withheld relate to misunderstandings about tolerance, physical dependence and psychological dependence. In contrast to intravenous drug users who develop rapid tolerance, patients with cancer rarely develop clinically significant tolerance and frequently require little increase in the dose over weeks or months. Physical dependence requires explanation and patients must be reassured that morphine can be weaned (by 25% a day) if their pain is relieved by other means. Psychological dependence occurs extremely rarely in patients with cancer and pain. Concerns about tolerance, physical dependence or psychological dependence are never a reason to delay treatment with morphine if it is indicated.
“Peter has been a terror for years now. We’ve had him to several psychologists, and we’re on our third psychiatrist. Now he’s in a residential school for further evaluation. Something has to be done to control these outbursts before he kills someone. They did an EEG, and now they say that this is epilepsy because the EEG is abnormal. I’ve read about epilepsy, and Peter has never had a seizure. It’s just that when someone frustrates him, or does something he doesn’t like, he erupts like a volcano. There’s no controlling him. He hits and bites and punches. I’m afraid he’ll hurt somebody. Gradually he’ll calm down and act as if he’s sorry. Could this be epilepsy? I almost hope so, since then we’ll have medicine to treat him.”
Sudden outbursts of bizarre, often violent behavior are not uncommon among emotionally disturbed children and also among those who are mildly or moderately retarded. Psychiatrists often ask their neurological colleagues if such episodes can be seizures. The answer is virtually always no! Studies have shown that apparently intentional violence almost never occurs during a seizure. If, during the confusion that commonly occurs during the “post-ictal” state, that is, after the seizure, a child is restrained or threatened, a child may react in a combative but random fashion. In this post-ictal, confused state, the child does not mean to fight back or even understand what he is doing.
Episodic behavioral outbursts are almost always precipitated by an event or by frustration. Seizures never are. Seizures usually have a postictal state in which the child is tired or confused. Behavioral outbursts never do. However, the EEG obtained between seizures or behavioral episodes may be either normal or abnormal and, therefore, does not help differentiate seizures from behavioral outbursts. Spikes on an EEG (see Chapter 7) can be observed in children who never have seizures.
Repeated episodic behavioral changes, in the absence of obvious seizures, are virtually never seizures and, therefore, do not respond to anticonvulsants.
Rare patients have confused even the best neurologists. In these cases, trying to capture the episode on video-EEG monitoring may be the only method of ascertaining what is a seizure and what is not. Needless to say, the same individual may experience behavioral problems and seizures also.
Muscular strength refers to the amount of force a muscle is capable of exerting. The most common way to assess strength in a resistance exercise program is to measure the maximum amount of weight you can lift one time. This value is known as the one repetition maximum and is abbreviated 1RM. Muscular endurance is defined as a muscle’s ability to exert force repeatedly without fatiguing. The more repetitions of a certain resistance exercise you can perform successfully (e.g., a bench press of one half your body weight), the greater your muscular endurance.
There are three key principles to understand if you intend to maximize muscular strength and endurance benefits from your resistance exercise program. Unless you follow these principles, you are likely to be disappointed in the results of your program.
The Tension Principle
The key to developing strength is to create tension within a muscle. The more tension you can create in a muscle, the greater your strength gain will be. The most common recreational way to create tension in a muscle is by lifting weights. While weight lifting is one method of producing tension in a muscle, any activity that creates muscle tension – for example, riding a bike up a hill – will result in greater strength. It really does not matter what type of equipment you choose to develop tension in your muscles; what matters is that you use the equipment in a way that produces the desired strength and endurance.
The Overload Principle
The overload principle is the most important of the three key principles for improving muscular strength. Everyone begins a resistance training program with an initial level of strength. To increase that level of strength, you must regularly create a degree of tension in your muscles that is greater than they are accustomed to. This overloading of your muscles will cause your muscles to adapt to the new level of overload. As your muscles respond to a regular program of overloading by getting larger (hypertrophy), they become capable of generating more tension.
