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A FANTASTICAL FATHER’S DAY
A FIREWORKS FILLED FOURTH
and A MOST ENJOYABLE SUMMER
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Sunday, May 19th --- Orange Belt Rehab at the Red Lobster Restaurant
Sunday, September 15th ---
Sunday, November 17th ---
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Your probably wondering why the top of this newsletter has two dates on it --- well, your newsletter editor (ME) has decided to take the summer off and relax. Also, I felt that the content of the articles in this newsletter was of such great import that I didn’t want to take any out for a later date. So, the next newsletter you receive will be the September/October one.
Have a GREAT summer.
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Our March 17th meeting was well attended. Those that were there voted to have additional meetings at the Red Lobster, so – our May 19th meeting will be held there.
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POLIOMYELITIS “HISTORY” SUMMARY
By Phyllis Hartke, pahartke@home.com, Aug 29, 2001 President of San Francisco Bay Area Polio Survivors (SFBAPS).
I write this summary for polio survivors and SFBAPS members in response to inquiries about polio’s history. This is a very abbreviated summary of polio’s history and how the medical profession struggled to understand its facets and determine appropriate diagnosis and treatment methods. I try to provide the reader with:
1. insight about the multi-century struggle of medical practitioners and researchers to understand polio epidemiology;
2. reason to appreciate our continuing struggle for medical and community awareness of polio’s late effects and remedial needs;
3. knowledge about how polio’s sporadic cases and epidemics created new fields of medicine and the “public health” arm of local and national governments; and
4. reason for being proud to be a survivor of a deadly infectious disease that has baffled the world for centuries yet contributed so very much to mankind worldwide.
The historical facts included in this summary were provided in “A History of Poliomyelitis” published by Yale University Press in 1971 and designated “Yale Studies in the History of Science and Medicine, 6.” The esteemed author is
John R. Paul, M.D. who the book’s jacket references as emeritus professor of preventive medicine and epidemiology at Yale University, a leading investigator of poliomyelitis and its epidemics for more than 30 years, and a contributor to the advances that eventually led to its control.
Evolution of Polio Terminology…
Names and terms by which “polio” is known changed over time in direct relation to increased knowledge, or confusion, about the nature of the disease.
The first term used - “Debility of the lower extremities” – is credited to a pediatrician’s description in 1789. The mid-nineteenth century saw multiple terminologies in use, based on the site of damage pathologists (a new field of science) believed caused the paralysis. Key terminology used is as follows: “Poliomyelitis anterior acuta” is derived from both Greek and Latin words, and was later shortened to “poliomyelitis” and ultimately its slang “polio”. [Greek words for “gray” and “marrow” (the gray marrow of the spinal cord), and the Latin suffix for “inflammation” are root words for “poliomyelitis. “Anterior” refers to the horns of the cord (i.e. the anterior part of the gray matter of the spinal cord). “Acuta” was sometimes replaced by the word “subacuta” when identifying the disease.]
· “Heine-Medin disease” terminology was introduced in 1907, honoring a German orthopedist and a Swedish pediatrician for their achievements that greatly expanded scientific understanding of the disease during the mid- to late-nineteenth century.
Interestingly,Poliomyelitis had become a fixed term, not able to withstand more evolutionary change, when its causative agent - the virus - was discovered in 1908. Instead of saying “poliomyelitis virus”, it was referred to as the virus of poliomyelitis. This terminology was shortened to poliovirus by the mid-twentieth century, and later, the family of enteroviruses absorbed the polioviruses.
It is suggested that poliomyelitis most probably dates back to the dawn of written history, even though early twentieth century epidemics made it a disease of that era. That era saw the introduction of modern sanitation and its impact on bacterial enteric infections and human immunity. Pestilences and epidemics of many kinds plagued the Dark and Middle Ages, as did an unusually high infant mortality rate, all of which likely overshadowed the endemic spread of the poliovirus that silently infected and immunized the great majority who did not develop paralysis or die from the disease.
In the Carslberg Glyptotek, Copenhagen, there is archeological evidence of poliomyelitis in ancient times. An illustration depicts an Egyptian stele dating from the Eighteenth Dynasty (1580 -1350 B.C.) showing a crippled young man, apparently a priest, with a withered and shortened left leg, with a foot positioned typical of flaccid paralysis, using his staff for support. Danish physician Ove Hamburger in 1911 identified paralytic poliomyelitis as the most probable cause of the priest’s deformity, and few physicians examining this picture since then have doubted that diagnosis or its significance.
History reveals descriptions of skeletons with abnormalities attributed to polio. Paralytic polio descriptions are also found in biblical and Greco-Roman times.
In ancient Greece there developed an appreciation of a scientific attitude toward disease, contrary to the beliefs of supernatural or magical causation factors. Hippocrates, born in 460 B.C., was science’s chief mentor during these times. This “father of medicine” kept headquarters on a Greek Island in the Aegean, but traveled widely and saw different people, places and things. He was an astutely observant physician and an epidemiologist, recognizing that disease varied under different conditions of climate and race.
Medical historians studying Hippocrates’ two volumes “Of The Epidemics” find no reference to a paralytic poliomyelitis epidemic. They conclude that its absence indicates paralytic polio outbreaks were rare and limited to sporadic cases rather than epidemics. Translations of the complete works of Hippocrates support this conclusion.
Notable are Hippocrates’ accounts of “clubfoot” cases, and the accounts of “club-foot” cases Roman physician Galen made 500 years later (138-201 A.D.) Medical historians maintain that this term included both congenital and acquired malformations, unlike today which links it to congenital deformities only, and covered most if not all deformities involving ankles and feet, including flail-like conditions of the lower legs and subluxations of the ankle joints leading to abnormal positions of the feet. They believe that sporadic paralytic polio surely caused some of these deformities acquired at an early age.
Eighteenth Century…..
It was not until the late eighteenth century that paralytic poliomyelitis was first described with a modicum of accuracy or that a fever was observed to precede limb weakness. The autobiographical account of Sir Walter Scott’s illness and resulting lameness significantly advanced the precision in diagnosing infantile paralysis.
