Tag Archives: stress

Various blogs related to treatment and ways of dealing with stress



Have you ever yearned after being a ballet dancer – that is often the case in growing up and mothers often dutifully take their children to ballet classes as I did for my three children until the tummy aches occur before lessons or with competing interests they can’t fit it into their busy schedules.

But there are some children who feel they have missed out  Or feel they want to rekindle that yearning and as adults they find a studio to reconnect or even start as a beginner.  Moreover, there are significant number of middle – aged adults who decide to join ballet classes and reap the physical and mental benefits of this challenging dance form.

I remember my daughter and friends who dance at any opportunity  often attended a well known studio ‘Pineapple’ in Convent Garden. They have classes for a wide variety of different types of dance classes.

women who do ballet over 50

L to R These women are all keen ballet dancers, or use ballet movements to stay fit and active –-these ladies are aged 50-68yrs

Subsequently  I came across an ex-ballerina from Sadlers Wells Ballet company in an acupuncture class as she wanted to learn to treat common injuries. She was teaching middle – aged pupils at Pineapple and was proud of the fact that she had a pupil of 76yrs!

Isabel McMeekan was principal dance at the Royal Ballet now runs classes for adults including Assoluta class for the over 60’s.  This is a unique class specifically created for 60 year olds and over, involving gentle stretching, core work, barre work and centre practice.



Hence, I was not shocked when a professional colleague told me she had just enrolled for regular ballet classes. As we talked I could appreciate the positive health benefits of maintaining flexibility and bone density well into your later years to stall the onset of osteoporosis and could also ward off dementia. That’s as well as improving your figure, looks and confidence, relieving stress — and maybe even helping your love life.

We know that about 9 percent of adults age 65 and older report having problems with balance. Poor balance can be a contributing factor to falling, which can result in broken bones and hospital admissions.

Hence, because it is well recognised that:-

The single most serious threat that older people face is falling

Good balance is essential to being able to control and maintain your body’s position while moving and remaining still. Good balance helps you:

• Walk without staggering
• Arise from chairs without falling
• Climb stairs without tripping

You need good balance to help you stay independent and carry out daily chores and activities. Problems with sense of balance are experienced by many people as they age.

Inevitably practising ballet is going to be invaluable in addressing maintaining good balance.

My story of joining an adult ballet class

I did ballet as a child until about the age of 12 when transitioning to secondary school and puberty meant focussing on other things in life. It wasn’t until 9 years ago, in my late 30s, when I joined an adult ballet class, that my love of ballet was reignited! The combination of dance to classical music is unique to ballet, and though I have tried and have enjoyed many other activities (yoga, ballroom, Zumba and flamenco amongst many other things), ballet is what I have stuck at with a passion for the last 9 years! Certainly the movements and positions we get into remind me of my childhood, and the music makes me feel nostalgic and emotional. Perhaps it is all this emotion combined with the fact that I’ve had a seriously good work out keeps me so addicted to ballet!
Music is an essential part of ballet, and through ballet I have learnt to love the piano again too. I found I was enjoying the music so much at the class, I would go home to bang out the tune immediately on the piano! Memories of my old piano teacher came flooding back…and I have since made contact with her through email. These two pastimes have brought me much joy and satisfaction in recent years, I feel my childhood has returned to me in middle age!



You may feel this is something you thought was too late to start but there is a chance out there and with the added bonus of physical and mental health benefits.










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Posted by on February 9, 2017 in Training and Advice


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Last year I blogged about mindfulness and recommending this has become an integral part of our practice as we constantly see patients faced with the stress of modern living. For those that are not aware of mindfulness, which involves meditation, is defined as:-

 “the intentional, accepting and non-judgemental focus of one’s attention on the emotions, thoughts and sensations occurring in the present moment”.


I was asked to proofread an  article written by Charlie Morgan, yogi and yoga teacher who promotes the slogan:-

                               ‘ Your health is your wealth, the rest is a bonus’

The article was to be published in the section on health and happiness on the blog of deliciouslyella the blogger, foodie, yogi, best-selling author, nut butter addict, Telegraph columnist, app creator & avocado enthusiast.

I was delighted to see it appear on her blog for many  people to view and subsequently read the positive comments.

Click on the link below to read the article:-

image                                     Mindfulness

Thank you Ella and Charlie for collaborating to promote mindfulness and help many people understand it’s value in today’s world.



Posted by on June 12, 2015 in Training and Advice


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I am sure that over the Easter holiday a large majority of people will have enjoyed the pleasure of eating Chocolate and a gift of chocolate will have given joy and excitement to many. Chocolate companies have referred to a variety of subjects to make it attractive to a wide range of people of all ages. From chocolate Kitty’s to chocolate frogs and boxes displaying a wide range of flavours and tastes  with nuts, chilies and fruit. It seems never ending. Some of the first advertisements promoted chocolate. Maybe some of you will recall the adverts where the daring hero bravely combats precarious weather conditions and situations to a supposedly inaccessible lady  to deliver a box of chocolates with the catchy words ” all because the lady loves Milk tray”!

As a child chocolate was something we only ate at Christmas and Easter and birthdays and was considered a real treat. However, every night before bedtime my father made a cocoa drink for my brother and sister and me. I was fascinated about the consistency of the cocoa in the milk as if was difficult to blend and how it was important to mix it with a small amount of milk before filling the mug with warm milk. It was always welcomed on a cold, frosty night the comfort of warm mug of cocoa, especially as we had no central heating. My father often told me stories about the people who grew and prepared it in the Caribbean where he had travelled many times as a young sailor. It was not surprising, how excited I was, at the age of 7yrs when my teacher, Miss Baird ordered a pack from the Caribbean embassy to demonstrate the stages of cocoa and chocolate production. I still feel the excitement writing about receiving that pack, even though I have been able to travel to see it grown for myself and visited factories where chocolate is made.

When we lived in France and the children attended school in a small village I realised how important chocolate was in French life. Our youngest child attended the ‘Maternelle, ( the nursery) and it became apparent that each child was gently settled into school by being given small pieces of chocolate at regu!lar intervals to settle them in. All the children at 4 o ‘ clock every afternoon for ‘ gouter’ were given a piece of baguette with a piece of chocolate. It is not surprising that my daughter is now a chocoholic! In the school were poor country children who had virtually no toys but were never deprived of chocolate! Likewise their parents always have a cup of coffee with a piece of chocolate.

Moreover, when I visited Kew Gardens this weekend, low and behold, the event for children was to discover was where chocolate comes from and how it is made.’s-on/easter

Besides a visit to these beautiful gardens there is still a chance to take part in this event encouraged by Shaun the Sheep! A visit to the Palm house or the Princess of Wales Conservatory to find the cacao tree with the hanging pods and then follow a trail to Joseph Banks building to take part in the workshops.


From bean to chocolate baa

Chocolate beans in a pod
Chocolate workshops showing you how chocolate is made, from the cacao bean to the chocolate baa – run by Chocolution experts in all things chocolaty.

Event date:

28 March 2015 to 12 April 2015, 11am to 4pm
Event details:
Pre-booked 30 minute timed sessions, pre book online 24 hours prior to your sessions or the wo
Adults £5; Members and children £4; Families £15 (2 adults, 2 children); Families members £13; (entry to the gardens not included)
Joseph Banks Building

Theobroma ( meaning food of the gods) cacao also cacao tree and cocoa tree, is a small evergreen tree in the family Malvaceae, native to the deep tropical regions of Central and South America. Its seeds, cocoa beans, are used to make cocoa mass, cocoa powder, and chocolate.

The cocoa “beans” that form the basis of chocolate are actually seeds from the fruit of the cacao tree. The seeds grow inside a pod-like fruit and are covered with white pulp.To make chocolate, cocoa farmers crack open the pods, scoop out the seeds, ferments them and dries them.


The beans are shipped to factories, where manufacturers inspect and clean them, then roast and grind them into a paste called chocolate liquor. More pressing, rolling, mixing with sugar and other ingredients, and heating and cooling yields delicious chocolate.

Researchers observed that the Kuna Indians of Panama, who drank cocoa as their main beverage, had very low blood pressure, a leading cause of heart disease and stroke.

Today chocolate is the ‘sweet snack of the people’ but many years ago, as a part of their rituals, Mayan and Aztec nobles drank their cocoa beans ground and brewed with chillies. When it first arrived in Spain in the 16th century some didn’t like it, one even proclaiming it ‘fit for pigs’. Sugar was added and it grew in popularity especially with the ladies of the Spanish court. Chocolate became a European luxury, with chocolate houses frequented by the elite springing up in the capital cities. Debates centred around its medical value, and whether it was it an aphrodisiac. Chocolate went on to be used as emergency rations for armies, navies and rescue teams, and eventually became a ‘luxury’ that everyone could enjoy.

