When A Stroke Strikes

Physiotherapy for stroke patients is not just about exercises and movement, but also incorporates technology such as functional electrical stimulation and virtual reality. — Photos: SUNWAY MEDICAL CENTRE VELOCITY

There you are, walking around the house, maybe on your way to get something to eat or to the living room to watch some TV.

All of a sudden, one side of your body goes numb and weak, and you lose your balance, causing you to collapse on the floor.

When you try to call for help, you find that you can’t speak properly with your speech sounding slurred.

You realise that you can’t see properly either, as your vision has become blurry.

And when you look at your face in the mirror, you realise that one side is drooping down, but not the other.

You are most likely experiencing a stroke, the third most common cause of death in Malaysia.

This emergency condition occurs when the brain is deprived of vital oxygen supply, either when a blood clot blocks off a blood vessel supplying the brain (ischaemic stroke) or when one of these blood vessels ruptures and starts bleeding (haemorrhagic stroke).

According to consultant neurologist Dr Kok Chin Yong. your brain cells will start to die within minutes after the stroke hits you – about 2,000,000 cells every minute.

Therefore, you need to get help and go to the nearest hospital’s emergency department as soon as possible.

The good news is that there are immediate treatments that can not only save your life, but also minimise any disability you might have from the stroke.

Ischaemic strokes are the most common type of stroke, comprising three-quarters of all cases.

For this type of stroke, the first and most immediate treatment is the administration of tissue plasminogen activators (tPAs), which help break down blood clots.

Says Dr Kok: “For an ischaemic stroke, the target is to unblock the blood clot as soon as possible.

“We can do this with an intravenous (IV) clot-busting agent called alteplase.

“The current guidelines state a cut-off point of 4.5 hours from the onset of symptoms in order to derive benefit from this treatment.

“Hence, time is brain.”

He notes that alteplase is the only US Food and Drug Administration-approved tPA for acute ischaemic stroke at the moment.

Another treatment available in certain hospitals, he adds, is a clot-removal procedure called mechanical thrombectomy, which is done by an interventional radiologist.

Meanwhile, haemorrhagic strokes are usually treated by the neurosurgeon or interventional radiologist.

Explains consultant neurosurgeon Dr Gerard Arvind Martin: “Choosing whether to take the patient to the operating room or not can depend on various factors, such as age and condition of the patient, the level of consciousness and extent of bleeding, all of which the surgeon takes into consideration before performing surgery.

“In those cases where a subarachnoid haemorrhage has occurred due to a suspected aneurysmal rupture, a further scan called an angiogram will be required to determine precisely the site of bleeding.

“Angiograms can be either via computed tomography (CT) scan or a catheter, which is typically carried out by a radiologist in an angiogram suite.

“Depending on the findings, the surgeon can then elect to operate and clip the ruptured aneurysm, or consider endovascular techniques, which are performed by an interventional radiologist.”

If you are lucky, you would have survived your stroke with no or minor complications and have a quick recovery.

However, many stroke survivors will face long-term disability, which can be physical or cognitive.

For example, patients may experience paralysis of the side affected by the stroke; weak coordination; difficulty in speaking, understanding, reading and writing; and difficulty concentrating.

This is where rehabilitation comes in.

A stroke patient exercises his muscles with the help of a machine, supervised by a physiotherapist.

A stroke patient exercises his muscles with the help of a machine, supervised by a physiotherapist.

Physiotherapy Treatment in Malaysia

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Says Dr Kok: “This is an area that is often given less attention, when in fact, to me, it is equally important as the acute treatment for stroke.

 “A good rehabilitation programme improves disability and prevents complications.”

According to Sunway Medical Centre Velocity Rehabilitation Centre head Maxim Chea, stroke rehabilitation has to be individualised to the patient as it depends on the part of the body or type of ability affected by the stroke.

He explains that there are three main types of rehabilitation therapy: physical therapy, technology-assisted physical therapy (e.g. functional electrical stimulation and virtual reality), and cognitive and emotional therapy.

Visual rehabilitation is also available for those whose vision is affected by stroke.

For example, consultant neuro-ophthalmologist Dr Lakana Kumar shares that “Double vision and peripheral loss of vision can be treated with prisms incorporated into glasses for patients to wear.”

Rehabilitation is usually carried out by a team consisting of physiotherapists, occupational therapists, speech therapists, and dieticians/nutritionists, among others.

In addition to physical and cognitive problems, patients might easily become depressed, overly anxious and panic easily.

Says consultant psychiatrist Dr Lim Wai Jenn: “Stroke survivors are at significantly higher risk for neuropsychiatric conditions such as post-stroke depression (one in three patients), anxiety (one in four patients), and other changes in personality and behaviour.

“These conditions impede the rehabilitation process and degree of recovery in post-stroke patients.

“They also significantly impact the patients’ long-term functioning and quality of life, and can even lead to higher mortality rates.

“Early psychiatric assessment and intervention is essential.”

She notes that caregivers also need support and psychoeducation on how best to support patients in regaining function.

While being affected by a stroke is a frightening event, rest assured that there are treatments and therapies available to help you manage this condition – just remember that you need to seek medical help as soon as possible.

By TAN SHIOW CHIN This article is courtesy of Velocity Neurocentre, Sunway Medical Centre Velocity.