In 1789 the first clinical description of poliomyelitis appeared in a medical text – Treatise on Diseases of Children (2d ed.) by Michael Underwood, a London pediatrician – under the heading “Debility of the Lower Extremities.” He was the first physician to consider poliomyelitis as an entity. He had distinguished medical credentials and extensive experience as a surgeon before changing his career to midwifery and child welfare for which he earned prominence and the appointment of Physician to the Prince of Wales. In 1799 his 4th edition of this medical text included in the paralysis, or palsy, section considerably more information about diagnosis, treatment, and prognosis.
About this same time, another landmark in polio history emerged. Timothy Sheldrake, a mechanic by trade but an astute orthopedist by interest, was a trussmaker to London’s Westminster Hospital. His wide experience in handling crippling deformities in children supported his London shop. His unique vision and efforts collecting, documenting, and classifying various kinds of foot deformities resulted in two books addressing clubfoot and acquired deformities in the legs and feet of children. Here is found the first series of paralytic poliomyelitis cases.
Early Nineteenth Century…..
During the next twenty-five years few took advantage of this new knowledge, and newly published medical texts stated nothing more about polio. The next landmark in polio history was in early nineteenth century. Although a well-known Italian physician and surgeon, a prolific writer of medical treatises, and supervisor of Italy’s small pox vaccination program, few outside of Italy knew Giovanni Battista Monteggia. His 1813 medical treatise included a vivid clinical description of poliomyelitis from onset to late physical effects.
Monteggia was the first person to record the paralysis as flaccid without muscular response to sensory stimulation and without foot withdrawal when the sole is tickled. Although the nature of polio was still vague, he was the first not to reference “teething” as a possible cause.
Ten years later, 1823, a medical text included London surgeon John Shaw’s clinical description of polio. Noted were paralysis and limb wasting during infancy that frequently caused spine distortion, the sudden attack aspect of the illness, and that it affected children outside of England, including first-hand observation in India. Now emerging was consideration of geography and environment as factors in the spread of polio (i.e. the possibility of different strains or types existing elsewhere and the effect of poor sanitary environment).
Scottish neurologist Abercombe, uniquely aware of separate functions of different parts of the spinal cord, surmised in 1828 that only part of the gray matter – the anterior segment that controlled motor nerves, not the posterior segment that controlled sensation – was involved. This remarkable discovery is today a diagnostic element of paralytic poliomyelitis.
The year 1840 marks the greatest achievement in the understanding of polio. Published was a 78-page study of polio by Jacob Heine, a German orthopedist and exponent of physical medicine. (Several members of the Heines family were noted orthopedic surgeons. Jacob’s father was the first to use osteometry to straighten bones, and Jacob’s son was noted for his orthopedic writings.)
Jacob Heine monograph was an accounting of his personal experiences with a series of paralyzed young patients that he decided to write after reading the 1836 immediate accounting by John Bedham in England of four cases. Dr. Bedham described accurately this apparent “outbreak” -- sudden paralysis in infants under age 3 ushered in by cerebral symptoms (drowsiness and abnormal state of pupils of eyes) without impairing the child’s health -- but failed to understand the nature of the malady (i.e. cerebral or cerebral-spinal lesion) and how to treat it.
By publication reaching a wide audience Dr. Bedham hoped to receive advice from more experienced physicians. This is perhaps the first evidence of a physician concerned about public health. Unfortunately, Dr. Bedham died of tuberculosis at a young age (33) and before publication of Jacob Heine’s 1940 report responding to Bedham’s inquiry.
For the first time there was more than a review of cases. The entire 78-page report meticulously and systematically addressed all features of the disease then known that Dr. Heines considered important. He concluded that the central nervous system, the spinal cord, was affected. He addressed therapy, bracing, and exercise. He listed clinical features prominent in every acute polio case, the stage preceding limb paralysis.
In the second edition of that book published 20 years later, Dr. Heine was even more convinced that the problem was in the spinal cord. He was perhaps the first to practice sensible treatment for paralyzed polio limbs – exercise, baths, simple surgical procedures, bracing. (Accepted practice in that era included purges, emetics, blisters and bleedings.)
Sir Charles Bell, a distinguished British neurologist, learned during consultation with a mother about her child with one wasted leg about an “outbreak” occurring in the early 1830s on St. Helena, an isolated island. This revealed that children over the age of 3 and up to age 5 were affected. Dr. Bell’s case report noted that the matter deserved inquiry, clear concern about the nature and circumstances of the disease.
Mid- to- Late Ninteenth Century…..
Knowledge of the nature of polio proceeded slowly, notwithstanding these landmark events. Different and opposing theories continued to exist about whether polio lesions affected the brain or spinal cord. Physicians in the United Kingdom and Europe still classified cases as “temporary paralysis in early life” and “morning paralysis” and “essential infantile paralysis,” observing the rather prompt disappearance of paralysis and seemingly complete cure. That controversy was finally set to rest some years later by the microscope. It revealed the cord lesions of poliomyelitis otherwise invisible to the naked eye.
In 1840, writings of orthopedic surgeon A.G. Walter indicate polio was in the United States as early as 1810. During this era paralysis acquired during infancy was not unusual and teething was still considered a cause. Walter’s publication described a series of cases he treated in Pittsburg since 1837, popularizing in the U.S. treatment by operation – cutting tendons in clubfoot, subcutaneous section of the Achilles tendon. France and England were already using this treatment method.
Then in 1841, the third epidemic was reported. The place was West Feliciana, Louisiana. Dr. George Colmer, an English physician who settled in Springfield, Louisiana, reported the epidemic. The short note in an American medical journal stated the facts and attributed “teething” as the cause given the age (under two) of affected children.
Great medical advances were made in the second third of the nineteenth century. Cellular pathology was advanced by the now perfected magnifying power of microscopes. Previously invisible cellular and tissue changes could now be seen. Physiology and pathological anatomy set clinical medicine free to develop its own scientific potential. Led by Louis Pasteur, the “germ theory” of disease and new fields, bacteriology and microbial infection, developed.
Neuropathologists advanced the study of poliomyelitis. They explored the site of the lesion in the spinal cord. French scientists Jean-Martin Charcot and his associate V. Cornil viewed under a microscope autopsied sections of the spinal cord. This showed large motor nerve cells in the cord’s gray matter, with a particular loss of nerve cells in the anterior horn of the gray matter when paralysis existed. This confirmed Heine’s views thirty years earlier.