 Cocoa is a good source of iron, magnesium, manganese, phosphorous and zinc. It also contains the antioxidants catechins and procyanidins.
Brand experts have sought to associate chocolate, and in particular dark chocolate, with the supposed health benefits of cocoa, which include protection against cancer and stress relief.



Blood pressure
A well-conducted 2012 review of the best available evidence on the effects of chocolate on blood pressure concluded that cocoa products – including dark chocolate – may help to slightly lower blood pressure. However, most of the studies were of short duration (between two and eight weeks) and there were some weaknesses in the available research. The authors of the review say longer term trials are needed to further our understanding of cocoa’s effect on blood pressure and cardiovascular health.

Some limited animal and laboratory research suggests a cocoa-rich diet could offer protection against bowel cancer. However, it’s impossible to conclude from research carried out in a laboratory that cocoa can protect people against bowel cancer.

In a small study from 2009, 30 healthy people who were given 40g of dark chocolate a day for 14 days experienced a reduction in stress hormones. However, the study, which was funded by a major chocolate manufacturer, had several limitations, including its short study period, and does not provide any evidence that chocolate as any benefits or effects on stress.

The dietitian’s verdict
Alison Hornby, a dietitian and British Dietetic Association spokesperson, says it’s important to remember that the studies on the health benefits of chocolate have focused on cocoa extracts, not chocolate.

She says: “A range of health benefits from the consumption of cocoa products have been investigated, particularly in relation to cardiovascular disease, with early results showing promise.
“However, the potential health benefit of some compounds in the chocolate have to be weighed against the fact that to make chocolate, cocoa is combined with sugar and fat.

“This means chocolate is an energy-dense food that could contribute to weight gain and a higher risk of disease. As an occasional treat, chocolate can be part of a healthy diet.

Sorry! Eaten too frequently, it is an unhealthy choice, but some cocoa nibs (unprocessed cocoa beans broken into bits) in a smoothie might be a better choice ! ( obtained in Holland & Barrett)

However, I am sure many people have enjoyed a Happy Easter by sharing some chocolate.


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Stressed out?

Stress is a word people use for feeling they feel when everything gets too much.

You might get this if:-

  • You have too much to do
  • If other people are asking a lot of you
  • You are having to deal with things you can’t control

To help keep your heart healthy, you need to take care of your body and your mind

You have a choice in that you can choose how you want to control your life and change it for the better by just taking

10 minutes out.

How does stress affect your heart?

Being stressed often makes you do things which are bad for your heart:-

  • smoking – stop to think whether you could consider a quit smoking day and contact Smokefree Ealing by calling 0208 579 8622 or visit
  • drinking too much – if you need support contact RISE –
    Phone: 020 8843 5900
    24hrs: 0800 195 8100
  • eating unhealthy foods that are high in saturated fat and salt so that you put on too much weight, raise your blood pressure and cholesterol levels.- contact your GP for advice or screening.

If you  smoke , have high blood pressure, high cholesterol or are overweight, you are more likely to get coronary heart disease, which means you might get angina or have a heart attack.

Drinking too much alcohol can cause problems with your heart rhythm, high blood pressure and damage your heart muscle.

If you have stresses you need help with contact IAPT  Self-referral line: 020 3313 5660 or visit :-

find out more about dealing with stress and helping your heart.  download the following:-



Posted by on February 14, 2015 in Training and Advice


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Back pain can impact on many things we want to do on a daily basis. Fortunately there are a number of things you can do to lower the chances of developing disabling back pain and reduce the impact back pain may have on your life.

Back pain

The first part of my career in my surgery consultations I saw many patients with lower back pain but this was as a result of heavy manual work by miners, steelworkers, labourers and farmers. Working conditions were hard and there was little attention paid to prevent chronic back problems. We only had limited ways of investigating and simply relied on our clinical skills to diagnose a problem and tended to air on the side of caution as we were unaware of what was occurring in the body . After years of carrying out sophisticated CT scans and MRI scans and following up patients we now realise we were being over cautious and pain did not necessarily mean serious damage and most cases of back pain could be treated by encouraging movement and over the counter painkillers. Physiotherapy and other treatments were not widely available and at that time the advise was bed-rest in every case! Many patients took to their beds for many weeks and as a consequence became long term invalids often never to work again. We now know that this bad advise and that 60% of acute back pain will have resolve after 2 weeks and most will resolve in 12 weeks. Also, by having regular exercise a recurrence can be prevented as well as advising manual workers at their place of employment how to lift and to encourage the use of equipment to assist lifting to avoid unnecessary trauma.

During the second half of my career the patients who I see with back pain are sedentary workers who develop it as a result of prolonged sitting.
Back pain
It is actually more about how the body has to adapt to all the sitting, standing, and lifting than the activity itself.
Musculoskeletal problems today affect more women than in men for all age groups. For both genders, prevalence is noted higher in the 75 years and above age group. Nationally evidence suggests that MSK pain prevalence is higher in ethnic groups 63%-89% than White subjects (53%) at 45-64 age groups. 11.2 million working days per year are lost through MSK problems. Patients with MSK conditions account for the second largest group of patients in receipt of incapacity benefits after mental health. Back pain occurs in 4 out of 5 people at some time in their life.

In Ealing this accounts for 16% of incapacity claims, which is higher than the London average (15%). Increasing longevity, obesity and lack of weight bearing exercise will increase the number of patients with MSK conditions. The Chartered Society of Physiotherapy found that nationally 36 per cent of employees worked through their lunch break and 31 per cent experienced pain at work at least once a week. The economic and personal costs could be greatly reduced by encouraging better working habits and recommending appropriate exercises and providing early access to services, such as physiotherapy, for people who develop ongoing musculoskeletal conditions.

Because of the amount of time spent sitting, the body must gradually adapt itself to that position. This happens in a number of ways. The first thing it must adapt to is how the weight goes through the hips and pelvis. Then, there is the sitting position – upright, slouching, or something in-between.
This position could be termed the Office Worker’s Slump. In the Office Worker’s Slump, the back curves forward, which means the abdominals are not engaged, while the lower back muscles (erector spinae) are constantly shortened. The result is stress on the lumber vertebrae and subsequent intervertebral discs.
Back -sitting
The Office Worker’s Slump puts the spine under unnecessary daily stress, and throws its surrounding supportive muscles into a state of imbalance. These muscles help prevent injury to the back; harm their effectiveness, and there is an increase risk of suffering back problems.
Then people with already susceptible backs attend training sessions at the gym and put their backs under undue strain. Simply moving heavy equipment around can cause damage – and that’s before making a start on those heavy weight bearing moves.
The results vary from mild to crippling back pain – but both can be easily avoided. It is therefore important to follow gym work in the correct fashion and far from amplifying back issues, it can help to lower the risk of spinal injury.

Back pain is not generally caused by a serious condition but if not treated promptly by exercise and painkillers a pain cycle can easily evolve.
Pain cycle

The back is a complex structure made up of bones, muscles, nerves and joints. This can often make it difficult to pinpoint the exact cause of the pain.

Back- anatomy
Causes of lower back pain
Most cases of back pain are not caused by serious damage or disease but by sprains, minor strains, minor injuries or a pinched or irritated nerve. In most cases, the pain gets better within 2 weeks and completely recovers in 4-6 weeks. As stated earlier it can usually be successfully treated by taking over the counter painkillers, keeping mobile and carrying out suggested back exercises for at least 6-8 weeks after recovery to prevent a relapse.
Back pain can be triggered by everyday activities at home or at work, or it can develop gradually over time as a result of prolonged sitting or standing or lifting badly. Other causes of back pain include:

  • bending awkwardly or for long periods
  • lifting, carrying, pushing or pulling incorrectly
  • slouching in chairs
  • twisting
  • over-stretching
  • driving in a hunched position or driving for long periods without taking a break
  • overuse of the muscles, usually due to sport or repetitive movements (repetitive strain injury)
  • Sometimes back pain develops suddenly for no apparent reason. Some people just wake up one morning with back pain and have no idea what has caused it.

Red flagYou should seek immediate medical help if your back pain is accompanied by:

  • fever of 38ºC (100.4ºF) or above
  • unexplained weight loss
  • swelling in the back
  • constant back pain that doesn’t ease after lying down
  • pain in your chest or high up in your back
  • pain down your legs and below the knees
  • loss of bladder or bowel control
  • inability to pass urine
  • numbness around your genitals, buttocks or back passage
  • pain that is worse at night

How to prevent back pain

Keeping your back strong and supple is the best way to avoid getting back pain. Regular exercise, maintaining good posture and lifting correctly will all help.
If you have recurring bouts of back pain, the following advice may be useful:

  • lose weight – too much upper body weight can strain the lower back; you can use the healthy weight calculator to find out whether you need to lose weight.
  • wear flat shoes with cushioned soles as they can help reduce the pressure on your back
  • avoid sudden movements which can cause muscle strain
  • try to reduce any stress, anxiety and tension, which can all cause or worsen back pain – consider Yoga, Pilates and/or meditation.
  • stay active – regular exercise, such as walking and swimming, is an excellent way of preventing back pain.