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7 stages of stroke recovery: Why home rehabilitation is important

A CT scan of a stroke patient’s brain, showing the affected area of their brain (in violet). The affected area will determine the type and extent of disabilities the patient will have. — Schering AG

By Matthew Teo Yong Chang

Stroke or a cerebral vascular accident (CVA) was the third leading cause of death in Malaysia in 2018, according to the Department of Statistics. The department reported that stroke caused 7.1% of all deaths in the country. However, two-thirds of those who have a stroke actually survive and will require rehabilitation.

The objectives of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. It is crucial as stroke survivors can lose the function of their affected limbs without rehabilitation, something we have observed in real life.

Even though the function of a stroke survivor’s affected limbs may seem lost after the stroke, our brain possesses a trait called neuroplasticity that can help the survivor regain the limb’s function.

Neuroplasticity enables the unaffected nerve cells (neurons) around the affected area of the brain to rewire and create new pathways around the affected area through repetition of physical and mental training, as well as regulated emotional feedback.

However, the extent for neuroplasticity varies in each individual. So, even though rehabilitation does not “cure” the effects of stroke, in that it does not reverse brain damage, rehabilitation can considerably help survivors achieve the best possible outcome in the long run.

Levels of disability

Rehabilitation, rehab, stroke, physiotherapy, activities of daily living, occupational therapy, Star2.com Rehabilitation is aimed at regaining practical function for the patient, like opening a door latch, turning a tap or pushing a switch.

Strokes happen when a blood clot or bleeding (haemorrhage) restricts the blood supply to the brain, resulting in the brain being deprived of oxygen, which leads to the death of brain cells.

Usually, it is only one part of the brain that is damaged and this affects the type and degree of disability the survivor will experience. This also influences how much rehabilitation can help the survivor.

Generally, stroke can cause five types of disabilities:

• Paralysis, or problems controlling voluntary movement

• Disturbance of the senses, including pain

• Problems using or understanding language

• Problems with thinking and memory

• Emotional disturbances

It is also imperative to know the severity of the stroke before deciding on the rehabilitation plan. There are seven recognised stages of stroke recovery through which most survivors progress through:

• Stage 1 – Flaccidity: No voluntary movement is observed.

• Stage 2 – Spasticity appears: Spasticity refers to the continuous contraction of muscles, which interferes with normal movement, speech and gait, and causes the arm or leg to make small involuntary jerky movements.

• Stage 3 – Increased spasticity: The e arm or leg becomes more spastic, and the muscles feel stiff and tight against external resistance.

• Stage 4– Decreased spasticity: Spasticity of the arm or leg decreases and the limb begins to move more easily.

• Stage 5 – Complex movement combinations: The movement of the limbs start becoming more coordinated and full movement begins to return.

• Stage 6 – Spasticity disappears: Muscle spasticity disappears and isolated joint movements are voluntary; however, spasticity may return if the patient is tired.

• Stage 7 – Normal function returns: Movements return to normal.

Each stage requires different types of approaches and exercises for rehabilitation.

Home rehab

Rehabilitation, rehab, stroke, physiotherapy, activities of daily living, stretching, Star2.com A volunteer helps a stroke patient with her exercises during a therapy session. Stroke survivors are recommended to do flexibility exercises two to three times a week for the rest of their life.

The rehabilitation programme for stroke survivors involves a multidisciplinary healthcare team consisting of a rehabilitation physician, nurses, occupational therapist, physiotherapist, speech therapist, dietitian and clinical psychologist.

However, the most important members of the team are the patient and their caregivers. This is as rehabilitation should be done daily at home, not just during therapy appointments.

Battling stroke disabilities is not as simple a remedy as taking a pill from the doctor or attending a session with the therapist for an hour a week. It requires compliance to medication and the continuous effort to practice the therapies repetitively with strong determination!

Contrary to common belief, stroke rehabilitation can be offered in any setting without sophisticated equipment or technology.

The American Heart Association recommends that stroke survivors perform aerobic exercises three to seven days per week, as well as strengthening, flexibility and neuromuscular exercises two to three days a week, for the rest of their life.

Training at home, in a familiar environment, by adapting and using utensils or tools at home is more meaningful than the therapeutic remedial therapy received at institutionalised centres.

For instance, toilet training at a hospital ward is not as useful as toilet training in your own home, as you will eventually be going home and using that toilet, rather than the hospital’s toilet.

After all, the ultimate goal of rehabilitation is to promote optimal functional independence in the survivor’s own living environment.

Besides, providing therapy in the home environment supports continuity of care, provides a relevant environment for daily function, and encourages patients to develop problem-solving skills.

Some of the other benefits of home rehabilitation for stroke include:

• Early discharge from the hospital to return to the comfort of your own home.

• Avoiding hospital-acquired pneumonia and other illnesses due to a shorter stay.

• Reducing the cost of care.

• Preventing deterioration and promoting health through physical activity.

• Preventing falls, which are common among older patients and can cause additional long-term disability.

Barriers to home rehab

The main barriers towards rehabilitation in stroke are a lack of motivation and apathy towards recovery. Most stroke survivors stop coming for their treatment regime after a period of rehabilitation because they do not see any significant improvement.

Over a period of time, they will begin to learn helplessness and compensate themselves – mostly incorrectly – for their abnormal postures and movement, leading to non-compliance in rehabilitation.

Poor awareness among the public about the different roles of the different therapists in stroke rehabilitation could also be another barrier in rehabilitation.

In addition, the lack of trained therapists in Malaysia for stroke rehabilitation is also another factor, as it contributes to increased cost of hiring in-house therapists for home rehabilitation due to their scarcity.