In 1888 Scandinavian neuropathologist Rissler’s, investigation revealed that poliomyelitis was primarily an acute systemic infection with lesions not necessarily limited to the central nervous system, the latter being the most serious lesions because of the resulting paralysis damage. He was convinced of Charcot’s theory that motor cells were the sight of destruction (myelitis) caused by some injurious agent, on the heels of which neuronal degeneration rapidly occurred, leaving atrophy and scarring in its wake. (The first accurate account of the cerebral type -encephalitic polio- occurred in 1884 in Vienna. Charcot’s ablest pupil Pierre Marie corrorborated Strumpell’s observation the next year.)
American knowledge of the disease, including neuropathology and neurophysiology, was scarce and faulty until Dr. Mary Putnam Jacobi brought to American physicians “the idea and evidence that meticulous studies of the neuropathology of poliomyelitis could be rewarding and that the real seat of the trouble lay in destructive lesions in motor nerve cells in the spinal cord.” In 1886 the distinguished Dr. Wm. Pepper (professor at Univ. of PA at Philadelphia and the acknowledged dean of American physicians) chose Mary to write the scholarly and exhaustive chapter on poliomyelitis for the 5-volume medical textbook “System of Medicine by American Authors.
Dr. Jacobi’s training and superior knowledge of the subject peculiarly qualified her to write this scholarly 50-page review article “Infantile Spinal Paralysis.” A member of the NY publishing family, she received a pharmacy degree in 1863, and her medical degree the next year. After two Civil War years, Mary determined her medical education was inadequate and went to Paris to get a second medical degree. She enrolled in courses at the Sorbonne in 1866, attended lectures, did autopsies, and studied histology before entering medical school. This exposed her to the exciting work of Charcot’s clinic and other Frenchmen studying the neuropathology of poliomyelitis, and aroused her pathology and physiology interests. (Returning to the United States in 1873, Mary Putnam opened her internal medicine practice in NYC and married Dr. Abraham Jacobi who later became the father and founder of American pediatrics.)
As to treatment of polio, Dr. Mary Jacobi followed the time-honored medieval remedies (ice applied to spine internally or subcutaneously in order to divert blood circulation to the surface, mercury ointment rubbed in along the spine, followed by blisters and treatment with iodides, and with electrical stimulation starting one week after paralysis). It took a long time before more effective approaches were devised.
Clinical medicine had come of age worldwide, and poliomyelitis was swept along in that movement. Recognition of polio occurring in adolescents and adults, its infectious nature, and the presence of epidemics fueled the explosive clinical understanding of poliomyelitis. Scandinavia was the site of the first polio epidemic.
Public health records reveal the first epidemic was in 1868 in Norway, near Oslo. The second occurred in 1881 in Umeo if northern Sweden. Epidemics were also beginning to be reported outside Scandinavia. France had an epidemic in 1886.
Late-Nineteenth and Early-Twentieth Centuries….
Scandinavia took center stage for advances in clinical studies of polio from 1890 to 1914. Stockholm pediatrician Oskar Medin (thoroughly reliable, articulate and experienced) gave a convincing and comprehensive presentation on the clinical features of the disease to the Tenth International Medical Congress held in Berlin in 1890. It was Medin who first expressed the view that there exists a systemic stage in the beginning – minor symptoms and signs such as slight fever and malaise signified a generalized process, which coincidentally and later was occasionally followed by serious damage to the central nervous system that almost amounted to a complication.
“Medin possessed that intangible quality that makes a great clinician, and when the suggestion was made that he deserved a place in the history of infantile paralysis, there was quick response – hence the name Heine-Medin disease. Although it may have been satisfying nomenclature, a disease as common as poliomyelitis could not remain designated by proper names for long.
Physicians and pediatricians from far and wide were surprised that they should have had to put to use so promptly the information about epidemic poliomyelitis that Medin had supplied. The world did not have a long wait for another epidemic – just three or four years. This time it came to North America.”
The first polio epidemic in America was in Vermont, summer 1893 (26 cases), but the first substantial epidemic was in Vermont in 1894 (132 cases) and was the largest reported in one year anywhere in the world. (An outbreak even half that size would have been the largest.) It was the first large epidemic to be studied systematically by a full-time local public health official, Dr. Charles Caverly. History also credits him as among the first to recognize the occurrence of a few nonparalytic cases.
Like in Scandinavia, American epidemiological phenomenon of “infantile” parlay-sis revealed an epidemic in sparsely populated area and a shift to increasingly older children and adults afflicted during polio epidemics. It is suggested that the Vermont epidemic could have been anticipated by the polio cases in nearby Boston the previous summer, interrupted by the cold weather and starting up in spring or summer in nearby territory. Also, the “contagious” and “infectious” cause of the disease was not yet recognized.
How the disease spread throughout the body and the community came under intense scrutiny during the devastating 1905 Swedish epidemic (1,031 cases). Ivar Wickman, a pupil and ardent admirer of Medin, systematically studied the “contagious” aspect of this epidemic. Included in his case count were abortive and nonparalytic cases as well as those with paralysis. He was the first to grasp the implications of observing the infection sometimes missed the central nervous system altogether, and the first to realize that abortive cases might equal or exceed paralytic ones and that they had a profound significance on the spread of human poliomyelitis.
By physically going door-to-door interviewing residents in order to trace the spread of the disease through abortive and paralytic cases throughout the hot summer of the 1905 outbreak, Wickman was able to designate a local school as the primary site from which the infection disseminated. Striking was the relationship between roads and railways and the spread of that epidemic.
Wickman concluded correctly that poliomyelitis must be regarded as a highly contagious disease, that mild cases should be considered along with the severe, that the disease was not entirely or even chiefly a disease of the central nervous system, that polio spread primarily through the medium of subclinical infections, and that the incubation period averaged 3 to 4 days measured from the time of exposure to the beginning of the minor illness.
The next recorded polio epidemic was in 1907 in New York City (750 to 1200 cases). The NY Neurological Society appointed a 12-member commit-tee, composed of the foremost authorities in the country, to study it. Polio outbreaks in the US sharply rose from 1908-1912. The committee’s report was published in 1910 and incorporated medical advances made during the interim.