Read more on:-

        • examine your posture at the working desk

Back posture

  • using pillows when lying down to support the back
    Back pain
  • regular exercises whilst at the desk
    imageIn view of the fact that the majority of cases of back pain are not related to serious damage or disease your GP will encourage you to take the above advice and carry out the exercises illustrated below or as instructed on the video below showing a demonstration from our physiotherapists at Ealing Hospital.

Recommended back exercises

Edited by Dr Ian Bernstein

Edited by Dr Ian Bernstein

In Ealing we are fortunate enough to have an excellent community based facility for assessing and treating musculoskeletal problems started by an enthusiastic GP who has pioneered assessment and treatment of MSK problems in the community and by passing on his expert knowledge this has empowered other GP’s in Ealing to select the appropriate patients to be referred for more specialist care. This is not only beneficial economically but has reduced waiting lists for secondary care Orthopaedic opinions and investigations such MRI scans. The service is constantly being expanded and along with specialised physiotherapists and now Orthopaedic surgeons there is a comprehensive team of therapists who are able treat a wide range of musculoskeletal conditions including back problems in Clayponds Hospital. Hence, in Ealing patients are now initially treating themselves and then if they demonstrate no significant improvement after 6 weeks can be referred for specialist assessment, investigation and treatment by this service.
If a very serious cause is considered the case can be fast tracked and the patient can be seen immediately or within 2 weeks.
For further information for those living with back pain:-

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Posted by on February 14, 2014 in Training and Advice


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Pain is inevitable suffering is optional

Pain is inevitable

Pain can be defined as a highly unpleasant physical sensation caused by illness or injury but can also be defined as mental suffering or distress.

Pain accounts for a substantial number of reasons for patient consulting with a doctor We know that 27% of patients attend with a musculoskeletal problem most of whom will describe an element of pain. There are also those who will complain of pain associated with their chest, abdomen or head of another part of the body. It can be localised or more generalised and can be referred from a site where the cause of pain originates. It is estimated that > 10 million people have persistent pain.

The following video attempts to give an understanding of pain

I have always been interested and puzzled about the concept and the complexities of persistent or chronic pain and how it manifests itself in people of all ages. It is one of the reasons why I took up acupuncture and studied Traditional Chinese Medicine(TCM) in an attempt to treat pain with something other than tablets, capsules or applications as well as develop a deeper understanding of pain and how it can be treated.

Pain words

Pain can be described using many adjectives such as shooting, burning, stinging, stabbing, throbbing and pricking but these all not only describe the unpleasant sensation but have association with a frightening experience. Hence, with pain there is usually a feeling of fear or emotion of some kind. I attended two lectures a few years ago; one was from an eminent American psychiatrist talking about the neurophysiology of depression and how depression could present with pain such as back pain, chronic abdominal pain or headaches and how these pains could be treated with antidepressants medication. The second lecture was from a Swedish neurophysiologist who impressed us by drawing intricate nerve pathways to demonstrate how acupuncture worked bug also by treating pain this could treat depression.

Many years ago it seemed appropriate that when I carried out intricate procedures on very premature babies that because I assumed that it must be painful, it was remarked by nursing staff that when I made the effort to talk reassuringly and stroke them the procedure went more smoothly but analgesia was never routinely given.

Premature baby
It was not until 2010 that research showed that premature babies do perceive pain and are now given analgesia routinely when procedures are performed. Infact premature babies are sensitised to pain by intensive care treatments they receive after birth, a study in 2010 suggested. Tests showed that pre-term infants that have spent at least 40 days in hospital feel pain more acutely than healthy newborns. From this study it was suggested that better pain relief should be given to premature babies under intensive care to prevent them becoming pain-sensitive. Brain activity comparing full-term babies and premature babies was seen when both sets of babies were gently touched on the heel and showed no difference, suggesting that the sensitisation of pre-term babies is specific to pain. This is important, since the sense of touch is triggered by being held or cuddled. It implies that premature babies can benefit from a mother’s touch as much as normal infants.

I remember a child coming to surgery with his mother in floods of tears and when I asked ‘What’s the matter?” He said” A lion bit my ear!” Clearly he felt the sensation of pain but expressed a terrifying fear of how it had occurred. Pain from an acute ear infection is probably for many children their first experience of severe pain and not only do they need pain relief but they need comfort and reassurance.

My personal experience of severe pain was when I was admitted with renal colic as a medical student and realising it was ‘for real’ not one of those pains that all medical students have as they study every speciality. I remember being petrified wondering, imagining what it was and although it was thoughtful to put me in a sideward I felt abandoned and desperate wondering if anyone realised how much pain I was suffering. I was given intramuscular pain relief, which gave me florid hallucinations of Monty Python feet descending on me and those around me changing in form in seconds. I was violently vomiting and terrified and this lasted several days. Then a very gentle doctor sat by my bed explained exactly what was happening and how the stone was working its way out of my system and if not it would be removed surgically next morning. He also listened to the effects I described( this drug has subsequently been taken out of use) changed the medication and then said in a gentle kind manner that if I felt distressed he was prepared to come and see me anytime. The pain instantly became more tolerable and I was able to cope much better feeling less fearful and knew it was happening. Much to the consultants chagrin, as he had come especially early to perform the surgery, about 10 minute before surgery I passed the stone! I never saw the kind doctor again but he taught me what was meant by bedside manner and what being a doctor was really all about – having the knowledge but combined with the gift of being able to allay fear by giving the time when it is needed.

Several cases of severe pain puzzled me for years and interestingly all were in severely mentally ill patients.
The first case was a gentleman who walked into A&E looking pale, cold and clammy holding his fist against his chest but not complaining of any pain despite being asked several times. A routine ECG was performed, at that time performed on all patients >50 yrs and this showed a massive hear attack across the anterior part of his heart.

The second case was of a gentleman again walking into A&E vomiting copious amounts of brown fluid clutching his distended, rigid abdomen but showing no history of pain and on palpating his abdomen no complaints of pain but X-ray corfirmed an obstruction with perforation and emergency surgery revealed widespread peritonitis.

The third case was that of a gentleman who had had a severe mental breakdown whilst working in the City as an analyst and had been treated for skin cancer and was attending a follow up appointment and it was found that he had spinal bone metastases. The day prior to being seen he had walked 7 miles on a country ramble, sadly a week later of widespread metastatic cancer.

The final case I would like to mention was that of a lady who I had been seeing in surgery regularly and knew she had a diagnosis of severe dissociative disorder,which had been the result of years of abuse in her childhood and early teens. Dissociative disorder is a condition whereby your sense of reality and who you are, which depends on your feelings, thoughts, sensations, perceptions and memories becomes ‘disconnected’ from each other, and doesn’t register in your conscious mind. Your sense of identity, your memories, and the way you see yourself and the world around you will change. This is what happens when you dissociate. It’s as if your mind is not in your body; as if you are looking at yourself from a distance; like looking at a stranger. She had been developing swelling of her joints which looked as if they should be painful but she denied severe pain and the distribution of the joint problem was typical of rheumatoid arthritis. I performed the relevant blood tests which came back extremely high supportive of the diagnosis of rheumatoid arthritis . After consultation with the rheumatologist she was seen and given high doses of intramuscular steroids. She then had to have surgery to her cervical spine as she was at serious risk of becoming paralysed from the neck down due to extensive disease in this area. She has been on many powerful drugs for rheumatoid arthritis but is now taking regular injections of an immunosuppressant treatment called adalimumab (Humira) which is a Tumour necrosis factor-alpha inhibitors (TNF-alpha inhibitors) – the human body produces tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is an inflammatory substance. TNF-alpha inhibitors are used for the reduction of pain, morning stiffness and swollen or tender joints. These drugs are only used in exceptional cases of Rheumatoid Arthritis.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously harm yourself without knowing it, or you might not realize you have a medical problem that needs treatment as in the case of those mentally ill patients. I realise many people are brought up not to make a fuss about pain but it is important that the symptoms of pain are shared with your doctor and necessary investigations are done, as treating an underlying cause can often cure the pain. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain and it has been found that a pain cycle evolves as shown below:-

Pain cycle

Sometimes chronic pain is due to an ongoing cause but sometimes the cause is unknown and usually there is a psychological element to a greater or lesser extent. The pain may occur because the brain can’t make enough endorphins. These are chemicals that shut down pain signals. Or, pain signals continue after an injury has healed. In some cases, increased pain sensitivity makes even minor injuries very painful.


The British Pain Society is the largest multidisciplinary professional organisation in the field of pain within the UK.