Matthew Teo Yong Chang is a lecturer in the School of Occupational Therapy at the Perdana University Graduate School of Medicine. This article is courtesy of Perdana University. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

Stroke Hand Exercises: For every stage of recovery

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Post-Stroke Exercises (Part 1: Upper Limb)

A physiotherapist explains safe lower limb exercises for stroke patients This video is brought to you by Singapore General Hospital.

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Post-Stroke Exercises (Part 2: Lower Limb)

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Stroke Exercises for Arm & Hand with Little to No Strength-for Home

"Famous" Physical Therapists Bob Schrupp & Brad Heineck demonstrate stroke exercises you can do in your own home for the arm and hand that has little to no strength.
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Stretches For Hand Spasticity - Best Stroke Recovery Hand Exercises

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Best Stroke Recovery Hand Exercises - Stage 1

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Best Stroke Recovery Hand Exercises - Stage 2

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Best Stroke Recovery Hand Exercises - Stage 3

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Covid-19 Affecting many organs in our body: road to recovery to gain Strength and immunity

 

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Recognition and Management of Stroke

Rehabilitation key to improving health

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Rehabilitation crucial for patients with...

DAEHAN Rehabilitation Hospital Putrajaya offers customised rehabilitation services that focus on intensity and discipline to give patients with neurological and orthopaedic disabilities optimal results.

Strokes and other neurological disabilities often leave individuals with lasting and damaging effects that can greatly impede their daily functions.

This brings to light the need to raise awareness on the crucial and beneficial role rehabilitation can play in the lives of such patients.

According to Dr Fazah Akhtar, studies have shown that early and high-intensity rehabilitation has given patients better outcomes.

“Certain neurological conditions such as strokes and traumatic brain injury have a window period of best recovery after the event,” said Dr Fazah.

“If an individual were to undergo high-intensity inpatient rehabilitation in a specialised hospital or unit, the recovery and functional outcomes of the patient have shown to be better than those who do not receive such treatment.”

Understanding this approach, Daehan Rehabilitation Hospital Putrajaya offers South Koreanstyled rehabilitation services in which they are on a one-on-one basis and are personalised to specifically match the needs of the individual.

Besides stroke patients, they also manage cases of traumatic brain injuries, hypoxic brain injuries, brain tumours, spinal cord injuries, musculoskeletal conditions and other complex conditions that require multidisciplinary rehabilitation.

With an emphasis on intensity and discipline, the inpatient rehabilitation programmes are planned and targeted for a duration of three months with extensions as needed.

A programme’s daily schedule usually features several rehabilitation sessions, starting at 9am and end at 5pm.

In addition, parts of the programme are practised in open and spacious therapy areas such as the gymnasium to enhance engagement and social interactions between patients.

This forms a support group system and such peer encouragement has seen a positive impact on the programme, says Dr Fazah.

All this is further augmented by technological advancements such as gait robotics, computerbased therapy, individualised hydrotherapy, and anti-gravity treadmills.

Their full list of therapy programmes includes physiotherapy, occupational therapy, functional electrical stimulation (FES), pain therapy, speech therapy, dysphagia rehabilitation, computerised cognitive function therapy, activities for daily living (ADL) training, return to work training, pulmonary rehabilitation, machine treatment, gait training with special equipment, robot-assisted gait trainer, hydrotherapy treadmill, and anti-gravity treadmill.

Meanwhile, their facilities and services include an emergency department, room and board, imaging department, specialist clinic, daycare service, inpatient and outpatient services, and outdoor therapy.

While Daehan Rehabilitation Hospital Putrajaya only offers its services to adults at this point, there are plans to expand to paediatrics rehabilitation soon.

Certain neurological conditions such as strokes and traumatic brain injury have a window period of best recovery after the event.

-Dr Fazah Akhtar

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Covid-19 Affecting many organs in our body: road to recovery to gain Strength and immunity

.Covid-19 can affect our blood vessels, causing blood to clot more easily, which can result in stroke, heart attack or pulmonary embolism, among other conditions - AFP

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Affecting multiple organs

Covid-19 can have a wide-ranging effect on many organs in our body

THE last time, you were telling me about many unusual Covid-19 symptoms, such as Covid toes, skin rashes. and loss of smell and taste (From taste to toes, StarHealth, May 31). What about the gut?

Yes. The SARS-CoV-2 virus that causes Covid-19 binds to our lung cells using the cell’s ACE2 (angiotensin-converting enzyme 2) receptor.

This receptor is also present in our intestinal cells.

The theory is that the virus is in our saliva.

When we swallow our saliva, the virus gets into our guts and binds to our intestinal cells using their ACE2 receptors.

Once this happens, we get diarrhoea, nausea and vomiting.

Sometimes, a Covid-19 patient may only experience these symptoms, without any lung problems like a dry cough or difficulty breathing.

Covid-19 patients with gut problems tend to be diagnosed later and have longer infections.

On average, Covid-19 patients have diarrhoea for five days.

Wait, if Covid-19 patients have diarrhoea, does that mean we have to be careful about using toilets then?

Yes. For example, if one of your family members has Covid-19, it might be advisable to allocate one toilet for their use only, or at least allocate one toilet paper roll for their sole use.

You should also disinfect the toilet seat the patient is using after each use and wash your hands.

I have also heard of the kidney being affected?

You are right.

It occurs through the same mechanism; the kidney also carries ACE2 receptors on its cell membranes.

Some studies are finding that as much as one-third of Covid-19 patients admitted to hospital, develop kidney problems, resulting in acute renal (kidney) impairment, or worse, outright acute renal failure. Some patients even require dialysis.