Simon Flexnor, first director of the prestigious and well-endowed Rockefeller Institute for Medical Research created in 1903, was a key participant of that committee and changed the course of medical history. Having discovered the bacillus organism responsible for dysentery in 1900 in the Philippines and formerly chairman of the Federal Plague Commission that investigated the bubonic plague of 1901 in San Francisco’s China district, Flexnor was a champion of the experimental pathological laboratory for solving infectious disease problems. Infantile paralysis was the ideal disease that would allow him to realize his goal - advancing the fields of bacteriology, pathology, and immunology and establish medicine on a sound scientific basis.
The dream that scientific medicine would conquer the disease seemed near realization. Discovery of the polio virus, announced December 18,1908, at a medical meeting in Vienna by immunologist Karl Landsteiner, M.D. and his assistant E. Popper, made that dream even more a reality. As of that point in time, only a few viruses had been detected as agents of human or animal diseases – the viruses of smallpox and vaccinia, rabies, and foot-and-mouth disease.
The use of tissue cultures for the growth of viruses was unknown until Landsteiner and Popper demonstrated microscopic slides of human and monkey spinal cords, all showing the histological picture of acute poliomyelitis and suggesting an invisible virus as the cause of poliomyelitis, an opinion soon confirmed by other experiments. By late 1909 the microbiological world accepted the viral etiology of poliomyelitis. Interestingly, experimental pathology on the polio virus established the fundamental clinical epidemiological truths Wickman earlier discovered.
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Continuation of this “Poliomyelitis ‘History’ Summary” will be included in future SFBAPS newsletters. |
a Clinical Review
More and more people are using herbal supplements. Most are using them as therapies for various medical conditions, or in the belief that there is some therapeutic or life enhancing value in their use. This may, or may not, be the case. We are often bombarded with hearsay evidence, but there are few unbiased studies available.
The January 2002 issue of Annals of Internal Medicine has a very thorough review of several commonly used herbs, with a risk-benefit profile of each. As part of the journal’s complimentary and alternative medicine series they looked at Ginko, St. John’s Wort, Ginseng, Echinecea, Saw Palmetto, and Kava.
The authors searched electronic literature, asked experts in the field for their assessments, and located as many articles on herbs as they could. All systematic reviews of randomized clinical trials in humans were included. They used standardized guidelines to estimate the quality of the reviews. Each review was put through a screening process. They rated the objectives of each study, the data sources, the methodologies, inclusion and exclusion criteria, and various other factors. Each review was rated “good”, “adequate”, or “poor”. This report summarizes the results of their findings on each herb.
Ginko (Ginko biloba)
Ginko probably has the longest history of use. It has been a common herb in Asia for centuries. It has been used for a multitude of ailments, including trauma, deafness, vertigo, impotence, and asthma. In clinical practice it is used mostly for memory impairment, dementia, tinnitus (ringing in the ear), and intermittent claudication (limp). Ginko’s action is based upon its ability to increase fluidity of blood.
The authors assessed 40 studies of ginko for “cerebral insufficiency”, which they described as memory impairment but not dementia. They concluded that there is encouraging data, but the evidence for ginko as a memory enhancement is not convincing. No compelling data exists that would prove ginko has any positive impact on normal cognitive function.
There was, however, good evidence that ginko was significantly better than a placebo in delaying clinical cognitive deterioration in dementia. Although many of the studies were flawed, the overall results suggested that the use of ginko might be relevant for dementia.
Ginko might also benefit tinnitus. Some results showed a statistically significant effect on the perceived loudness of the ringing. But, here again, the studies appeared to be flawed, and the therapeutic value of ginko on tinnitus is uncertain.
Tests using ginko for claudation showed that its effect is moderate, but might be clinically relevant. The ginko recipients were able to walk farther without pain than the control groups.
The adverse effects of ginko when used alone are usually mild, but the risks increase significantly if used with other drugs, especially anticoagulants. Serious bleeding has been reported.
Historically, St. John’s Wort has been used for bronchitis, burns, cancer, enuresis, gastritis, hemorrhoids, insect bites, insomnia, and a host of other ailments. It is now used almost exclusively as an antidepressant. Its action seems to lie in selective inhibition of serotonin and dopamine in the central nervous system.
The authors studied a large number of clinical trials, and evaluated the quality of each. The average quality of these trials was assessed as good, and most showed the efficacy of St. John’s Wort in mild to moderate depression. They determined that St. John’s Wort is more effective than placebo and is similar in effectiveness to low-dose tricyclic antidepressants.
Taken alone, St. John’s Wort appears to be very safe, and it is in some respects is superior to conventional antidepressants. The only potential side effect is sensitivity to sunlight, and manic depression in predisposed patients. Both of these are extremely rare.
As with ginko, the risks increase when St. John’s Wort is combined with other drugs. St. John’s Wort can decrease the effectiveness of a wide range of prescription drugs. These include anticoagulants, oral contra-ceptives, and antiviral agents. Clinically serious consequences may occur.
Ginseng (Panax ginseng)
There are so many types of ginseng i.e. Siberian or Russian, Chinese or Korean, Japanese and American, etc. that is difficult to find a standardized formula. Ginseng has been used as a sedative, hypnotic, aphrodisiac, antide-pressant and diuretic. It is said to improve stamina, concentration, and well-being.
The authors found few high-quality, double-blind, placebo-controlled clinical trials using ginseng. There were many studies, but few with proven worth. Most used healthy volunteers rather than patient samples. They concluded that there was no compelling evidence on the efficacy of ginseng on any of the above conditions, and both animal and human studies do not support ginseng as an aid to physical performance.
The authors did, however, find one large study where the population consumed fresh Korean ginseng as part of their regular diet. It appeared that this regimen significantly reduced the risk of some forms of cancer. They cautioned that there was no proven casual relationship, but the results clearly showed that further study was warranted.
Another study indicated that 3 grams of American ginseng lessened glycemic fluctuations following meals. The effect was seen in non-diabetic persons and those with type 2 diabetes. They cautioned that American ginseng should be taken with a meal to prevent hypoglycemia in non-diabetic individuals. And ginseng has several serious adverse effects, ranging from insomnia, diarrhea, vaginal bleeding, and severe headache.
Echinacea (Echinacea species)
Echinacea products contain many potentially active ingredients, but no single active constituent has been found. It appears that some ingredients may stimulate the immune system, provide local anesthesia, and have anti-inflammatory, hormonal, and antiviral properties. In the past echinacea has been used for wound healing, abscesses, burns, and eczema. The most common usage today is for upper respiratory tract infections.
