Cupping: Good, Bad and Ugly- A Talk Delivered in SIP Conference 2017

Cupping has a long legacy. It had been mentioned in Egyptian scriptures as old as 1550BC. Prophet Muhammad recommends it in Hadith. Hippocrates had mentioned about it in his books.

A. Dry Cupping: Simple, run of the mill cupping. Vacuum can be created in various ways to latched the cups to the skin for desired duration.

Dry Cupping

B. Mobile cupping: The cups (and the suction force) are dragged over the surface of the skin. Kind of effluerage, but with negative pressure.

Mobile Cupping.  The cup is moved on The body surface. Another variation is,  when the patient is asked to move the body part with cups on them! 

 

C. Flash Cupping: Cups are attached and withdrawn immediately.

Flash Cupping

D. Needle Cupping

Needle Cupping

E. Herbal Cupping: The cups are heated with herbs.

Herbal Cupping

F. Water Cupping: Needs a lot of manual skills!

Water Cupping

G. Wet Cupping/ Hijama: Blood letting Cupping

Wet Cupping

How does cupping work? There are multiple theories.

Cupping in Traditional Chinese Medicine  style is based on Meridian system.

Wet Cupping supposedly removes the harmful waste materials from the body.

There are even elaborate theories on diagnostic significance of residual cupping marks. Impressive?

By far the best scientific evidence comes from UCSF. By the way, they don’t call it cupping. “Myofascial Decompression Therapy” is the name they use. Old wine in new bottle?

The marks on Michael Phelps are from this particular form of therapy.

There are a few research articles that validate Cupping

However, as you can see, good quality studies are hard to find.

There are quite a few reasons why a physio should consider incorporating cupping in their arsenal

Although vacuum therapy is hardly a new entity in the field of physiotherapy

Hurdles that a physio face while justifying cupping

 

So while cupping is an exciting tool in the field of manual therapy a lot of issues have to be sorted out before it can be called a mainstream physiotherapy modality. The onus is on the practitioners and propagators to justify it’s use.

(more…)

Dry Needling Assessment form

Assessment and recording of Dry Needling is an integral part of a DN session. However, there is no standardized procedure. Hence I have made this form, which should make the whole documentation process easy to record and easy to retrieve.

This form is dry needling specific and not a complete assessment form by itself.

Please leave your e-mail id to get a pdf version for clinical use, along with a guideline of how to use it.

SPIDER: Needling with the web of safety

One of the major dangers associated with dry needling is pneumothmorax. Although documented cases are rare a needler should still exercise utmost precautions because of two reasons. First, it is a serious, even potentially fatal hazard. Second, the margins of safety are low. One article reports iatrogenic pneumothorax caused even by a dry needling instructor with 45 years of experience, so one should always take enough measures to ensure safety while needling around the thorax.

SPIDER is a combination of six very important steps which I believe would provide significant protection against the risk of pneumothorax (and also other needling related adverse effects like nerve damage or injury to the hollow organs). I would recommend going through these measures mentally every time one needles a patient.

S-surface anatomy

It is always a good idea to review the anatomy of any structure that you are going to needle. To prevent pneumothorax ALWAYS review the surface anatomy of pleura before needling around chest wall.

The Pleura extends into the neck superiorly, from the medial 1/3 of the clavicle to the sternoclavicular joint. The apex lies about an inch (sometimes higher) above the clavicle.  One should be careful in while needling the structures here as the pleura can be just half a centimeter below the skin for lean individuals. The superior part is bound laterally by first rib. As it does not enjoy the protection of the ribs in the top where only covering is Sibson’s fascia, it is very easy to damage the pleura at this area. Remember the entry scene of Achilles in the movie ‘Troy’? He killed the giant with one clean strike by digging his sword precisely in that area.

Pleura also needs to be avoided diligently while needling the structures in the back. The medial margin of the pleura extends along the transverse processes of C7 till T12, sometimes L1. The book “Trigger point dry needling” by Jan Dommerholt mentions a ‘safe needling zone’ which is about a finger width lateral to the spinous process. Needle anywhere beyond that and you have a risk of reaching the lung.