Patients who develop kidney problems are usually the ones who also have the worst lung symptoms.

It may be that the amount of virus in them is very high and/or their immune system is acting up very badly.

When the immune system is heavily provoked, what happens is that it releases a cytokine storm.

The blood vessels are affected and they start to leak fluid.

When there is less fluid going into the kidneys, they do not get enough oxygen and their tubular cells get damaged.

Gosh! What are the other organs Covid-19 affects?

There is also the liver. Once again, this is an organ with cells rich in ACE2 receptors.b

Over half the patients hospitalised for Covid-19 develop some kind of liver impairment.

This is diagnosed by a blood test showing elevated liver enzymes.

Luckily, the liver is not usually affected so badly by Covid-19 that it results in acute liver failure.

The theory for this is that the kidneys may be directly affected by the virus, but the liver is not, and any ill effects on it are more a result of the body’s own cytokine storm.

I really think I don’t want to risk getting Covid-19! Are there any other organs affected?

You are wise. It really is not worth the risk as we can be one of those that are affected very badly.

As for your question, the brain is also affected.

The brain? How?

It has all to do with the ACE2 receptors again.

You see, many blood vessel cells also have these receptors.

As blood vessels are present all over our body, any effects on them are not restricted to a specific organ, like the lung, kidneys and intestines.

So if Covid-19 directly affects the blood vessels of a patient, they will cause blood clots more easily as they are damaged.

In autopsies done on deceased Covid-19 patients, blood clots are apparent throughout many organs in their bodies.

This suggests that many blood vessels and organs are affected by the disease.

Once you have blood clots, you may have complications like stroke where blood clots travel to the arteries of the brain and clog them up.

Doctors have also observed patients with dizziness, confusion, delirium, altered mental state and muscle weakness.

This has to do with the brain getting inflamed.

Wait, when blood clots form in blood vessels, not only a stroke can happen, right? This can also cause a heart attack.

True, blood clots can lead to a heart attack or a pulmonary embolism when a clot gets into your lungs

In fact, Accident and Emergency departments in some hospitals have received patients with heart attacks who turn out to have Covid-19 when they were tested.

Covid-19 can also attack the heart directly by inflaming the heart muscles.

This is known as myocarditis.

It can lead to chest pain, abnormal heart rhythms and heart failure.

There is also a condition called “happy hypoxia”.

This is when a Covid-19 patient has very low levels of oxygen as shown on the monitor, but appears to be breathing more or less normally.

Many doctors have theorised that this condition could be due to blood clotting in the lungs.

DR.Y.L.M

Dr YLM graduated as a medical doctor, and has been writing for many years on various subjects such as medicine, health, computers and entertainment. For further information, email starhealth@thestar.com.my. The information contained in this column is for general educational purposes only. Neither The Star nor the author gives any warranty on accuracy, completeness, functionality, usefulness or other assurances as to such information. The Star and the author disclaim all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information

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COVID-19: Damage found in multiple organ systems

Boosting immunity

Here are nine ways to strengthen your body’s defence system against illnesses through healthy eating and daily habits.
 

dehydration makes you more susceptible to falling sick, so ensure that you fill up on fluids, especially if you are outside under the hot sun.— Filepicb

LATELY, we’ve all been wondering if we are doing enough to keep our bodies strong and warding off illnesses.


One critical way to ensure that you have a fighting chance is to boost your immunity.
The immune system is made up of organs, cells, tissues and processes that fight against germs and toxins trying to enter our body.

You can bolster your immune system by making good lifestyle and food choices; and you’ll see results by being consistent.

Your body will feel healthier, you’ll have more energy and you’ll spend less time waiting to see the doctor for a common ailment.

It’s important to note, however, that no matter how strong an immune system is, you cannot stop bacteria and viruses from entering your body.

In order to avoid contracting a dangerous disease like Covid-19, you should still practise social distancing, wear a mask and wash your hands frequently.

So just to be clear, the tips below are not to protect specifically against Covid-19, but to help you boost your immune strength to fight off all types of infections.

Get the proper amount of sleep

Adults need an average of seven to eight hours of sleep every night.

Teens need eight to 10 hours, and younger children and infants up to 14 hours of sleep daily.

A lack of sleep or poor quality sleep has been linked to a higher frequency of falling sick, leading researchers to believe that sleep and immunity have close ties.

Also, sleeping for longer periods when sick, lets your immune system fight illnesses more effectively so that you heal faster.

In a study involving 164 healthy adults, those who had less than six hours of sleep per night were more susceptible to colds, compared to those who had at least six hours of sleep.

To avoid having trouble falling asleep, there are several things you can do:

> Keep your room completely dark, e.g. close the curtains fully, remove any night lights or use a sleep mask.

> Keep your bed time consistent, even during weekends and holidays.

> Exercise regularly, even if it’s just brisk walking for 20 mins a day.

> Limit screen time (TV, phone, laptop) at least an hour before bed in order to prevent the impact of blue light from disrupting your circadian rhythm (your body’s natural wake-sleep cycle).

Eat lots of whole plant foods

Whole plant foods like vegetables, nuts, seeds and fruit are rich in antioxidants, vitamin C and fibre.

Eating more of these nutrientdense foods helps to lower your risk of infections.

This is because the antioxidants in the foods decrease inflammation by battling unstable compounds known as free radicals.

Chronic inflammation has been found to occur more frequently in patients with heart disease, Alzheimer’s disease and certain cancers, so it’s important to find effective ways to reduce inflammation.