The authors found that the quality of clinical trials varied greatly. A few had value and a few were suspect. There is some evidence that echinacea may have a beneficial effect in preventing upper respiratory tract infection, but the trial data was weak and inconclusive.
There seems to be few adverse effects to Echinacea, consisting mostly of allergic reactions. Some of these can be serious however. Other reported adverse reactions include hepatitis, asthma, nausea, and anaphylaxis. Further studies are urged because of echinacea’s increasing popularity, and the study found the quality of many echinacea products to be unsatisfactory.
Saw Palmetto (Serenoa repens)
This herb has traditionally used to treat genitourinary problems, increase sperm production, breast size, enhance libido, and as a diuretic. It is currently most used to treat benign prostatic hyperplasia. Why it works is not fully known, but experiments have shown an antiandrogen effect, and it may inhibit the enzyme that converts testosterone into dihydrotestosterone, the form metabolized by the body. It may also inhibit estrogen receptors in the prostate.
Several studies were reviewed for this article. Most were deemed to be “good on average”. Most were placebo controlled, and some used a combination of saw palmetto and other herbs or saw palmetto with finasteride, a commonly prescribed prescription drug for benign prostatic hyperplasia.
The results of most studies indicated the superiority of saw palmetto over a placebo in terms of peak urine flow and nocturia. The results also indicate that saw palmetto might be as effective as finasteride.
Most of these studies were short-term and the long-term benefits have not been proved. Given this caveat, saw palmetto has shown few adverse effects, and the authors quote from a 6-month, randomized, controlled trial that confirmed saw palmetto as, “a safe and highly desirable option for men with moderately symptomatic benign prostatic hyperplasia.”
Kava (Piper methysticum)
Kava is used in the South Pacific as a recreational drink. It has been used experimentally to lesson seizures and to treat psychotic episodes. It is most often used for its anxiolytic effects.
A review of past trials indicates that kava, when used at recommended dosages, resulted in a reduction of anxiety using a standardized anxiety scale. One study compared kava with the prescription drug oxazepam and found that they were equally effective in the short-term.
Serious side effects have been reported, but this seems to be rare. Several cases of liver damage were recently reported with kava self-medication. Long-term use of kava is associated with flaky, dry, and yellowish skin, ataxia, hair loss, and partial loss of hearing. Most of these are reversible when use is discontinued. As with all herbals, the risks increase when used in combination with other drugs, or in some cases, with other herbals.
All of the herbs studied had problems of quality, purity, and standardized extracts. Some are associated with positive risk-benefit profiles. Ginko, St. John’s Wort, and saw palmetto appear to have benefit when used for the conditions discussed. The evidence for ginseng, echinacea, and kava is less compelling.
The authors comment that, “Generally speaking, trials of herbal medicinal products have been too few, too small, and too short. The lack of long-term studies is especially unfortunate. Benign prostatic hyperplasia, for instance, clearly requires long-term therapy, but trials of saw palmetto to date are mostly short-term (4 to 48 weeks). Thus the clinician is caught between encouraging results of randomized clinical trials and the relative lack of controlled long-term data. The latter information is needed to make responsible therapeutic decisions.”
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Each year, many older Americans are injured in and around their homes. According to the U.S. Consumer Product Safety Commission (http://www.cpsc.gov)
over half a million people each year who are over age 65 are treated in hospital emergency rooms for injuries associated with products they live with and use everyday.
SAFETY CHECKLIST
Use this checklist to spot possible safety problems. You should be able to answer yes to all and if not, then go back and take actions to correct those items that may need attention.
· Are lamp, extension, and telephone cords placed out of the flow of traffic?
· Are cords attached to the walls, baseboards, etc., with nails or staples?
· Are all small rugs and runners slip-resistant?
· Are emergency numbers posted on or near the telephone?
· Are smoke detectors working and properly located?
· Are small stoves and heaters placed where they can not be knocked over, and away from furnishings and materials such as curtains, rugs, furniture, etc.?
· Do you have an emergency exit plan and an alternate emergency exit plan in case of a fire?
· Are towels, curtains, and other things that might catch fire located away from the range?
· Do you wear clothing with short or close-fitting sleeves while you are cooking?
· Are kitchen ventilation systems or range exhausts functioning properly and are they in use while you are cooking?
· Are all extension cords and appliance cords located away form the sink or range areas?
· Does good, even lighting exist over the stove, sink and countertop work areas especially where food is sliced or cut?
· Do you have a step stool which is stable and in good repair?
· Are hallways, passageways between rooms, and other heavy traffic areas well lit?
· Are exits and passageways kept clear?
· Are bathtubs and showers equipped with nonskid mats, abrasive strips, or surfaces that are not slippery?
· Do bathtubs and showers have at least one (preferably two) grab bars?
· Is the water temperature 120 degrees or lower?
· Are all medicines stored in the containers that they came in and are they clearly marked?
· Are lamps or switches within reach of each bed?
· Are ash trays, smoking materials, or other fire sources (heaters, hot plates, teapots etc.) located away from beds or bedding?
· Do you avoid having anything covering your electrical blanket when in use?
· Do you avoid going to sleep with a heating pad which is turned on?
· Is there a telephone close to your bed?
· Can you turn on the lights without first having to walk through a dark area?
· Is the grounding feature on any 3-prong plug being used properly (i.e.: no removal of the grounding pin or improperly using an adapter)?
· Are stairs well lighted?
· Are light switches located at both the top and bottom of the stairs?
· Do the steps allow secure feeling?
· Are steps even and of the same size and height?
· Are the coverings on the steps in good condition?
· Can you clearly see the edges of the steps?
· Do you avoid storing anything on the stairway, even temporarily?
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The following article was sent to us by Dr. Norman Minard. Norman was a member of the Long Island PPSG when I was its chairperson, and now spends the winters in Boca and is a member of their support group as well as a member of ours. Thank you for this most interesting article.
CHALLENGE THE
SUPREME COURT!
Why should we who are in post polio support groups be concerned about
the recent Supreme Court decision (Toyota vs. Ella Williams) that limited
the application of the employment provisions within the Americans with
Disabilities Act of 1990 (ADA)? That decision narrowly defined the
definition of what it means to be a person whose disability substantially
limits major activities of daily life and the application of that limitation
to employment.