Our membership comprises doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients.
It has published several publications which can be easily downloaded

  • Managing pain effectively using ‘Over the Counter’ (OTC) Medicines (2010)
  • Understanding and Managing Pain (2010)
  • Help the Aged – Pain in Older People: Reflections and Experiences from an older person’s persepctive (2008)
  • Opioids for persistent pain: information for patients (2010)
  • Managing Cancer Pain – information for patients (2010)

It is very important to communicate how your pain effects you describing it carefully , what you do to ease it and what makes it worse and how intense it is using a scale as below:-

Pain scale

It is useful to keep a diary either using a calendar or using an App
This helps to communicate progress that is being made and how it is affecting daily life.

Pain can be classified into several categories:-

Nociceptive Pain:

Nociceptive pain is believed to be caused by the ongoing activation of pain receptors in either the surface or deep tissues of the body. There are two types: “somatic” pain and ” visceral” pain.
“Somatic” pain is caused by injury to skin, muscles, bone, joint, and connective tissues. Deep somatic pain is usually described as dull or aching, and localized in one area. Somatic pain from injury to the skin or the tissues just below it often is sharper and may have a burning or pricking quality.

Somatic pain often involves inflammation of injured tissue. Although inflammation is a normal response of the body to injury, and is essential for healing, inflammation that does not disappear with time can result in a chronically painful disease. The joint pain caused by rheumatoid arthritis may be considered an example of this type of somatic nociceptive pain.

“Visceral” pain refers to pain that originates from ongoing injury to the internal organs or the tissues that support them. When the injured tissue is a hollow structure, like the intestine or the gall bladder, the pain often is poorly localized and cramping. When the injured structure is not a hollow organ, the pain may be pressure-like, deep, and stabbing.

Neuropathic Pain:

Neuropathic pain is believed to be caused by changes in the nervous system that sustain pain even after an injury heals. In most cases, the injury that starts the pain involves the peripheral nerves or the central nervous system itself. It can be associated with trauma or with many different types of diseases, such as diabetes. There are many neuropathic pain syndromes, such as diabetic neuropathy, trigeminal neuralgia, postherpetic neuralgia (“shingles”), post-stroke pain, and complex regional pain syndromes (also called reflex sympathetic dystrophy or “RSD” and causalgia). Some patients who get neuropathic pain describe it as bizarre, unfamiliar pain, which may be burning or like electricity. The pain may be associated with sensitivity of the skin.

An interesting account of the mystery of chronic neuropathic pain

click on link below:-

Mystery of chronic pain

Psychogenic Pain:
Most patients with chronic pain have some degree of psychological disturbance. Patients may be anxious or depressed, or have trouble coping. Psychological distress may not only be a consequence of the pain, but may also contribute to the pain itself. “Psychogenic” pain is a simple label for all kinds of pain that can be best explained by psychological problems.

This close relationship between pain and psychological distress means that all patients with chronic pain should have an assessment of these psychological factors, and psychological treatments should be considered an important aspect of pain therapy. In some cases, psychological problems appear to be a main cause of the pain. This does not mean that the person is not actually experiencing the pain. Rather, the patient is truly suffering but the main cause somehow relates to the emotions, or to learning, or to some other psychological process. Although doctors sometimes encounter patients who pretend to be in pain (some can be called malingerers), this appears to be a rare occurrence. Most patients with pain that appears to be determined primarily by psychological processes are hurting just like those who have pain associated with a clear injury to the body.

Sometimes, psychogenic pain occurs in the absence of any identifiable disease in the body. More often, there is a physical problem but the psychological cause for the pain is believed to be the major cause for the pain.

Another website which gives interesting insights into pain is:-
It also has a series of podcasts which talk about various aspects of pain the edition talks about exploring the possibility of controlling pain through techniques that focus on the brain and the mind using mindfulness a topic I wrote about in a previous blog.



Because chronic pain is so complex, there are often multiple treatment goals. These goals may include more comfort (being “pain-free” is often not possible when pain has become chronic), better physical functioning, improved coping and less distress, getting back to work, helping the family cope, and other positive outcomes. To accomplish these goals, chronic pain often is best managed using what is called a “multimodality” approach.

The patient’s response to therapies may be influenced by age, gender, race or ethnicity, cultural beliefs, or any of a variety of physical, emotional, social, family, occupational, and spiritual circumstances. Treatments for pain must be tailored to the individual, based on each person’s unique condition.

A multimodality approach to chronic pain includes a combination of therapies selected from eight broad categories:

  • drug therapies
  • psychological therapies
  • rehabilitative therapies
  • anesthesiological therapies
  • neurostimulatory therapies
  • surgical therapies
  • lifestyle changes
  • complementary and alternative medicine therapies

In many cases, a multimodality strategy requires the involvement of several types of health care professionals -the interdisciplinary team.

Effective pain management is therefore collaborative in nature, involving good communication among the patient, family, and the practitioners involved in the care. A sense of partnership in trying to find the best therapeutic approach promotes the most creative, and ultimately the most effective, approaches. Patient-practitioner partnership can maximize the patient’s involvement and sense of control in the healing process. Patients must feel empowered to seek the best care and to act in a way that uses their own resources in the service of health. If an interdisciplinary team of practitioners is involved in developing a multimodality approach, the members must communicate freely to ensure the appropriate targeting of therapy. Family communication helps promote positive patterns within the family and may reduce the stress caused by prolonged pain and impaired function.

Integrative pain managementFrom this perspective, Integrative Pain Therapy is a natural extension of state-of-the-art conventional pain management.

Integrative Pain Therapy

The term, “integrative pain therapy,” can be used to describe a broad therapeutic approach to the management of chronic pain, which attempts to combine the best of traditional treatments for pain and disability with the best of the therapies widely considered complementary or alternative. It is part of a larger effort to develop an “integrative medicine approach” to many clinical problems.

This integrative medicine approach links traditional, so-called allopathic, medical treatments with varied complementary and alternative treatments. It is a comprehensive system of medicine, which emphasizes wellness and the healing of the whole person (physical, psychological, social, and spiritual), above and beyond the treatment of any specific symptom or disease (Bell, 2002). It involves the use of all safe and effective therapeutic approaches that can potentially facilitate healing, while empowering the patient to participate in the process of healing. Integrative medicine acknowledges the complexity of health and illness by identifying multiple causes of disease and multiple interventions based on the physical, biochemical, psychological, social and spiritual aspects of health and disease. It recognizes that multiple outcomes may be positive for the individual, and that these outcomes may vary from one person to the next (Rosomoff, 1999).

The goals of an integrative pain therapy approach may include:

  • reducing or eliminating pain
  • using medicines that are appropriate, provide sustained benefits, have tolerable side effects, and support the functional goals of the patient
  • reducing distress and enhancing comfort, peace of mind and quality of life
  • improving the understanding of the role of emotions, behavior and attitudes in pain
  • improving the ability to function physically and perform activities of daily living
  • improving the ability to function in social and family roles
  • supporting the patient’s ability to return to work and function on the job
  • educating patients in ways to maintain rehabilitation gains and avoid re-injury
  • empowering patients to actively participate in pain control strategies
  • promoting awareness and understanding of the factors that contribute to physical and emotional distress related to pain
  • developing the skills and knowledge needed to increase the patient’s sense of control over pain

Integrative pain therapy draws from a broad spectrum of therapeutic approaches. It recognizes the value of multiple approaches to pain management (a multimodality approach) and acknowledges the individualized nature of good medical care. The goal is to employ the safest and most effective therapies to provide maximum benefit.

Foundations of Health

In developing an integrative approach to pain therapy, the starting point is a broad view of health and well being. The foundations of health include at least four elements:

    • stress management
    • proper diet and nutrition</li
    • regular exercise
    • psychosocial support

There are literally thousands of studies confirming the importance of each of these foundations. Careful attention to each can have profound effects on health and illness. The work of Dean Ornish (Ornish, 1999), for example, demonstrated that interventions targeted to these areas can not only halt, but actually reverse, coronary artery disease.
Stress Management.
All people experience stress and some degree of stress may be needed to generate excitement, engage fully in tasks, and perform well. However, too much stress, or poor coping with stress, can undermine health and well being.There are many tools available to help reduce the debilitating effects of acute and chronic stress. The most important approach is to recognize triggers and behavior patterns, and to utilize emotional and spiritual approaches to reverse stress’s negative effects. These approaches can be learned in a variety of ways, such as psychotherapy, education, and training in mind-body techniques. Sometimes, herbal, nutritional or pharmacologic therapies are needed to assist in coping with persistent stress.

Proper Diet and Nutrition

Although science has a great deal more to learn about the role of nutrition in health and disease, it is certain that poor nutrition can contribute to a range of problems. Poor nutrition is common in many developing countries, and there is clear evidence that people living in developed countries, such as the United States, may not obtain enough of the essential nutrients needed for maintaining health (Fairfield & Fletcher, 2002). Because the diet may not be a complete source of all the nutrients needed for optimum health, the use of supplements may be necessary, either to help prevent disease or to aid in treatment.