At the same time, whole plant foods are high in fibre and feed your gut microbiome (the community of healthy bacteria in your gut).

A robust gut microbiome can improve your immunity and help keep harmful pathogens from entering your body via your digestive tract.

Additionally, other nutrients found in whole plant foods, like vitamin C, may help to reduce symptoms of the common cold.

Eat foods like papaya, broccoli, spinach, garlic, ginger, bell peppers and kiwi fruit.

Consume healthy fats

Sunflower seeds or kuaci, in this filepic are good source of healthy fats.

Healthy omega-3 fats have anti-inflammatory properties.

These fats could be a key weapon in fighting against illnesses, considering that chronic inflammation prevents your immune system from performing at its best.

Healthy fats can be found in foods such as olive oil, salmon, chia seeds, sunflower seeds and almonds.

Olive oil, in particular, is highly anti-inflammatory, and has been known to decrease the risk of chronic problems like heart disease and type 2 diabetes.

The anti-inflammatory properties of these healthy fats may be critical to helping your body fight off harmful disease-causing bacteria and viruses, so try to get more of it in your diet now.

Have more fermented foods

We are learning that immunity and gut health are intertwined.

Your digestive tract contains beneficial bacteria (probiotics) that you can increase in amount by eating fermented foods like yoghurt, sauerkraut, kimchi, kefir and natto.

This may help strengthen your immune system by helping it to identify harmful microorganisms as a healthy ecosystem of gut bacteria teaches your immune system how to tell the difference between good bacteria and bad bacteria (pathogens that cause problems).

In a three-month study in 126 children, those who drank 70ml of fermented milk every day were found to have less childhood infectious diseases by about 20%, compared with a control group.

Another study of 152 people infected with a rhinovirus found that those who supplemented with the probiotic Bifidobacterium animalis had a much better immune response and lower levels of the virus in their nasal mucus.

Cut your sugar intake

A high intake of sugar and refined carbohydrates contribute to obesity, heart disease and other conditions that disrupt your immune system.

According to an observational study in around 1,000 people, obese people who were administered the flu vaccine were twice as likely to still get the flu, compared to non-obese individuals who received the vaccine.

Curbing your sugar intake can decrease inflammation and aid weight loss, thus reducing your risk of chronic health conditions.

Strive to keep your added sugar intake to 5% or less of your daily calories, which is equal to about two tablespoons of sugar for a 2,000-calorie diet.

Throw in some exercise

Moderate exercise can give your immune system a boost.

Studies indicate that even a single session of moderate exercise can boost the effectiveness of vaccines in people with compromised immune systems.

By making it a regular routine, moderate exercise helps your immune cells to regenerate often and reduce inflammation.

Some types of exercises you can do include brisk walking, indoor cycling, jogging, swimming and hiking.

Aim for a minimum of 150 minutes of moderate exercise per week.

Drink enough fluids

Dehydration paves the way to making your body susceptible to falling sick.

Without enough water, you may experience headaches and hinder your physical performance, focus, mood, digestion, and heart and kidney functions.

Hydration itself doesn’t protect you from germs and viruses, but dehydration increases your susceptibility to illness.

To know that you are drinking enough water regularly, the colour of your urine should be a clear, light yellow.

Plain water is the best option to stay hydrated – it is free of calories, additives and sugar.

You will need more fluids if you exercise a lot, work outside or if the weather is hot.

Keep stress at bay

Reducing anxiety and stress will help to improve immune health.

In the long run, stress increases inflammation and messes with your hormonal balance and immune cell function.

Long-term stress is especially taxing on children, weakening their immune response

Activities that are often recommended to help people manage stress include exercise, journaling, drawing or painting, meditation, outdoor walks and other mindfulness practices.

If you feel a need to express how you feel to someone, then seeing a certified counsellor or therapist can help.

Supplement wisely

;
Two things to note about supplements: the first is that they are not a replacement for a well-rounded diet, and the second is that they don’t guarantee that you will be free from getting sick.

Some studies however, have found that supplements may fight off viral infections, or at least give your immune system a helping hand in staying strong.

If you would like to take supplements, choose wisely.

Here are some vitamins and minerals to consider taking that may help improve your immunity:

> Vitamin E

This vitamin is a powerful antioxidant that helps the body fight off infection, and is found in foods like nuts, seeds and spinach.

> Zinc

A peer review of 575 people with the common cold, who took more than 75 mg of zinc per day, reduced the duration of their cold by one-third, compared to those who didn’t take the supplement.

> Vitamin D

A deficiency in this vitamin may increase your chances of getting sick, so supplementing may counteract this effect.

> Vitamin B6

This vitamin is vital to supporting biochemical reactions in the immune system.

Vitamin B6-rich foods include chicken, cold water fish such as salmon and tuna, green vegetables and chickpeas.

The bottom line is that improving your lifestyle and making better dietary choices can help strengthen your immune system to fight off harmful pathogens and keep you healthy and well.

By Datuk Dr Nor Ashikin Mokhtar,

who is a consultant obstetrician and gynaecologist, and a functional medicine practitioner. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information

When muscles shrink

Despite having normal nutrition, many senior citizens actually have low muscle mass, making them more prone to falls and fractures.

MUSCLE loss or sarcopenia is a natural part of ageing and one of the main contributors to musculoskeletal impairments in the elderly.

Photo: 123rf.com Photo: 123rf.com

Strong muscles support the joints as they help absorb the stress placed on the joints when you move.