P-position

Be mindful of both patient’s position and the position of the needle. One should be aware that with alterations in body position the arrangement of muscles gets changed in surface. For example in prone lying if the arms are kept forward the lower border of the trapezius muscle shifts superior and somewhat medially. Similarly, with posture change the ribs may open up more (e.g. in side lying if the arm is abducted, to needle serratus anterior).

The needle should be positioned over the skin with precision before tapping it in. If possible move the target tissue over a rib. Travel and Simon has also recommended fixing the target tissue by keeping one finger each in upper and lower intercostals spaces of the rib. The needle should always be positioned away from pleura and other vulnerable structures (e.g. femoral nerves, while needling the adductors.)

I-incidence Angle

Incidence angle is the angle at which the needle is inserted. While needling structures like rhomboids the angle should be very narrow, almost parallel to the skin to avoid pleura. For the muscles that attach to scapula it is usually recommended to aiming the needles towards the bone which stops the needle like a shield and protects the pleura.

It is important to recognize that at the same point of entry a wrong incidence angle can easily reach the pleura and create problem, for example, whie needling the thoracic multifidus in the ‘safe needling zone’ if the needle is angled laterally (instead of the recommended medial direction) it will definitely puncture the pleura. Similarly, while needling the piriformis directing the needle away from the sciatic nerve will be essential.

Correct incidence angle is also important for needling the correct structure.

D-depth

The depth of the target tissue should be judged and the size of the needle should be selected accordingly. The needler should have a fair bit of idea about the depth of the tissue and needle should be advanced no further than necessary.

If you are not comfortable inserting the needle at a depth stay superficial. You will still give the patient A delta mediated analgesia and there is a fair bit of possibility that the trigger point will get resolved by SDN mechanism.

E-educate

While taking the informed consent the patient should be educated about the potential adverse effects and how to identify them whether they are simple soreness or pneumothorax. Many a times pneumothorax can develop after a patient has left the clinic. This article reports a case of pneumothorax which was developed about six hours after dry needling. The article also mentions the symptoms of it as the patient (a medical doctor) experienced them. The patients should know what action they need to take if the adverse effects appear.

One should also educate the patient about the do’s and don’ts after needling. A small poke to the pleura may remain asymptomatic and heal itself if the patient avoids heavy upper limb activity for the remainder of the day of needling.

R-record

Like any manual therapy sessions needling interventions should be recorded. Every relevant detail need to be mentioned. I have created a simple dry needling recording technique which I will post soon.

While practicing SPIDER will definitely reduce the risk of pneumothorax and other adverse needling effects while needling, be weary of at risk population. Patients who are lean individuals, have a history of emphysema or other lung diseases or have chest wall deformities are not the best candidates to receive DDN on the chest wall. Above all, remember this maxim from Benjamin Franklin: When in doubt, don’t.

Demystifying Dry Needling: Analgesia

pain mod


Many healthcare professionals are skeptical about dry needling. Indeed, for the uninitiated it is difficult to comprehend how a seemingly innocuous needle without any medicine can produce any therapeutic benefit beyond placebo. This article series will try to answer some of those questions. In the present installment we will focus on the analgesic effects of dry needling.


Dry needling modulates pain and produces analgesia which lasts considerably longer than the duration of the needling. In fact, the analgesic effects of needling continue up to 3 days after the needling has been done. The analgesic effect of dry needling involves multiple mechanisms including immune, hormonal, and nervous systems. In this article we will focus our attention to the neuronal mechanisms involved in needling induced analgesia. To explain this let us take the help of the diagram of a simplified pain pathway (below). Of course, the actual anatomy of the pain pathway is far more complex. A good overview can be found here: http://neuroscience.uth.tmc.edu/s2/chapter07.html

Pain Pathway

As it is shown in the figure below the pathways of fast (Aδ) and slow (C) pain are different. The fast pain travels via neospinothalamic tract (Navy blue) where the first order neurons (Aδ) synapse with marginal cells (M) which then takes the impulses straight to thalamus (Ventral posterolateral nucleus of thalamus). This pathway can be compared with a highway, as there is no interruption in between. However, the neospinothalamic tract has projections to some important areas of brain.