Practically of us are over 50 years old and most have retired. For us retired persons the issues of fair opportunities to and in employment are no longer top priorities.
For many of us, other provisions within ADA having to do with access
to
places of public accommodation have been almost our sole concern. Issues
of accessible restrooms, ramps, parking tend to dominate our attention. We
may no longer care about jobs. If you are in the group outlined above, it is
time for you to repent!
A dangerous consequence of the Supreme Court decision is to divide us
persons with disabilities into competing groups, for it points in the
direction of saying that some of us are more disabled than others, and
therefore discrimination charges may depend on the severity of the
disability. That must be challenged quickly.
As we have aged, people with other causes of disability have enlarged
our ranks -- cerebral palsy, head trauma injury, spinal cord injury,
multiple sclerosis, stroke and many more. (It's a long list!). The ADA is a
whole fabric, and each time the Supreme Court tears out a chunk of its
provisions (as it has been doing for the past few years), the time draws
nearer when your favorite pro-vision and its protection will be nullified.
We must all be outraged about the injustices to employment against persons with disabilities that are being perpetuated. Each of us may have taken pride in being Type A persons who persevere against all obstacles, but lurking in our memories there must be countless painful times when we experienced employment discrimination because of our paralyzed bodies. Should those kinds of insensitivity and prejudice by employers be perpetuated?
Injustice against one of us is injustice against all of us. Our
remedy lies in persuading President George W. Bush (whose father gladly
signed ADA into law), our senators and representatives to rewrite and
strengthen the weakened provisions of ADA immediately. This is our battle,
too, not just of those who have carpal tunnel syndrome. Write or if phone
them today. Relate some of your adverse experiences in getting a job or in
advancement. Rest assured those same injustices happen today. .
The following article is reprinted with the permission of The National Center on Physical Activity and Disability -- website:- www.ncpad.org/whtpprs/postpolioex.htm
To Reap the Rewards
of Post-Polio Exercise
In this year, 2002, we know more about exercise for persons who had polio than we did fifteen years ago. There have been a variety of studies conducted by superb and caring scientists, along with numerous personal accounts from polio survivors, themselves, which warrant a new way of thinking about exercise.
Exercise is different than physical activity. For the purposes of this article on exercise, it may be helpful to define these two terms. Exercise is generally defined as planned, structured and repetitive bodily movement, whereas physical activity is the movement you do throughout the day. Physical activity does increase the amount of calories you burn, but unlike exercise, is not necessarily planned, structured or repetitive motion. One benefit of exercise can be an improved ability to take part in ongoing daily physical activity.
Whether you have a planned exercise program or simply rely on day to day physical activity to stay fit, the message to polio survivors today is "beware of inactivity!" In the 1980s polio survivors across the nation heard and heeded a strong medical warning about the dangers of doing exercise, especially too much exercise and/or physical activity, but now post-polio scientists have qualified their advice. New knowledge tells us that no matter what our level of disability is, we should be encouraged to value exercise, enterprising enough to come up with a highly customized plan and enduring enough to reap the rewards. When it comes to exercise, we need to be smart, not scared! One woman in our University of Michigan wellness study told us that in the late 1980s she quit exercising completely out of fear of muscle loss, and gained 35 pounds. Dismayed, she joined the 1996 wellness study to find out what she could do to feel better and it worked! Exercise was put back on her list. She was guided to be selective and conservative as she designed her weekly plan for "working out." She found out that polio survivors need to:
1. First, gather the best medical literature from post-polio researchers, educators and clinicians such as Grimby, Agre, Perry, Halstead, Headley, Maynard, Birk, and Yarnell. They will all say that we must each have a custom-tailored plan since we were all affected a little differently by the capricious poliovirus. (See Selected References on Post-Polio Exercise at the end of this paper.)
2. Next, find professionals to work with. A well-selected physician and a physical therapist or exercise physiologist who each know or are willing to learn about post-polio issues would be most appropriate. There are no specific formulas for any individual that can be written in an overview article such as this. You must have one-on-one, in-person evaluation and testing to see what works and what does not work for you.
3. Then, together, literature in hand, establish a plan for exercise.
4. Start slowly, recognize limitations along the way, make adjustments in the weekly activity plan and keep going. Thomas Birk, Ph.D. (1997), recommends a two-month start up period in which your response to exercise is supervised and monitored by the professionals you have chosen to work with.
The best place to start a literature search on post-polio exercise is to tap the International Polio Network's resources. They have a variety of the latest articles from the best researchers in the world on this very specialized topic. They can be reached by calling 314-534-0475 or connecting with their website at www.post-polio.org. You may also want to do a literature search of the medical journals at your local library. Librarians can help you do a "Medline search" for pertinent medical publications or you can do one on your own by tapping into the internet, going to www.medscape.com, then clicking on Medline.
You need to establish an exercise coaching team. This can include you, your physician, and a therapist. If you have a post-polio physician that you trust, he or she is the best person to start with. This physician can then recommend a physical therapist or exercise physiologist to work with as part of your new "exercise coaching team." If you need to first find these professionals, the journey will be longer since knowledgeable post-polio helping professionals can be difficult to find or cultivate. Be encouraged to begin your search however. Remember, if you sense that a professional is not interested in post-polio issues, move quickly on to find someone who will work with you and is willing to learn and help. Once again, the International Polio Network in St. Louis, Missouri can provide you with leads in this search. They publish a national/international directory of self-identified post-polio health professionals and support groups whose members know about the best helping professionals in their geographic area.
The experts now agree, when it comes to exercise, a polio survivor doesn't have to do a lot, but one is highly encouraged to do something! Once you have gathered your exercise team, decide together what type of exercise is best for you and whether you want to join a group or exercise independently--or both! The amount of physical activity you do will also need to be addressed as you develop this action plan.
Maynard and Headley (1999) emphasize that the main focus of a new exercise program should be on stretching and general aerobic or cardiovascular conditioning exercises to improve endurance. Strengthening exercise, also called resistance training, needs to be approached much more cautiously, however, with a focus on very gradually building up functionally important muscles to a modest degree.