Proper exercise maintains fitness and is very helpful in reducing stress. Intense aerobic exercise is not necessary to achieve these benefits. Brisk walking may be sufficient for many people. Modest, regular exercise, particularly when combined with stretching and relaxation, or approaches such as yoga and tai chi, provides another essential element for optimum health.

Psychosocial Support

There is a huge body of research that demonstrates the importance of psychological and social factors in health and disease. Emotions, thoughts, connections to others, the response of others to our behaviors-all these factors contribute. Dealing with these types of issues and problems is an essential part of pain management.
Although integrative pain therapy as an approach to the management of chronic pain is in its infancy, several recommendations are possible.

Based on current research the integration of psychological approaches (such as behavioral and relaxation therapies) with conventional medical treatment is strongly recommended for the successful treatment of chronic pain conditions. Some mind/body strategies, like biofeedback, hypnosis, and imagery, are already considered to be mainstream treatments by pain specialists. Others, such as meditation, Qigong, and yoga have extensive historical use and need more study to determine their exact role in an integrative program. The potential benefit of all these approaches is the ability to learn to regulate anxiety, improve coping, and possibly reduce pain.

Research also supports physical activity and exercise as a part of most treatment programs for chronic pain. For example, active back exercises can be effective in reducing pain intensity, pain frequency and disability, as well as in helping to prevent recurrences of back pain. Activity can be supported by conventional physical therapy and exercise approaches, or by a wide range of movement therapies.

There is strong support for a treatment strategy that combines therapies that address the physical, psychological and social aspects of chronic pain. Based on a slowly growing experience, the integration of complementary/alternative approaches with standard treatments may offer the best chance of addressing these broad concerns. All patients should be educated about the range of options and the goals of treatment.

The interdisciplinary approach to chronic pain may involve not only traditional health care providers, including physicians, nurses, psychologists, and physical therapists, but integrative providers comfortable with the widest array of healing modalities, whether conventional or complementary, as well as specialists in specific complementary approaches.

In Ealing we are fortunate that we have an excellent Community Musculoskeletal service which offers standard treatments alongside Complementary therapy.
Shortly,The Ealing improving access to psychological therapies (IAPT) service offers support for common mental health problems such as depression, anxiety and panic for people living in Ealing.
It can provide self-help treatments, cognitive behaviour therapy (CBT), counselling and sign-posting to other servces. For more information view
It will be offering Mindfulness therapy with a special reference to Chronic Pain in the New Year.
Referral information
Ask your GP for more information, or call 020 3313 5660 or email

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Posted by on December 20, 2013 in Training and Advice


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Have you ever felt that your mind is over full, cluttered with so many thoughts and worries that you almost feel your head is about to explode?

Moreover,have you developed techniques to deal with this?

This need has been recognised since the beginning of time and I feel as soon as we become aware of the world outside ourselves as a child we instinctively know how to do this. Unfortunately, children are not encouraged or nurtured to preserve this skill and many modern toys are brightly coloured and noisy and the opportunity to just ‘be’ and enjoy stillness and silence and the simple life around them is missed.

One of the best pieces of advice I was given when I had my first child was ‘if the baby cries remember she may just want to be put down’ and it often worked.

Several years ago I talked to a group of 5-6 year olds about being quiet and still and I was surprised when most of them revealed how this was something in their own way they found a way of practising. They then proceeded to tell me how they found space to do this. “I always go under my sisters bed,” said one child. “I go in the garden behind the shed” said another.” I sit under the stairs” said another.


I then sat with them and focused on a candle, which I allowed one of them to carry to the table. The child who was the noisiest and most active carried it with great care and placed it on the table. I spoke with these children on several occasions and on each occasion a child carried the candle a short distance to the table and we all sat in silence. Week by week the length of time they remained silent and still grew until they were able to sit quietly for up to 5 minutes. Following this they came out of the silence quieter and played together in a much calmer, friendlier manner.

Similarly, talking to children in a a quiet monotone causes absolute relaxation and puts them in a state of selfhypnosis. This technique I have used on many occasions to administer injections and take blood from children. On one occasion when I was a junior paediatrician and a child was admitted with an asthma attack. The nursing staff were lining up to hold him down to put up a intravenous infusion. The child was distressed and frightened. I asked the staff to leave the room and quietly spoke to him with full eye contact and gradually the child quiet ended and he cooperated fully to allow me to put up the infusion much to the surprise of the nursing staff.
On another occasion more recently I was working as a locum in a practise and a mother came to the surgery with 3yr old active twins. She was distraught as her husband had terminal cancer and she had no-one to look after the children and wanted to talk about her own problems. When I looked at the computer notes there were four entries from previous doctors recording that they were unable to have the consultation with the mother and she should return on her own. I started to talk to the twins and then gently massaged the centre of their scalp (a calming acupuncture point) and both children stood still for long enough for the mother to pour out her concerns. The children were then led calmly away by their much calmer mother.

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As an adult to achieve this level of relaxation we need to focus on a sound, a picture or simply your own breath sounds and may need help from another person.
Using techniques like this, meditation, breathing and yoga can help us pay attention to the present moment. It helps us become more aware of our thoughts and feelings so that instead of being overwhelmed by them, we’re better able to manage them.
This awareness of the present moment or Mindfulness as a psychological concept is based on the concept of mindfulness in Buddhist meditation. It has been popularised in the West by Jon Kabat-Zinn. Despite its roots in Buddhism, mindfulness is often taught independently of religion.
Mindfulness teaches individuals to be present in the moment rather than being distracted about the past or projectingd into the future. It doesn’t stop you feeling emotions per se, but it does allow you to deal with them more dispassionately.

Practising mindfulness can give people more insight into their emotions, boost their attention and concentration and improve relationships. It’s proven to help with stress, anxiety, depression and addictive behaviours, and can even have a positive effect on physical problems like hypertension, heart disease and chronic pain.

Mindfulness practice, is increasingly being employed in psychology to alleviate a variety of mental and physical conditions.

I think that mindfulness is something many of us have done – have you ever sat looking out to sea and found yourself listening to the rhythmic sound of waves or watching the trees/ grass swaying in a breeze or listening to your favourite music and suddenly realised that time has passed and for a short time you were only aware of that present moment and following this you feel more at ease. Have you swum lengths in a swimming pool with gentle rhythmic arm and leg movements and your mind taking up by feeling of movement in the water and finished the swim feeling that problems have seemed less or gone. Jogging at a gentle rhythmic pace around the park in a similar vein can give the same effect. This is not overexerting the body but calming the mind in a similar way to yoga. However, the benefit is only appreciated by being aware of the present moment and your thoughts and emotions at the time.
This can be a start to achieving full awareness or mindfulness by zoning in on the feeling of relieving the mind of excessive, overwhelming clutter so that eventually you can reach mindfulness with perfect stillness of body and mind.


Although the practise of meditation is in no way a religion it may be it is part of your religious practise and you need to be aware of how it can be helpful physically and mentally; you may want to call it prayerfulness.

I have been surprised as to how many people from all walks of life benefit from regular meditation although it is now it can be referred to as mindfulness.

Mindfulness. If you’re not yet au fait with the concept, it might be a good idea to familiarise yourself with it now, because you’ll be hearing a lot about it in 2013; from business leaders, academics, politicians and educationalists they are all making it part of their lives.

It is also being introduced into some schools as part of the curriculum.
I read an account of a school that played music and instructed the schoolchildren that when played they were to stay still and think about themselves. After a while the head teacher only had to start the music and the whole school became quiet.
Mindfulness is being increasingly recognised as an incredibly effective way to cope with stress and also recognised by NICE and the NHS as the most effective way to prevent relapse into depression and anxiety states. It has been found to help with pain management and weight loss.

It has been discussed in Parliament as a therapy in relation to both unemployment and depression. But it isn’t about zoning out. If anything, it’s about zooming in; paying attention to the present and decluttering the brain to make room for creativity – and in business that means boosting the bottom line.

To that end, mindfulness training has been embraced by organisations as diverse as Google, Transport for London, PricewaterhouseCoopers and the Home Office, by way of an antidote to the relentless pressure and information overload common in many workplaces.


1) Make it a formal practice. You will only get to the next level in meditation by setting aside specific time (preferably two times a day) to be still. At first it maybe for only 3-4 minutes.

2) Start with the breath. Breathing deep slows the heart rate, relaxes the muscles, focuses the mind and is an ideal way to begin practice.

3) Stretch first. Stretching loosens the muscles and tendons allowing you to sit (or lie) more comfortably. Additionally, stretching starts the process of “going inward” and brings added attention to the body.

4) Meditate with Purpose. Beginners must understand that meditation is an ACTIVE process. The art of focusing your attention to a single point is hard work, and you have to be purposefully engaged!

5) Notice frustration creep up on you. This is very common for beginners as we think “hey, what am I doing here” or “why can’t I just quiet my mind already”. When this happens, really focus in on your breath and let the frustrated feelings go.