Without adequate muscles, the joints take a beating, and can cause the individual to become frail and more likely to suffer from falls and fractures.

The 2018 Malaysian National Health and Morbidity Survey (NHMS) reported that 15% of those aged above 60 had fallen at least once over 12 months.

Half suffered injuries, while one in five were hospitalised.

Even if you are active, it is still possible to have some muscle loss beginning in your 30s.

However, there are steps you can take to slow down or prevent losing muscle.

Missing muscles

According to Asia’s largest clinical study of its kind on nutritional outcomes in the elderly, there was a prevalence of low muscle mass among the elderly, despite them being active, healthy and without any chronic medical illnesses.

The two-part Singaporean study, called Strengthening Health in Elderly through Nutrition (Shield), was jointly carried out by Changi General Hospital (CGH), Sing Health Polyclinics and healthcare company Abbott.

Results from the first phase of the study was published in the Plos One journal last year.

This observational phase looked at 400 healthy individuals in Singapore aged 65 and older.

The results revealed that the prevalence of low muscle mass was higher in females (24.9%) than in males (15.5%), with even adults with normal nutritional status at risk for having lower muscle mass. (See Maintaining muscles during menopause).

Every one-year increase in age over 65 years was associated with 13% higher odds of having low muscle mass.

And 52% of participants had vitamin D insufficiency despite living on an island where sunshine is available the whole year round.

“The majority (93%) of the subjects were fully independent and self-caring in the community.

“All the subjects were living at home and able to walk independently without any walking aids, and were relatively active prior to the study

“Participants were not subjected to any exercise programmes before or during the study.

“We assessed their physical activity level using the PASE (Physical Activity Scale for the Elderly) questionnaire.

“The average PASE score of the study participants was 119.45, similar to the norm of older adults,” says principal investigator Dr Samuel Chew, adjunct associate professor and senior consultant at the geriatric medicine department at CGH.

However, the subjects’ daily diet was not collected in this first part of the study.

A combination of physical activity, which includes weights or resistance training, and a balanced diet with an adequate amount of high-quality protein (e.g. chicken breast, fish, eggs, tofu and other soya products), is essential for good muscle health and function.

However, many seniors don’t embark on strength training programmes and cite difficulty in chewing meats and poultry due to deteriorating teeth, so they avoid eating protein or get little of it in their diets.

Assoc Prof Chew says, “We are unable to comment on the possible reasons for the observed low muscle mass, but from the available literature, there is a measurable decline in muscle mass from the age of 40.

“The decline rate increases by about 8% every 10 years and accelerates after the age of 70 to about 15% every 10 years.

“There are many factors that contribute to this loss in muscle mass, such as changes in hormone and endocrine levels, the loss of connections between the nerves and muscle units with the onset of ageing, acute or chronic illness, and inactivity.

“In addition, those above the age of 65 require more dietary protein in order to stimulate the same amount of muscle protein synthesis as a young person.”

Other factors that may impact elderly diets are:

> The lack of knowledge about good nutrition

> The lack of awareness about the high prevalence of low muscle mass and inadequate levels of micronutrients such as vitamin D

> Poor oral health

> Loss of appetite due to physiological and sensory/taste changes associated with ageing

> Living alone

> Other illnesses

> Use of multiple medications

Get some sunshine

As for the lack of vitamin D, it is apparently common in older adults.

“The results from our study are consistent with previous studies performed in Asia.

“Therefore, while the finding is not unexpected, it still poses a cause for concern.

“Vitamin D is produced in the body naturally when the skin is exposed to sunlight.

“It is also found in dietary sources such as dairy products, oily fish, eggs and mushrooms.

“As such, it is likely that the vitamin D insufficiency is related to a lack of exposure to sunlight and/or insufficient intake of vitamin D-rich food sources,” explains Assoc Prof Chew.

To overcome this deficiency, one method is to get 15 minutes of exposure to outdoor sunlight daily.

He asserts, “It is vital for the activity to take place outdoors, as the component of sunlight that stimulates the production of vitamin D in the human skin does not penetrate glass windows very well.

“However, be mindful of direct overexposure to sunlight, which may result in skin damage and other health complications.”

The Shield study compares to a similar European ageing study that was carried out in Berlin, Germany, where the prevalence of sarcopenia was 24.3%.

“Many factors can affect the results, such as the characteristics of the study participants, methods used to measure muscle mass and cut-off criteria used to define low muscle mass, and participants’ nutritional status.

“The study conducted in Europe included generally healthy community-dwelling older adults who may have had normal nutritional status or were at risk of malnutrition, which is a risk factor for low muscle mass.

“Therefore, the true prevalence of low muscle mass in the general population aged 65 years and above in Singapore is likely going to be higher than the prevalence observed in our study, as they would include individuals who are at risk of malnutrition,” says study co-investigator and Abbott Scientific & Medical Affairs divisional vice-president Dr Low Yen Ling.

While no similar studies have been carried out in Malaysia, it is believed that our elderly could also be having low muscle mass.

Statistics from the Global Burden Disease Study 2010 shows that the lifespan of Singaporean men is 78.8 years, and for women, 83.3 years. So, even with lower muscle mass, women are living longer.

Dr Low reflects: “Biological, behavioural, and environmental factors can all contribute to this topic.

“One possible explanation is that men smoke more often than women.

“Some evidence also suggests that although both men and women are living longer as the burden of infectious diseases falls, such reduction may disproportionally benefit women.

“This is an ongoing effort and researchers are still studying how all these potential factors influence life expectancy and ways to improve longevity.

