Author: noorali

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Can we do anything about restless leg syndrome?

A sailboat in New York City. (Dr. Noorali Bharwani)
A sailboat in New York City. (Dr. Noorali Bharwani)

Restless legs syndrome (RLS) is a common condition that is frequently unrecognized, misdiagnosed and poorly managed.
Restless leg syndrome: is it a real problem?
Paul E Cotter and Shaun T O’Keeffe
Ther Clin Risk Manag. 2006 Dec; 2(4): 465–475.

Restless Leg Syndrome (RLS) is a neurologic disorder and is the most common movement disorder, characterized by an irresistible urge to move the legs when at rest. This affects sleep, daytime productivity and mood. It can affect your personal health and can cause harm to others. It is usually a long-term disorder.

RLS is also known as Willis-Ekbom Disease. In 1672, Sir Thomas Willis first described RLS. It was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom provided a detailed and comprehensive report of this condition.

Ekbom described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy.

RLS affects about 10 per cent of the population, most commonly in women older than 35 years of age. I know some men suffer from this as well. The prevalence increases with age. There may be a family history of the condition.

There are no tests to confirm the diagnosis. Symptoms of RLS are classical. Mostly the symptoms start in the evenings when a person is trying to relax. There is urge to move the legs. This is associated with a burning and prickling sensation. Symptoms ease up if the person gets up and starts moving.

Some people may not have any cause for RLS, some have the condition secondary to medical conditions like iron deficiency or kidney disease. Symptoms of RLS may be associated with many other medical conditions.

Dopamine deficiency may be implicated in RLS. Dopamine is a neurotransmitter made in our brain. It plays a role as a “reward center” and in many body functions, including memory, movement, motivation, mood, attention and more. Imbalances in dopamine can lead to a variety of disorders, including Parkinson’s disease, ADHD, addiction, and schizophrenia.

Since there is no cure for RLS, treatment may be required for life. None of the treatment is going to relieve symptoms all the time. But it may provide some relief.  Treatment requires lifestyle changes and medication to improve quality of life, improve sleep, and correct underlying conditions or habits that trigger or worsen RLS symptoms.

If your symptoms are mild, a few lifestyle changes may be enough to control your symptoms. Avoid tobacco, alcohol, and caffeine. Regular exercise, massage to the legs, heat or ice packs can help. Taking calcium and magnesium before bed may help. Patients whose serum iron level is low may benefit with iron therapy.

If your symptoms are more severe, specific medication may help control the urge to move and help you sleep. There are different types of medications and you may have to try a few to find the one that works best.

The best evidence exists for use of dopaminergic agonists such as Ropinirole (Reequip) and Pramipexole (Mirapex) and anticonvulsant such as Gabapentin (Neurontin) agents in treating primary RLS with dopamine agonists favoured. In some cases, opioid (tramadol, codeine, oxycodone) pain medication may be required.

If the medications do not help or you are having side effects, you may have to try other treatments, such as a pneumatic compression device. This device pumps air in and out of sleeves to make them tight and loose around your legs while you are resting.

In conclusion, I will take a quote from John Hopkins (Neurology and Neurosurgery) website, “Unfortunately, there is no known cure for restless legs syndrome. At present, there is no one drug which works for everybody, but most individuals with restless legs syndrome will find some benefit and relief with the currently available medications for treating this disorder…”

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What is new about the benefits of walking?

A couple walking in Lisbon, Portugal. (Dr. Noorali Bharwani)
A couple walking in Lisbon, Portugal. (Dr. Noorali Bharwani)

In order for man to succeed in life, God provided two means, education and physical activity. Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise can save it and preserve it.
—Plato 400 B.C.

Many studies have shown that higher-intensity exercise yields more favorable effects on mortality and disease risk than lower-intensity exercise. But lower-intensity exercises like walking have health benefits as well.

As we get older and our bodies start to slow down, people tend to spend thousands of dollars to fight off old age. There is a cheaper way to fight the aging process and preventing disease – walking! But until now there wasn’t much scientific research to back that by number.

As is known, benefits of walking are many. Walking can reduce risks of dementia, cancer and heart disease. One question which has not been answered is exactly how many steps people should walk per day to optimize those benefits.