Ann Swartz, Ph.D. (personal communication, February 28, 2002), exercise physiologist at the University of Michigan Health System, describes each of these three types of exercise:
Stretching or muscles and joints is important to maximize and maintain function. For instance, arm circles can help maintain the function of your shoulders, making it easier for you to reach for something, or move something out of your way. Preventing tightness in your hips, knees, and ankles will help maximize your walking ability.
These include arm circles, wrist circles, shoulder shrugs, calf stretches, lifting your knee up towards your chest, bending and extending your knee, knee to chest stretches, back stretches and ankle circles. Many people also enjoy the movements that are part of Yoga or Tai Chi. The following Yoga stretching exercise was part of the University of Michigan Wellness for Women with Polio Workshop and was particularly well received:
Cardiovascular exercise is also known as aerobic exercise. It is exercise that increases your heart rate and blood flow, and makes you breathe a little more heavily than you would when performing your daily tasks. There are numerous benefits, some you may notice, and some you may not. The benefits you may notice include increased ease of accomplishing your activities of daily living and such things as getting in and out of the car, or going from place to place, and an improved mood. Benefits you may not notice include lower blood pressure levels, improved blood cholesterol levels, and lower blood sugar levels to name a few.
Swimming, biking, and walking are examples of cardiovascular exercise. Machines such as the elliptical machines (low impact equipment that combines the movements of walking and stair climbing), stair climbing machines, rowing machines and a machine called the NuStep are also useful for cardiovascular or aerobic exercises. Swimming may be the best exercise for polio survivors because it minimizes mechanical stress on the body. However, you may not have access to a pool, or may not enjoy swimming. So, do what you enjoy, what feels good, and what is accessible.
Health professionals will usually recommend a moderate or low intensity. This means that you should be exercising at a level where your heart rate increases and you are breathing heavier than you would normally (when you are performing your daily tasks.) If you cannot easily carry on a conversation, slow it down!
Strength training, also known as resistance training, improves muscle strength. When your muscles are stronger, it is easier to carry in your groceries, take out the garbage, and other tasks of your daily routine.
Any exercises that involve hand-held weights, weight machines, stretch bands, or even balls are usually strength exercises. These types of exercises, like the stretching exercises, can involve any muscle of your body-- from your head to your toes.
You may choose to exercise alone or with an "exercise buddy." Often, sharing the experience with a friend can be more fun, a chance to learn from each other and stay motivated. Joining or starting a wellness program with other polio survivors may also help. Our 1996-1999 study at the University of Michigan (Tate & Leonard, 2001) of a holistic wellness program for women who had polio found that the biggest change was in participants' exercise routines and resultant physical activity. Program participants changed dramatically in their reported regular participation in vigorous exercise. While prior to their participation 57% never regularly exercised vigorously and 23% did so often or routinely, after their participation, only 26% never did and 41% reported exercising regularly often or routinely. Similarly, program participants demonstrated a marked improvement in terms of the regularity with which they exercised with moderate exertion. Prior to the program's onset, 63% stated that they did so three or more times per week. Following the program's conclusion, 78% of program participants reported conducting moderate exercise with this regularity. Also, while prior to the program's onset 42% of participants said they never engaged in stretching exercises and 23% said that they did routinely, following program participation only 11% said that they never did stretching exercises; 35% of participants said that they did them routinely. Six months following the conclusion of the program, 61% of participants said that they had increased their level of physical activity during the last six months. We also found that exercising vigorously at least three times per week was associated with improved assessments of depression and distress.
Whether with a group or on your own, exercise programs can occur on land or in the water. It is important to do whatever works best for you. If swimming is not possible, you may want to exercise in your house, at a health club or gym, or outdoors. Pick an exercise you enjoy, whether it is walking, stretching, or any other exercise, and begin with small bouts. It is not necessary for you to perform only one activity. You can combine all your favorites. Also, you do not have to do the activity all at once. For instance, Tom enjoys biking, stretching and walking, so his exercise program was as follows:
Morning:
2 minutes stretching
2-5 minute break
2 minutes walking
2-5 minute break
2 minutes stretching
2-5 minute break
2 minutes biking
Afternoon:
2 minutes stretching
2-5 minute break
2 minutes walking
2-5 minute break
2 minutes stretching
2-5 minute break
2 minutes biking
This is how he began his exercise program, and slowly, over the course of months, he began to increase the bouts of exercise and decrease the length of his breaks. It is very important to rest between exercise sessions. Make sure you rest long enough to fully recover after the exercise; otherwise you may remain in a constant state of overload, which has negative effects on function. Incorporating regular rest periods into an exercise routine is called "interval training."
Exercising in a warm pool is another way to work out. According to Lauro Halstead, M.D. Water therapy was the exercise of choice for many persons during their recovery from the original polio. It is still excellent therapy. Because of the buoyancy of water, it allows people to do things they can't perform on land. For especially weak limbs, inflatable cuffs can be used to float an extremity. For other limbs, water resistance provides a workout that can be fine-tuned to each person's strength. The principal disadvantages of hydrotherapy are that the temperature may not suit one's body and it may be difficult to find pools that have lifts (if needed). Also, the surfaces around pools tend to be slippery and dangerous for anyone with a tendency to fall.
Aquatic programs for exercise have been recognized as morale boosting and physically beneficial. An early study by Hoffman and Maynard (1992) describes a swimming program for polio survivors as having a "therapeutic effect." Emphasizing the added benefit of group exercise, the authors go on to say: " it is of great importance to recognize that perhaps one of the greatest benefits of a program that brings together individuals who share a common concern is the emotional support they receive from knowing they are not alone in their efforts to confront the late effects of polio." In a more recent Swedish study by Willen and Sunnerhagen (2001), 15 persons with polio's late effects worked out in a pool for 40 minutes twice a week for 5 months. At the end of the study, participants reported an increased sense of well being, pain relief and increased physical fitness. Additionally, at the end of the 5-month period, their heart rates during exercise were down. The study's investigators recommend this program of pool exercises in heated water.
In his 1998 book, Managing Post-Polio: A Guide to Living Well with Post-Polio Syndrome, Halstead additionally provides general guidelines for customized exercise based on his personal and clinical experience with the effects of polio:
· Individualized and supervised program. Exercise programs should be supervised initially by a physician or physical therapist experienced in neuromuscular diseases, if not polio. Each program should be customized to your personal needs and residual strengths. Given these constraints, research studies have shown that some polio survivors (but not all) can improve muscle strength (as a result of new muscle hypertrophy, or enlargement) and enhance cardiovascular endurance with a closely monitored training program. In fact, some studies have reported an increase in strength in muscles both with and without new weakness.