“What we know is that scientific evidence has shown that low muscle mass is associated with negative outcomes such as higher risk of functional impairment, fractures, complications, and even mortality.”

Less muscles, poorer immunity

Skeletal muscle accounts for about 40% of total body weight and contains at least half of all body proteins.

Data suggests that loss of muscle mass is associated with compromised immunity and infections.

Research in older adults has shown increased markers of inflammation associated with low muscle mass and muscle function.

Immunity is affected if an older adult loses more than 10% of their lean body mass, while a decrease of more than 30% can make them susceptible to pneumonia.

This is probably because muscles produce and release compounds that play an important role in the proliferation, activation and distribution of certain immune cells.

Assoc Prof Chew says, “Hospitalised patients with pneumonia may have poor outcomes, and this is often associated with very low muscle mass and poor nutrition – two factors that are also linked to a weakened immune system.

This is because muscles are a natural reservoir of amino acids, which are required for proper functioning of the immune system.

“Decreased muscle mass, together with the associated loss of physical strength and function, can lead to an impaired recovery from critical illness.

“Infection in an individual with deficient muscle mass causes further inflammation in the body, which can cause further loss of muscle mass and impairment of the immune system, resulting in a vicious cycle that may ultimately result in poor health outcomes.”

To help preserve muscles, Dr Low provides these tips:

> Engage in regular exercise

Aim for at least 150 minutes of moderateintensity exercise a week, and include resistance training to maintain muscles and strength.

> Eat enough protein

Incorporate chicken, seafood, eggs, beans or dairy into your diet, and aim for about 20-30g per meal.

Adults 65 years and above may need up to 50% more protein than younger adults.

To further amp up protein intake, snack on proteins between meals or supplement your diet if needed with protein powders or shakes.

> Follow a balanced diet

Choose a balanced diet full of vegetables, fruits, whole grains, proteins, healthy fats, and key vitamins and minerals like calcium and vitamin D.

> Consider HMB (beta-hydroxy-betamethylbutyrate)

HMB is a metabolite of the essential amino acid leucine and a naturally-occurring compound that has been shown to preserve muscle mass in healthy older adults when taken as a supplement.

While HMB is naturally found in very small amounts in foods such as avocados, grapefruit and catfish, it’s hard to get enough from food sources alone to achieve the desired health benefits.

Having healthy muscles is critical to ensure that the elderly can continue to retain their mobility, strength, energy levels and independence as they age – the Shield study reinforces that.

There is also a correlation between skeletal muscle and bone health – healthy muscles link to healthy bones, but strong bones do not necessarily mean that the muscles are strong.

Dr Low suggests: “It is important to perform early screening to identify those who have low muscle mass, so that appropriate interventions can be implemented.

“Muscle health can be determined by using a handheld dynamometer (to test hand grip), measuring calf circumference or measuring muscle mass using the bioelectrical impedance analysis (BIA).”

The second phase 2 of the Shield study, to be completed this year, will involve 800 elderly participants at risk of being malnourished, who will be placed on oral nutritional supplements.

The aim is to find out how the supplement will affect their nutritional status, and their rates of hospital admission and re-admission.

The signs of muscle loss

Maintaining muscles during menopause

NEW European research has found that keeping physically active during menopause could help women maintain muscle mass.

 Keeping active during menopause can help maintain a woman’s muscle mass, which is important to staying active and independent.—AFP

Carried out by researchers at the University of Jyväskylä, Finland, the new study looked at 234 women aged 47 to 55, who were followed from perimenopause to early postmenopause, which is the stage after menopause when menstruation has permanently stopped.

The women had their muscle mass measured and hormone levels tested in the perimenopausal state and right after entering postmenopause.

The women were also asked to self-report their physical activity levels and wear an accelerometer for seven days, which is a wearable device that records movement.

The findings, published in the Journal of Clinical Medicine, showed that the average duration of menopausal transition was one-and-ahalf years, although the researchers note that the time it takes to go through menopause is unique for each woman.

For some of the women in the study, it took less than six months, and for others, it took more than three years.

The researchers also found that during this time, the women experienced significant decreases in various measures of muscle mass, with an average of a 1% decrease in muscle mass.

However, women who were more active during the menopausal transition had higher muscle mass before and after menopause, compared to the less active women.

The researchers say this highlights the importance of keeping active during the transition from perimenopause to postmenopause, when the production of oestrogen stops and leads to a decline in muscle mass.

“We already knew that oestrogen has a role in the regulation of muscle properties,” says doctoral student Hanna-Kaarina Juppi.

“By following the hormonal status, measuring many aspects of muscles, and by taking into consideration the simultaneous chronological ageing of women going through menopausal transition, we were able to show that the decrease of muscle mass takes place already in early postmenopause.”

She adds: “The observed change does not seem like much, but what is meaningful is that the decline happens in a short period of time and can have an impact on metabolism, as muscles are important regulators of whole-body metabolism.” – AFP Relaxnews

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Weights and protein: Are protein supplements really the whey to go?

Protein shakes have divided nations! Some will be critical of the singlet toting gym junky’s protein shaker and others will feel inspired to shake themselves. So should you protein shake?

To shake or not to shake?

One quality scientific review, found protein supplementation with resistance training to increase muscle mass more than resistance training alone. Additionally, in conjunction with a healthy diet protein supplementation can aid in fat loss (1). A further review study found protein ingestion with resistance training to increase muscle mass, strength, explosive power and power during endurance based tasks more than resistance training alone (2). This tells us you should get shaking!