A study published in JAMA Internal Medicine (September 12, 2022) says walking 10,000 steps a day is a very healthy target and walking faster is even better.

Scientists from the University of Sydney and the University of Southern Denmark studied 78,500 adults in the U.K. between 2013 and 2015. The data set was composed of mainly white, healthy, well-educated individuals between 40 and 79 years old.

The study participants wore activity trackers 24 hours a day for one week, which recorded how many steps they walked as well as the pace at which they walked. Researchers looked at their health outcomes seven years later. Their results are summarised here:

  1. Walking 10,000 steps a day lowers the risk of dementia by about 50 per cent, the risk of cancer by about 30 per cent and the risk of cardiovascular disease by about 75 per cent.
  2. You don’t have to walk the full 10,000 steps a day to get significant health benefits. Every 2,000 steps walked lowered the risk of premature death incrementally by eight to 11 per cent, up to approximately 10,000 steps a day.
  3. The study found beyond 10,000 steps, health outcomes plateaued.
  4. Walking at a faster pace was associated with further benefits for all outcomes they measured. For example, walking 10,000 steps a day cuts the risk of dementia by 50 per cent — but walking at a faster pace can add an extra 10 to 15 per cent reduction in risk.
  5. Very high step counts – in the range of 20,000 steps and beyond – may actually decrease health benefits.
  6. This study is the first to examine the link between walking and health outcomes like cancer, dementia and cardiovascular diseases.

Over the years I have discussed the benefits of walking and exercise in my columns. There have been many studies published from various institutions promoting benefits of walking. If you have difficulty walking then take up swimming or other activity that will keep you moving.

There is a great need for any approach that could slow the rising epidemic of dementia, cancer and heart disease.

Move more and move often.

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What do we know about long COVID?

Echo Dale Regional Park in Medicine Hat, Alberta. (Dr. Noorali Bharwani)
Echo Dale Regional Park in Medicine Hat, Alberta. (Dr. Noorali Bharwani)

Three months ago, my friend contracted COVID-19 infection. He is 75+ years old with cardiac and other medical conditions. He got COVID-19 infection although he was fully vaccinated with four COVID immunization shots. His COVID test was positive for about 10 days. At-home antigen tests may return positive results for 10 days – or even longer, up to 14 days. He was seriously ill for four days. He survived.  He is currently negative for COVID-19. But he continuous to have multiple symptoms.

He has significant fatigue and joint and muscle ache. Lower back stiffness and pain comes and goes several times a day.  His memory is not very good. He thinks he has “brain fog”. His symptoms sound like long COVID. He wonders how long is this going to last.

1. What is long COVID?

Most people recover fully after contracting COVID-19 infection. But current evidence suggests approximately 10 to 20 per cent of people experience a variety of mid- and long-term effects after they recover from their initial illness.

World Health Organization (WHO) website says, “If you have recovered from COVID-19 but are still experiencing some symptoms, you could have what is known as post-COVID condition. This is also referred to as ‘long COVID’ sometimes.”

2. How common is long COVID?

WHO estimates 10 – 20 per cent of people who have COVID will develop post-COVID conditions, which would mean that Canada has at least 388,000 long COVID patients. To date, 3.8 million Canadians have had COVID-19 (COVID-19 epidemiology update – Health Canada website).

Among people age 65 and older, 1 in 4 has at least one medical condition that might be due to COVID-19. Women, and people who already had poor physical or mental health have increased risk of long COVID.

3. What are the symptoms? How long do the symptoms last?

Some of the most common symptoms of post COVID-19 condition include shortness of breath, cognitive dysfunction, which people call “brain fog”, as well as fatigue. Those are the three most common. Cognitive dysfunction involves difficulty with mental process to learn, process and communicate.

It is estimated more than 100 to 200 symptoms can be associated with long COVID. Symptoms can get worse with physical and mental effort. Statistics show nine per cent of people are unable to return to work after three months.

4. Diagnosis

Diagnosis of long COVID is made by ruling out other disorders with similar symptoms. Right now, there is no test to confirm the diagnosis.

Diagnosing long COVID remains a big challenge. And long COVID symptoms like fatigue, dizziness, and other symptoms are fairly nonspecific.