6) Experiment. Although many of us think of effective meditation as a Yogi sitting cross-legged beneath a Bonzi tree, beginners should be more experimental and try different types of meditation. Try sitting, lying, eyes open, eyes closed, etc.

7) Feel your body parts. A great practice for beginning meditators is to take notice of the body when a meditative state starts to take hold. Once the mind quiets, put all your attention to the feet and then slowly move your way up the body (include your internal organs). This is very healthy and an indicator that you are on the right path.

8) Pick a specific room in your home to meditate. Make sure it is not the same room where you do work, exercise, or sleep. I may help to use a candle and gentle music or sounds to help you o feel relaxed.

9) Read a book (or two) on meditation. Preferably an instructional guide AND one that describes the benefits of deep meditative states. This will get you motivated. John Kabat-Zinn’s Wherever You Go, There You terrific very  good for beginners.

10) Commit for the long haul. Meditation is a life-long practice, and you will benefit most by NOT examining the results of your daily practice. Just do the best you can every day, and then let it go!

11) Listen to instructional tapes and CDs.

12) Generate moments of awareness during the day. Finding your breath and “being present” while not in formal practice is a wonderful way to evolve your meditation habits.

13) Make sure you will not be disturbed. One of the biggest mistakes beginners make is not insuring peaceful practice conditions. If you have it in the back of your mind that the phone might ring, your children might wake, or an alarm is about to go off then you will not be able to attain a state of deep relaxation.

14) Notice small adjustments. For beginning meditators, the slightest physical movements can transform a meditative practice from one of frustration to one of renewal. These adjustments may be barely noticeable to an observer, but they can mean everything for your practice.

15) Use a candle. Meditating with eyes closed can be challenging for a beginner. Lighting a candle and using it as your point of focus allows you to strengthen your attention with a visual cue. This can be very powerful.

16) Do NOT Stress. This may be the most important tip for beginners, and the hardest to implement. No matter what happens during your meditation practice, do not stress about it. This includes being nervous before meditating and angry afterwards. Meditation is what it is, and just do the best you can at the time.

17) Do it together. Meditating with a partner or loved one can have many wonderful benefits, and can improve your practice. However, it is necessary to make sure that you set agreed-upon ground rules before you begin!

18) Meditate early in the morning. Without a doubt, early morning is an ideal time to practice: it is quieter, your mind is not filled with the usual clutter, and there is less chance you will be disturbed. Make it a habit to get up half an hour earlier to meditate.

19) Be Grateful at the end. Once your mediation is finished spend 2-3 minutes feeling appreciative of the opportunity to practice and your mind’s ability to focus.

20) Notice when your interest in meditation begins to wane. Meditation is hard work, and you will inevitably come to a point where it seemingly does not fit into the picture anymore. THIS is when you need your practice the most and I recommend you go back to the book(s) or the CD’s you listened to and become re-invigorated with the practice. Chances are that losing the ability to focus on meditation is parallel with your inability to focus in other areas of your life!


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Posted by on September 28, 2013 in Training and Advice


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September 1st
  marks the arrival of a vaccine for people aged 70 years (routine cohort) and 79 years (catch-up cohort) to protect against shingles The efficacy of the vaccine declines with age and so it is not recommended for people aged 80 years or older.
The brand name of the shingles vaccine given in the UK is Zostavax

Unlike the flu jab, you’ll only need to have the vaccination once.
The vaccine is expected to reduce your risk of getting shingles. If you are unlucky enough to go on to have the disease, your symptoms may be milder and the illness shorter.
It’s difficult to be precise, but research to date suggests the shingles vaccine will protect you for at least three years, probably longer.
There is lots of evidence showing that the new shingles vaccine is very safe. It’s already been used in several countries, including the US and Canada, and no safety concerns have been raised. The vaccine also has few side effects.

What is Shingles?
Shingles or Herpes Zoster is a debilitating condition, which occurs more frequently and tends to be more severe in older people. It is estimated that around 250,000 people are affected in England and Wales each year, including 30,000 people in their 70s. Around one in 1,000 people over 70 who get shingles dies of the infection.

About 1 in 5 people have shingles at some time in their life. It can occur at any age, but it is most common in people over the age of 50. It is uncommon to have shingles more than once, but about 1 person in 50 has shingles two or more times in their life.

Most people have chickenpox ( varicella Zoster)in childhood, but after the illness has gone, the virus remains dormant (inactive) in the nervous system. The immune system (the body’s natural defence system) keeps the virus in check, but later in life it can be reactivated and cause shingles.
It is not known exactly why the shingles virus is reactivated at a later stage in life, but it may be due to having lowered immunity (protection against infections and diseases). This may be the result of:
being older
being stressed
a condition that affects your immune system, such as HIV and AIDS
Debilitation associated with cancer or medication affecting the immune system.

Each spinal nerve supplies an area of skin called a dermatome. The virus lies dormant in a part of the spinal nerve called a ganglia and as each spinal nerve supplies a particular region of the skin the area of skin where the symptoms and rash appear will correspond to that dermatome.

Signs & Symptoms,
Prodrome (1–4 days before the rash) — fever and myalgia, with burning, tingling, numbness, or intense itching in the affected skin.
Acute (painful rash lasting 7–10 days) — a rash starts with red flat lesions and then raised lesions and these develop into vesicular (blistery)lesions in a dermatomal distribution. These blister type lesions then burst, releasing varicella-zoster virus.
Healing (2–4 weeks) — the lesions crust over.

Most patients feel unwell and very often emotionally labile and many a time has a patient with shingles burst into tears during a consultation for no obvious reason.


An oral antiviral drug (such as aciclovir) should be started within 72 hours of rash onset for a certain group of people, such as people aged 50 years or older, people with non-truncal involvement (e.g. shingles affecting the neck, limbs, or perineum), and people with moderate or severe pain or rash.
If it is not possible to initiate treatment within 72 hours, antiviral treatment can be considered up to 1 week after rash onset, especially if the person is at higher risk of severe shingles or complications (e.g. continued vesicle formation, older age, immunocompromised, or severe pain).

Most people have shingles on the trunk or chest region and it is uncomplicated. However, some people are unfortunate in that they are infected in the facial area, develop a complication, are severely immunocompromised, or pregnant and may need urgent admission or a Specialist opinion.

Less urgent referral may be necessary if new vesicles are forming after 7 days of antiviral treatment, healing is delayed, or if pain is inadequately controlled by oral analgesia.

For further information:-

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Posted by on August 3, 2013 in Training and Advice


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Mariusz Krezolek, was found guilty of the “callous and wretched” murder of Daniel Pelka along with Magdelena Luczak.

Sadly another child dies after heinous child abuse and yet again questions are being asked as to where were social services and the school in not reporting suspicious signs.
I am afraid it makes me recall two particular distressing experiences I have had as a doctor and revealing no identity I want to share them in this blog. But if you don’t want to read further please read the next paragraph:-

Would you report something to the local authority or the NSPCC if you noticed something suspicious?

NSPCC website
Local Authority
It is everyone’s responsibility to bring to attention any suspicions of any form of child abuse be it physical,emotional, sexual abuse or in intentional neglect.
If as child you need someone to talk to, most children have access to a computer or mobile phone and you will be taken seriously.
Approximately 50,500 children in the UK are known to be at risk of abuse right now.
One in four young adults (25.3%) were severely maltreated during childhood.
Startlingly, even if a person reports a concern many of these people have waited one month.

When Dr John Caffey, a reputable paediatric radiologist wrote an article pub- lished in 1946 describing six young children with subdural hematomas and fractures of the legs or arms and made a suggestion that these injuries could be a sign of child abuse it was dismissed and ignored. Nobody could comprehend that an adult could intentionally harm a child and he was looked upon scornfully.
However, a stream of physicians drew attention to the abusive origin to some of these injuries but it wasn’t until 1962 that the publication of the blockbuster article “The Battered-Child Syndrome” by pediatrician Henry Kempe and his col- leagues. Kempe played a leading role in bringing child abuse to national attention during the 1960s and 1970s.