What, when, how to shake:

If it is an entire protein supplement you are consuming such as whey powder, then consuming the product within 30 minutes post workout appears to offer maximal strength and muscle mass benefits (3). Consuming protein after a workout becomes even more effective when it is consumed with a high GI carbohydrate like glucose or maltodextrin. Try adding a spoonful of honey to your shake or buy maltodextrin powder and add a sprinkle.

Amino acids are the building blocks of proteins and one such amino acid is Leucine. It appears that protein supplements containing 3-4g per dose of leucine most optimise the amount of protein effectively used (synthesised) by the body. Consuming any normal whey protein should achieve this.

Alternatively, If you consume an isolated amino acid supplement (more expensive), you’re best taking this pre-workout. Although these are more expensive than protein supplements and confer no further benefit (3).

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The deep historical roots of racism

The #Blacklivesmatter protests have countries around the world examining their own problems with race.

Colonialism

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IT has been 400 years since the first ship carrying 20 enslaved Africans arrived on American soil, in Virginia – stolen lives in a stolen land. Slavery ended long ago but its legacy lingers on, in the callous disregard for black lives.

The killing of George Floyd, caught on video, has led to protests across the United States and catapulted the Black Lives Matter movement around the globe, with many “taking a knee” in solidarity.

Modern racism based on skin colour has its roots in the slave trade. (Note that Roman slavery in ancient times was not race-based.) To justify enslaving fellow humans, a narrative was perpetuated: dark skin was inferior. Slaves were “stupid” and “lazy”, as were natives who “needed” to be colonized. One common belief was that black people did not feel pain as whites did. This justified physical mistreatment and horrific experiments performed on blacks. J. Marion Sims, the “father of modern gynaecology”, repeatedly cut the genitals of enslaved women without anaesthesia in experimental surgeries.

Ideas like white superiority still persist. Systemic racism traps people of colour, making social mobility difficult.

There are some parallels here. Among Malaysians, more Indians die in police custody – they account for almost one in four deaths in custody, despite making up only 7% of the population.

Some cases have come to light. N. Dharmendran died in custody aged 31 from “breathing difficulties” in 2013. But a postmortem found multiple trauma injuries and stapler bullets in his ears. A. Kugan was only 22 when he died in a cell in 2009. His family broke into the morgue and fought for a second autopsy, which found injuries from repeated trauma.

Indians are falling behind in all areas. Among major races, they have the lowest life expectancy, highest suicide rate and lowest relative home ownership, a 2017 study from the Centre for Public Policy Studies found. They also own just 1.5% of shares in limited companies and have a relatively high involvement in crime and gangs. Inequality breeds crime – studies show if there’s little chance of legitimate success, unlawful activities are more likely.

How did Indians end up in this state? The answers lie not in race but history.

It has been close to 200 years since the first ships carrying indentured workers from India docked in ports of her Majesty’s colonies. After slavery ended in the British empire in 1833, giving black slaves manumission, plantation owners looked to India for replacements.

The Indian indentured workers were desperate, impoverished peasants, burdened with debts from British taxes. They arrived to horrific conditions in plantations in the Caribbean, Fiji or Mauritius. They were treated like slaves. In British Guiana, Indians stayed in the “ni***r yard”.

In Malaya, most Indians came as indentured workers bound for rubber estates. Some also worked on railway and road construction. Malaria killed many of those clearing jungle. Many died from “the most cruel conditions of treatment, malnutrition and misery”, writes George Netto in his 1961 book Indians In Malaya. This history has barely been acknowledged.

They often worked nine to 10 hours a day, six days a week, writes KS Sandhu in his 1969 book Indians In Malaya: Some Aspects Of Their Immigration And Settlement (1786-1957). Employers sometimes withheld pay for unsatisfactory work or inflated workers’ debts, making it very difficult to end the indenture. They were thus living “almost in slavery”, or not far from it, Sandhu writes. Often, only “flight or death” could end the misery. Death rates in some estates were as high as 80% to 90%, says Sandhu. Suicide was common, as it was for plantation slaves. Not till 1929 did births of Indians exceed deaths. Later, toddy shops were opened by the management as a form of control and debt. Alcoholism became a problem, alongside poverty, sickness, shoddy housing and violence from supervisors. Conditions never improved. In 1910, indentured labour to Malaya was banned. But the “kangani” recruiting system that replaced it was little better. Finally, in 1938, the Indian government placed a complete ban on assisted immigration to Malaya.

Communities long suffering decay and abuse do not easily move upwards, unlike immigrants. Governments may leave them to languish.

When I lived in Washington DC while on a fellowship in the 1990s, I interviewed a black woman from a ghetto. She had only met a white person once, when she gave birth. That’s how great the city’s black-white divide was.

Plantation Indians here were always isolated. When plantations closed, 300,000 Indians were evicted, losing their jobs, housing, crèches, and, significantly, community support as well as plots of land for farming. Brutally, there was no programme to resettle them. The result was an underclass that fell even further behind – now, 40% of Indians are at the bottom of the income ladder.

Poverty eradication programmes have overlooked Indians. Aid has often been siphoned away. After so many years of neglect, when will they get the help they need? When will people start to care? When will Indian lives matter?

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By Mangai Balasegaram

Mangai Balasegaram writes mostly on health, but also delves into anything on being human. She has worked with international public health bodies and has a Masters in public health. Write to her at lifestyle@thestar.com. my. The views expressed here are entirely the writer’s own.

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