5. What is “brain fog”?

“Brain fog” is not a medical condition. If you have difficulty thinking then you have “brain fog”. It has been found some patients after recovering from COVID-19 infection have short-term memory loss, confusion and difficulty concentrating. It feels as if you’re driving through a fog.

6. Conclusion

A research paper published on September 7, 2022 in the journal JAMA Psychiatry from Harvard says people who felt stressed, anxious, lonely, depressed or worried about COVID before getting infected were at higher risk of developing long-term symptoms from their illness.

Physical activity and relaxation techniques can be valuable tools to help you remain calm and continue to protect your health during this time. WHO recommends 150 minutes of moderate- intensity or 75 minutes of vigorous-intensity physical activity per week, or a combination of both

So, I say to my friend, post COVID-19 symptoms may last anywhere from three months to a year. Nobody knows. Sometimes the symptoms can go away and come back. We are still learning about this disease.

It is important to prevent COVID-19 infection, that will prevent the development of post COVID- 19 condition. Prevention is better than cure.

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Physician Burnout is Alarmingly High

The Saskatoon Farm in Foothills County, Alberta. (Dr. Noorali Bharwani)
The Saskatoon Farm in Foothills County, Alberta. (Dr. Noorali Bharwani)

Earlier this year, Canadian Medical Association (CMA) President Dr. Katharine Smart appeared before the House of Commons Standing Committee on Health to welcome a study on Canada’s health workforce. In her remarks, she explained physician burnout is at an all-time high and the health workforce is in the midst of a crisis.

Many concerned people have written about physician health and burnout over the years. I wrote a column about this on December 5, 2010 — about 12 years ago. Many medical conferences in Canada, USA and UK have discussed this subject and proposed solutions. But we are still talking about it. COVID-19 pandemic has made things worse for doctors and nurses.

More than 13,000 physicians across 29 specialties were surveyed (advisory.com) between June 29 and Sept. 26, 2021. Across all specialties, 47 per cent reported feeling burned out last year.

According to one study, there are five things causing physician major stress — caring for the chronically ill, managing mental illness, improving communication with patients and other providers, keeping up with technology and using technology to engage patients.

Burnout has become a major risk for physicians. Doctors tend to focus on patient health, often at the expense of their own. Yes, physician health matters because physicians are a valuable human resource.

In 2006, I was in Ottawa attending International Conference on Physician Health. It was organized by the CMA and the American Medical Association (AMA). The conference was attended by delegates from Canada, U.S.A., Europe, Australia, New Zealand and many other parts of the world.

This was 18th in the series since its inception in 1975. The theme was: Physician health matters: preserving a valuable human resource. After all these years we are still talking about the same thing.

The delegates at the conference heard about the latest research on physician health, about new skills to survive and thrive in their career and learned about the progress that is being made around the world to protect the health of physicians.

The organizers of the conference said by raising physician health issues at an international policy level, the conference seeks to promote a healthier culture of medicine and decrease the stigmata associated with the physician ill health, thereby decreasing barriers to physicians seeking timely personal care.

In 2003, a survey conducted by the CMA found that 46 per cent of Canadian physicians were in an advanced stage of burnout. Physicians feel they have to work harder and longer hours because there is a shortage of medical manpower. With the information overload there is a significant pressure on physicians to satisfy the public and there is constant political battle within our health care system to obtain fair share of resources to provide good patient care. All these factors do affect physicians’ personal and mental health and their capacity to deliver good patient care.

In the past doctors have been very reluctant to seek help and lived in a culture of denial. Now more stressed-out doctors are willing to seek help. Society and medical disciplinary organizations have moved to better understanding of the challenges faced by stressed out doctors and their families.

Recent studies have shown where such doctors are identified and undergo treatment, outcomes seem to be good. Such approaches both reduce the suffering of ill doctors and protect the public.

We keep talking about physician shortage, nursing shortage, ICU bed shortage, hospital bed shortage and many other medical service issues. We have hundreds of overseas qualified doctors and nurses who cannot get a license to practise in Canada. The obstacles faced by foreign medical and nursing graduates are immense. Their education and skills are wasted.

Canada should have one licensing body for doctors like they have in the United Kingdom. If you are licensed to practise in one province then you should be able to practise anywhere in Canada. But I doubt this will ever happen.

I know we will be talking about this again 20-years down the road!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!