When I trained, child abuse was only mentioned and signs of detection were not formally taught. I started as a paediatric junior doctor in 1978/9 and my way of learning was at that time.
Several babies and children were admitted with suspicious injuries but only in one case was court action taken. Onevbaby was admitted at least 3 times and always the parents had some explanation but it did not tie in with the injuries. The baby was investigated for any possible medical reason- these investigations in themselves often not pleasant. I remember the Local authority lawyer turning up to question doctors; he was elderly, vague and dressed like a farmer in contrast to the parent’s lawyer who was young, bright and slickly dressed. We all despaired we didn’t stand a chance of proving the case. Ironically, the baby was admitted again and for some reason the father broke down and admitted exactly what happened.
It was not long after this when the consultant discussed with us child abuse and what to look out for that I was able to involved directly with the worse case I have ever witnessed. This remains indelible of my mind and will rest with me forever.
I was called to A&E to see a child who had ‘fallen downstairs’.
When I entered the cubicle I was in the process of examining a child who was seriously ill, infact dying and as I proceeded to look over her she gasped her last breath. I shall never forget her pale complexion, her soft flaxen hair and the look on her face – a beautiful young child only 3 years of age.
My registrar who was present immediately called the Police surgeon, who I knew well as he was a GP who worked in the practise where I had done my placement. When he realised this was a clear cut case of physical abuse he immediately called the Coroner but in passing told me that although I would be off duty and this would not be a pleasant experience that I should attend the Post-Mortem. It was not long before the Coroner arrived clad in formal evening dinner dress and even wearing a black cloak then he was followed by the the pathologist. There was an eerie silence as the men, who had only a short time ago been laughing and happily merrymaking were now stunned to silence with what lay before their eyes. I was introduced to the Coroner who briefly acknowledged my presence and I sheepishly took my place against the wall to observe the proceedings. These men beavered away carefully examining the small child and recording everything fastidiously. Laurence( the Police Surgeon) whispered asides to let me know the significance of every sign and I remained speechless. I didn’t write anything down as the pictures would be stored in my internal photoshop indefinitely.

Incredibly, this case never reached the Local let alone the National newspapers or the media probably because it was still considered inconceivable and I have no idea whether there was a prosecution I am doubtful. I like many others were part of the denial despite seeing and feeling the evidence. I recall it with great feeling and deep sadness.

When I was a student I helped on a voluntary basis in a local children’s home and remember how I went before the ‘matron’ to air my concerns about potential abuse. She was horrified and dismissed me and told me never to return.This was my experience of being ignored and dismissed out of hand and no comparison to the many thousands of witnesses and victims ignored by those they addressed with worries or claims. I realised how this horrendous problem can be concealed and how people knowingly or unknowingly keep it hidden.

It was in 2006/7 when I was working with the Atos as an EMP(Examining Medical Physician) in Bromyard avenue examing claimants who had been off sick for a prolonged period and were claiming, at that time ‘Sickness Benefit’. A lean gentleman in his late 50’s was the next customer (as they were called) entered and I routinely asked him why he was off sick. He then proceeded to explain that he had been in prison for most of his adult life. Infact, when he entered the army as a young man he had been sent to Military prison for assault but when he had been summoned to his officer to explain himself had tipped the table against him pinning him to the wall. Following this he was dismissed from the army sent to Wormwood Scrubs category B men’s prison. This was the story of his life in and out of prison and hating any form of authority. He was therefore unemployable but now he had a malignant cancer. As I listened I could feel the tangible emotion of despair and frustration and self hate but in no way did I feel threatened or intimidated.
I then asked him ‘what do you enjoy doing most?’ Simply as a way of attempting to complete the medical and understand what he could do. His reply was quite a surprise and tears welled up in my eyes when he replied in a calm genle manner looking up to the ceiling, ‘sitting peacefully alone in the Park watching he birds’ Somehow, I had pressed a button and he then began to tell me his life story totally without punctuation. He related how he was brought up on a farm in Ireland and had been sent away to school (a school run by the infamous Christian Brothers) then relating how they serially physically and sexually abused the boys on entry to the school and persistently afterwards. As he told the story he became that small child again flinching visibly as he described how he was whipped repeatedly. He acted as if it was happening at that moment and then started peering out of the window describing the horrors of physical and sexual abuse he had witnessed those many years ago. He told me how he told his parents and the priest and they had punished him for making such a terrible accusation. As I listened, pen now fallen to the floor as I was too numb to record anything. I acknowledged his need to express how he felt and tell the tale he needed to tell. He then told me of one of the boys who was very intelligent and had vowed to the other boys that he would study hard and become a lawyer and expose these perpetrators and eventually that same boy did qualify as a lawyer and was now in a position to gather evidence and expose these people once and for all. This lawyer had approached this customer to be a witness but sadly he felt with his criminal record his story would have no validity. I had become that person for him to tell and to listen to his evidence. As he took a breath I told him I believed him implicitly and he didn’t need to say more and with that he rose to his feet and took flight and sped rapidly down the road into the abyss as if free at last.
Greatly disturbed by this consultation ,I requested that I could speak to one of my colleagues who listened sensitively and allowed me to debrief. It was a few years later that the full scandal was released in the press. A childhood of abuse, a lifetime of suffering and frustration in not being able to trust anyone especially those in positions of authority or trust. I felt absolutely impotent all I could do was listen and hope whatever time he had left on earth could be peaceful just watching the birds.

These 2 experiences have made a lasting impression but account for why I strongly feel that we should all be responsible safeguarding our children. It is why I always try to show an open door to any new mother even if the reason for the visit is trivial and I like to see them during their pregnancy in order to give them support and khelp if coping is a problem. Having a child is an amazing experience and privilege and with all the will in the World we don’t always get it right and we cannot predict what stresses will prevail.
“life is like a box of chocolates, you never know what you’ll get” forrest gump?
There are provisions in place for support to families who are not coping in any form and contact with them could prevent a Tradegy.

SAFE – Supportive Action for Families in Ealing

Ealing Local authority has a team which is made up of psychologists, therapists, counsellors, pupil/ school workers, family workers and other experts. They also have links with other support groups and services in Ealing to ensure you are given support within your community and the area where you live.
contact the Ealing Children’s Integrated Response Service on 020 8825 8000.

Now it is mandatory that all staff working in the surgery attend a Child Protection Training every 3 years. We are CRB checked and even if we work in another setting eg Out of Hours we must have a CRB check. I have made my own children aware from an early age even if they were babysitting in their teens and emphasised to the parents and them how they must call me if the child is not easily pacified. Infact, when my daughter was in the surgery several years ago doing somee light administrative work as a student,she reported a concern she had observed and this was taken up by Social Services and the child was put on the ‘At Risk Register’ and the mother was given support and practical help whilst under great personal stress and the child was able to remain with the mother.

Where I work in Hillingdon Urgent Care Centre whenever a child of under 16 years is seen it is necessary to report who brought the child and you as the doctor satisfied there are no child protection concerns. It is fixed in my mind to do the same every time I see any child. All attendances of children are viewed by the health visitors and followed up if appropriate.

Please familiarise yourself with warning signs as everyone has direct for indirect contact with children and report as suggested or talk to one of us in surgery- it will always be considered highly confidential and dealt with sensitively.
We are ALL responsible for the welfare of children in our midst.

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Posted by on August 1, 2013 in Training and Advice


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What is ‘mental health’?

I am now continuing to air my views on mental health along with ideas that I have extracted from the Slovenian psychiatrist Andrej Marušič I mentioned in my last blog about depression
I have often wondered what we mean by Mental Health and was interested in his ideas but then when I read the news today proclaiming that one third of children under the age of 16yrs contemplate suicide I realised that the mental health of the nation is a serious problem and stretches deeper than one could imagine.
Mental illness accounts for 23% of the UK’s total burden of disease (compare this to cardiovascular disease or cancer which each account for 16% of the total burden of disease). Yet only 13% of current NHS health expenditure is on mental health. The World Health Organisation estimates that depressive disorders were the third biggest global health problem in 2004 and by 2030 they will be the largest.
What is important is, that when we talk about ‘mental health’ we take into account everything we see – appearance, behaviour, the way the person moves and what they say. Based on this we can assume what we think and guess which mood someone is currently in. If I was crying five minutes ago and then yelled at you in the next five minutes you would probably think my mood very unstable and would benefit from seeing  a psychiatrist.

This is mental health, as we see.  Psychiatrists frequently make assumptions – GPs do the same – and, actually, this is not a big deal. Firstly,what we see and assume about mental health, about the health of someone’s mind, is captured between two very important determinants – one is genetics and the other is environment.