It will be important to gradually begin your personalized exercise routine-only do little bits at first. One approach might be to apply the "20% Rule." If you have chosen to do a conditioning program, Stanley Yarnell, M.D. (1991), post-polio specialist, suggests a general conditioning exercise program to restore stamina or endurance using this "20% Rule." You establish your maximum capacity (the point at which you begin to tire) for any one exercise. Then you begin your program by working at 20% of that maximum exercise capacity. Do that 3-4 times per week for one month and then increase the rate (time) of exercise by another 10%. Each new month, increase the time exercising by another 10% until maximum capacity is reached. Yarnell clearly warns polio survivors to stop if they become fatigued during their exercise program, or if they experience pain or aches in their muscles. Most survivors, he says, "are able to continue increasing their exercise program to nearly the maximum capacity. " Rests are to be taken every few minutes. This 20% Rule can also be applied to home stretching and flexibility programs too.
Halstead also lays out the following guidelines as you begin your exercise program:
Having the tenacity to stick with the program and make the proper adjustments is a real challenge, but polio survivors are good at setting goals and achieving them. Across the country men and women who had polio are beginning to apply these principles of exercise and are experiencing much success. The real reason to get into motion is that exercising can make you feel better! Joan Headley (personal communication, February 26, 2002), high profile polio survivor with a mild disability attests to that in her personal account:
"In 1994, seven years after I had switched jobs from teaching school (and being on my feet most of the day) to working at the International Polio Network where I consciously stayed off of my feet, several observations caused me to rethink my approach to activity.
The pain in my 'good' leg was gone, but was replaced by a pain in the hip of my 'polio' leg. Shopping trips and other family outings were cut short because I did not have the stamina to be on my feet for more than a couple of hours. Each year it became more difficult to climb the stairs to reach my symphony seat because my legs were weak. Then one night, while walking up those stairs and "listening to my body," I also realized I was panting and "out of shape."
One day an elderly polio physician suggested that the pain in my 'polio' leg was not from muscle weakness, but from connective tissue tightness and perhaps I should 'stretch it.' It was at that point I decided to make a change. I visited Bally's with my brother and sister-in-law and we made the circuit trying each machine identifying my weakest muscles. So, I began an 'exercise' program using Dr. Stanley Yarnell's (St. Mary's Hospital, San Francisco) 20 % Rule. I did a select exercise to the greatest extent I could, and then cut it back to 20% and slowly added repetitions and distance carefully observing if there were any consequences.
Today, eight years later, I have eliminated the pain in my leg by doing 30-35 repetitions at least five times a week, as well as two exercises for my arms. I also walk one mile an average of four times a week and do about an hour of stretching exercises once a month in the pool.
For a few years, I walked in the neighborhood park and an added benefit was that I left all of my daily work problems there. I now walk at the YMCA on an official track with no worry about bumps in sidewalks or my safety when I walk in the evenings. I still leave my problems behind, however-the happily embraced extra benefit of a good exercise program.
Agre, J. C., (1995). The Role of Exercise in the Patient with Post-Polio Syndrome. Annals of the New York Academy of Sciences, 753, 321-339.
Birk, T. J., (1997). Polio and Post-Polio Syndrome. In J. L. Durstine (Ed), ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities (pp. 194-199). Champaign, IL: Human Kinetics, Inc.
Halstead, L. S., (1998). New Health Problems in Persons with Polio. In L. S. Halstead (Ed), Managing Post-Polio: A Guide to Living Well with Post-Polio Syndrome (pp. 20-53). Washington DC: NRH Press.
Silver, J.K. (2001). Post-Polio Syndrome: A Guide for Polio Survivors and Their Families. Yale University.
Call Gazette International Networking Institute at 314-534-0475 or visit their website at www.post-polio.org to order:
Exercise for Polio Survivors, Gazette International Networking Institute, 2001.
Maynard, F. M. & Headley, J. (Eds.). (1999). Handbook on the Late Effects of Poliomyelitis For Physicians and Survivors. Saint Louis, MO: Gazette International Networking Institute.
Birk, T. J., (1997). Polio and Post-Polio Syndrome. In J. L. Durstine (Ed), ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities (pp. 194-199). Champaign, IL: Human Kinetics, Inc.
Halstead, L. S., (1998). New Health Problems in Persons with Polio. In L. S. Halstead (Ed), Managing Post-Polio: A Guide to Living Well with Post-Polio Syndrome (pp. 20-53). Washington DC: NRH Press.
Maynard, F. M. & Headley, J. (Eds.). (1999). Handbook on the Late Effects of Poliomyelitis For Physicians and Survivors. Saint Louis, MO: Gazette International Networking Institute.
Hoffman, C., & Maynard, F. M. (1992). A Program of Nutrition Education and Exercise for Polio Survivors: A community-based model for secondary disability prevention. Topics in Clinical Nutrition, 7(4), 69-80.
Tate, D. G. & Leonard, J. (2001). [Wellness for Women With Polio: A Holistic Program Model]. Unpublished raw data.
Willen, C., & Sunnerhage, K. S. (2001). Dynamic water exercise in individuals with late poliomyelitis. Archives of Physical Medicine and Rehabilitation, 82(1), 66-72.
Yarnell, S. K. (1991, Summer). Non-Fatiguing General Conditioning Exercise Program (The 20% Rule). Polio Network News, 7(3).
NCPAD is part of the Department of Disability and Human Development in the College of Applied Health Sciences at the University of Illinois at Chicago. Please direct any comments about this site to: NCPAD Webmaster
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This came to us through one of our e-mail friends. Forgive me I forgot to note the name.
TOP 10 SECRETS TO A
STRESS-FREE PERSONAL LIFE
1. Create boundaries.
Boundaries reflect what other people can or cannot do or say to you, for instance, "I am only able to listen to you when you speak calmly without shouting." This will leave you feeling protected from hurtful situations.
2. Ask people to help you.
Choose 3 things today that you can receive help with and ask for it. You will have less to cope with and get done, can stop being a hero who does it all and leave the other person feeling important with a sense of responsibility.
3. Quiet your mind at least once a day.