Some women avoid resistance exercise because they fear that they’ll develop large “bulky” muscles, while others are frustrated because their weight-lifting efforts in the gym don’t produce the results they see in their male friends. The main reason for this difference is the hormone testosterone. Before puberty, testosterone levels in blood are similar for both boys and girls. During adolescence, testosterone in men increases about tenfold to its adult level; testosterone in women remains at prepubertal levels throughout adulthood. Women’s muscles will achieve hypertrophy from regular exercise but typically not to the same degree as in adult males. Using the exceptional muscular development of elite female bodybuilders as our example, we know that considerable muscle hypertrophy is possible among women. Most likely, many of these women used anabolic steroids to increase their muscle mass and development. The difference in maximum attainable hypertrophy between men and women (without the aid of anabolic steroids) is not currently known.
The Specificity of Training Principle
This principle refers to the manner in which a specific body system responds to the physiological demands placed upon it. According to the specificity principle, the effects of resistance exercise training are specific to the area of the body being exercised. If the overload you impose is designed to improve strength in the muscles of your chest and back, the response to that demand (overload) will be improved strength in those muscles only.
During the past century, there have been marked changes in the disease profile in the developed and developing countries. The noncommunicable diseases like diabetes, hypertension and heart disease have replaced the infectious diseases and are posing a major cause of morbidity and mortality.
The WHO study linked data from WHO developed global database on diabetes with UN demographic projections in order to estimate the number of people with diabetes in all countries of the world at 3 points in time – 1995, 1000 and 2025.
Introduction: According to the study by WHO, between 1995 and 2025, the number of people with diabetes in INDIA is projected to rise from 19 to 57 million, i,e. an increase of 195%, indicating global burden of diabetes.
In the developed countries the 1995 figure of 51 million diabetics is expected to rise to 72 million by 2025 (42% increase). By 2025, the developing countries v/ill be home to 76% of all persons with diabetes as compared with 62% in 1995.
Worldwise, 122% rise is projected from the total of 135 to 300 million. That is more than 2 fold global increase will occur because of population gain and growth, as well as from obesity, unhealthy diets and sedentary life style. These later factors are closely associated with urbanization and industrialization.
The 3 top countries with diabetes in 2025 are India (57 million ), followed by China (38 million) and the USA (22 millions).
Prevalence of type 2 diabetes increases with aging. Harris found in 1990 that by the age of 65 years, 18% of the U.S. population has been diagnosed with diabetes. Some suggest that the increased prevalence of type 2 diabetes with aging is due to “aging genes.” In fact, 91 % of cases of type 2 diabetes are associated with environmental factors, and most can be prevented by a physically active lifestyle.
Seals et al studied glucose tolerance in athletes and sedentary men. Master’s athletes (60 years old) who averaged 8 miles/day of running did not have the age-associated higher rise in postprandial blood glucose and insulin. Moreover, the post-meal rise in blood insulin was half that occurring in the young, untrained men. Young, untrained subjects were able to maintain normal blood glucose levels in an oral glucose tolerance test by the pancreas compensating with a higher secretion of insulin. Increased postprandial rises in blood glucose and insulin in the “old, untrained, and lean” are called insulin resistance or the “pre-diabetic” state.
Thus, the insulin sensitivity of old Master’s athletes was higher than untrained young and old subjects. Old Master’s athletes had no insulin resistance, i.e., their physical activity levels were sufficient to totally prevent the so-called aging-associated increase in type 2 diabetes. The conclusion may be drawn that physical activity can delay/prevent the “age-related” onset of type 2 diabetes!
Q.   What and how much exercise do you advise for the elderly?
A. As a simple principle, we have to live our age. Football and hockey may provide an excellent form of exercise at 20 but not at 50. After the age of 50 any exercise that causes undue or unduly prolonged breathlessness, or a feeling of tiredness or pain in the chest even for a few minutes must not be indulged in. In fact, at any point of time you should not be forcing yourself to exercise. Any unaccustomed exercise must not be undertaken in the beginning. You must first accustom yourself to the exercise and its intricacies.
Q.   How should I go about doing this ?
A. You should start with small bits of exercise and gradually increase the quality. Attune yourself over days and weeks to perform more and more exercise. Once so attuned, continue this trend. By and large, walking is the best form of exercise in the advancing years, starting at a slow pace and Covering a small distance. Gradually increase your pace and speed as well as the distance walked. The easiest way to measure the distance of your walk is by the use of your watch.
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