Genetics may appear less important when it comes to mental health, but that’s not true because two thirds of our genes determine our brain function, whilst the remaining third determines all our other organs. Hence, genetics is very important when it comes to mental health, but clearly it is not the only thing that is important. Each and every one of us is like a book – full of genes that only express themselves if we allow them to do so. If you spent all your life in the same town and had the same job as your father who also lived and worked in the same town all his life, it is clear, that you will be more likely to suffer the same diseases as your father. But if you move from one town to another , or even another country, you would probably be experiencing something else as different genes would appear in your book.
But we must remember that we should never underestimate the role of genetics in mental health. For instance, have you ever heard of two elderly people in care homes been accidentally “swapped”? I doubt it. Babies, however, have been accidentally swapped. This implies that our unique genetic fingerprint becomes more defined each day and with every day we become more and more who we are, and those of you who would like to be as different as possible from your parents should be aware that we become more and more like our parents every day.
I have to say when I worked in a community in South Wales where extended families stayed in the same village or town and rarely moved away the genetic element of disease was very more obvious but when I came to London I have been aware of how the environment has more of an impact on health. I remember a type of woman who functioned reasonably well and then periodically took to her bed unable to open her eyes or respond to anyone and was often married to a doting, caring husband who waited on her hand and foot but was descibed as ‘just like her mother or aunt’ implying a genetic element. Everyone feared that if the husband died as to how she would cope but as often happened the husband did die first but surprisingly enough the woman thrived in more ways than one. If I speak to anyone from that community they know exactly what I mean. Is it depression? Is it unhappiness but whatever it is the person often female needs to withdraw or opt out to survive and in my experience survived to a good age. However,in London most people troubled by mental health problems associate it with stress or change of environment with perhaps some genetic factors.
The second very important thing to consider when assessing ‘mental health’ is that it is ‘captured’ between temperament and behavioural habits. What is temperament ? when a person attends surgery they adopt very similar behavioural pattern on each visit and it makes it virtually impossible for to say anything about a persons temperament when they are seen in surgery.
We all have a temperament which should be tested frequently to determine to what each of us is prone. When I was in a family practise with may be four generations of a family in a close community it was easier to establish the temperant as receptionists or other people gave you the ‘gossip’ “she is always the life and soul of the party” or “he nevers goes out, never has!”

We also have behavioural patterns, this is what we do during most of our waking hours depending on what our role or work is and different behavioural patterns are prone to different diseases.

The third most important thing is the fact that mental health falls somewhere in between mental health in a very narrow sense and mental illness. Whenever someone develops a mental disorder, or mental illness they can be restored to full health. When famous athletes injure themselves, their performances drops that season, but in the seasons to follow they can improve their results.
Or for example, when a manager gets depression, if he recovers he will manage his company better, I believe, because he starts to understand other people and empathises with them better.
I remember being in conversation with GP colleagues and telling them that there were some days I could get full score on depression assessment and some colleagues agreed but one colleague said “I never get depressed”. Not only were we surprised but wondered how she managed to empathise with most of her patients.

When you go to the gym you learn to lift increasingly heavier weights for longer periods of time without developing aches in your muscles. You can use the same principle to practise psycho-fitness.
In the same way that someone who regularly goes to the gym can say “I have been practising this for six months now. I can run for quite some time, I don’t feel at all tired and I am in very good shape”, someone who practices psycho-fitness can develop their abilities to put up with 8Mb of stress instead of 4Mb, or even 12Mb and still go to bed without any worries on their mind.

This makes sense as I am aware when you have a stressful job alongside personal stresses I is imperative that you practise psycho-fitness.

The best thing our mothers and teachers can give us while we are growing up is self-confidence. Self-confidence strengthens our psycho-skeleton which can then put up with more, which means that we can live more easily and are less likely to develop different mental disorders. Italian and Jewish mothers constantly build up their children’s self-confidence by telling them that they are the best looking, the smartest and so on. Whilst it can be difficult to work with such people, who are so full of themselves, you must admit they never suffer mental health problems.
You may be familiar with the phrase ‘nervous breakdown’ for depression. The best way to describe what really happens: the psycho-skeleton breaks, the psycho-muscularity breaks, and this expresses itself on the monoamine level.
Our ability to deal with problems diminishes, our hardware becomes soft. The bottom line is something breaks under the burdens we carry in our backpack, for example physical disability, diabetes or cancer. Sometimes the trigger can be a physical or mental illness which one of our parents may be suffering from.

Imagine,a newly retired lady who resolves to go to her holiday home, everyweek-end, with her husband. But then her mother develops dementia and, she has to become her mother’s carer and something she has looked forward to doing is thwarted. In short, burdens like this can break us, and when we get hit; from the left or from the right – it doesn’t matter from which direction – this hit is like a loss and when we lose something the chance of developing depression increases.
If we are afraid of something the chances of us getting anxious are greater. This is scientifically proven and this breaks us, and when it breaks us we develop depression, which usually manifests itself via biological symptoms, so even though this is a psychiatric disorder it manifests with typical biological symptoms, i.e.a person wakes up every two hours and cannot sleep and if he sleeps for six or eight hours he is just as tired because he lacks the REM (rapid eye movement) dream phase, which helps him reorganise his thoughts. Then he develops psychological symptoms, such as guilt feelings or other distressing feelings. Or the other way around: there are people whose psychological structure is so inclined to depression that they push themselves into depression. The explanation is that they have loads of negative thoughts; that they are inclined to think negatively.
In 1952 Norman Vincent Peale wrote a book ‘Power of Positive Thinking’ which was created a significant following for many years. He quoted
“The way to happiness: Keep your heart free from hate, your mind from worry. Live simply, expect little, give much. Scatter sunshine, forget self, think of others. Try this for a week and you will be surprised.”
However, as Andrej Marušič suggested it could be argued whether there are such things as negative or positive thoughts. “If I tell my children they are not going out until they have finished their homework, this is a positive thought for me, because I am raising them up to be good citizens, although it is a negative thought for them as they are not allowed to go out.
So who will be the judge of what’s positive and what’s negative? The Prime Minister? I don’t consider anybody able to judge what is negative and what is positive.”
Let me illustrate how people think. Basically, we think all the time and our thoughts usually follow the same pattern. Every initial thought is followed by a second thought, usually associated with the first, and so on – moving around universe of thoughts, quite healthily thinking both positively and negatively. This is completely normal, but what happens if a “short circuit” occurs? A short circuit can even occur with completely positive thoughts. Let’s imagine the thought “If I stop going to work, I’ll be fired”. This is a positive thought, in general, since someone who thinks like this is smart and can anticipate consequences. But if this thought is so disturbing and causes so many worries that this person actually stops going to work then this thought – due to its monotony – bears potential for depression.

Now, let’s see how I – and a few others – distinguish between the different types of depression by dividing them into three groups: Blue depression, Red depression, Yellow depression.
Blue depression is the most prevalent and this is why the circle is the biggest and that is the so-called serotonin depression, which is characterised by sleeping disorders, people wake up two hours earlier, they are tired, their appetite is weak and their libido low. A weak appetite doesn’t mean less food intake and a low libido doesn’t mean less sex.
But to me sexuality is not just lying back and thinking of England, it should be joyous.
In short, lack of serotonin reduces libido. In this picture dreams are coloured blue. Dreams are very important but not because you are explaining what you were dreaming while lying on the couch. Dreams are nothing other than recollections of what you experienced through the day put into perspective against your past experiences. This enables us to store only relevant data, as if cleaning up our computer desktop and we place these files into different directories and, according to how much we save, our day may appear long or short.

For example, if you go to Taiwan for a week, this week will appear much longer to you because you will store more data during your dreams than you would during a week at work where you’ve been employed for the last 10 years. We accumulate our memories from our dreams. As we age we experience things we have already experienced before, so time appears shorter. There is a big difference between four years at school and four years at work, when we are 40 years old. We think time passes quicker as we age, because we don’t store memories we have already laid down – we are not travelling to Taiwan.


Red depression is a lack of will, a lack of motivation and a lack of energy. This is a very important depression, so-called noradrenergic depression, and doctors know, that when they give a patient noradrenalin in intensive care, the patient suddenly wakes up, gets up and this is what a noradrenergic depression patients is lacking.

Patients with yellow depression related to levels of dopamine lack enthusiasm and “joie de vivre” or motivated behaviour- “get up and go”. This type of depression is more complex and there are still no specific antidepressants for this type of depression although those on the market do help in some situations. It can be drug induced or in diseases such as Parkinson’s disease which is classically due to severe lack of Dopamine.

With all three types of depression people develop specific psychological symptoms
People with blue depression feel emotionally empty, people with red depression become sad, I know that about I wanted you to see; and people with yellow depression feel extreme hopelessness.

All these people can develop feelings of guilt, low self-esteem and so on. A good psychiatrist, or GP, will listen to you to understand when and how your depression started. If he/she puts you on an antidepressant before you stop talking, turn around and walk out. What’s the target? Every good psycho-pharmacologist must know what he is treating. However. sometimes it is more obvious and the target is reached immediately but in more complex depression which may involve a mixture of more than one types it may changing medication until the appropriate target is met.When the correct medication is found biological depression disappears automatically within four weeks, while psychological symptoms remain. Feelings of guilt are usually the last to disappear.
In summary mental health falls somewhere in between mental health in a very narrow sense and mental illness. It must take into account – appearance, behaviour, the way the person moves and what they say. It is determined partly by genetics and partly by environment depending on where a person spends their life , either remaining in the family circle or moving away. It is also captured between temperament and behavioural patterns.
The type of depression if diagnosed properly medication can treat it effectively. Healthy mental health can be maintained by psycho-fitness which will be my next blog!


The Samaritans is available for anyone struggling to cope, round the clock, every single day of the year. Call 08457 90 90 90, email or find local branch details at


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