The slow pain on the other hand travels largely via paleospinothalamic tract (light blue). The first order neurons (C fibers) of this pathway hand over information to Substantia Gelatinosa (SGR), which in turn propagate the impulses to Wide Dynamic Range (WDR) nociceptors. The signals then travel via a multi synaptic system to Reticular Formation (RF) area and finally to thalamus (parafasciculus and centromedian thalamus). Because this pathway has multiple intersections it can be compared with a city road with slow moving traffic with signals which can stop the transmission altogether.

pathway+


The difference in the pathways of fast and slow pain is because the purpose they serve is different. While fast pain alerts an organism from external threat (e.g. fire) and thus helps in the survival, the slow pain draws attention towards existing pathology.

Pain Modulation via Needling

Because C pain is less related with survival of the organism the nervous system has mechanisms in place to block C pain at various levels. The various pathways involved are shown in the second figure which is essentially same with the previous diagram, but with some more connections.

pain mod

Segmental inhibition:

Dry needling produces A delta simulation. As it is seen in the diagram, apart from stimulating the marginal cells, the A delta fibers also activate enkephalinergic stalked cells (ST) within the spinal cord. These stalked cells inhibit the SGR and reduce the transmission of slow pain impulses.

The Serotonergic System:

As the neospinothalamic tract carries the needling induced fast pain towards brain it sends collaterals to Periaqueductal Gray Matter (PAG) of mid brain. Neurons in PAG direct a nucleus in Medulla(Nucleus Raphe Magnus:NRM) to release serotonin which activates the stalked cells via descending neurons. Similar to segmental inhibition, the stalked cells release enkephalin and blocks C pain at the level of SGR. The prefrontal cortex can influence the PAG activation via hypothalamus and influence this descending pain suppression system.

The Noradrenergic System:jaipur

Large collaterals from neospinothlamic tract connect nucleus paragigantocellularis (PGC) of Medulla. When stimulated (via needling), PGC in turn influences Locus Coeruleus (LC) of pons (or similar brainstem structures) which releases noradrenalin in SGR and thereby controls the transmission of C pain. The noradrenergic system too can be influenced by prefrontal cortex hypothalamus axis.

The Diffused Noxious Inhibitory Control (DNIC) Mechanism:


Reticularis dorsalis (R) in medulla receives direct input from A delta fibers. In response it releases opioids to dorsal horn of spinal cord, which again inhibit SGR. The DNIC is a powerful mechanism which is especially active during the initial analgesia after needling.

And there is more:

A few things before I finish. First, in the introduction I have mentioned needling can produce analgesia up to three days. This needs an explanation. Although the needles are withdrawn from the skin within a few minutes the miniature wounds that they create remain. They continue to provide some A delta stimulation until healed thus prolonging the analgesia. Second, because of the prefrontal cortex hypothalamus axis influence in needling induced analgesia the emotion, mental state etc can affect the outcome. Third, while the above information provides a basic overview of needling induced analgesia, the facts here is oversimplified. Interested readers can refer to David Bowsher’s work for a more in depth discussion.

Exclusive Interview with Prof. C K Senthil Kumar, PhD

“Council Will Have A Tremendous Positive Effect  On

 Physiotherapy  Profession”

Professor C K Senthil Kumar, PhD wears many hats. He is a11224360_1067902773242707_3191209352288901836_n physiotherapist, a teacher, an administrator, an organizer, a researcher and a philanthropist; duties that need him to travel across the nation, working impossible hours. And yet, he performs all these work with easy elegance, wearing a crisp suit, a brilliant smile and a great sense of humour.

We caught up with Senthil sir in a typical busy day. He shifted back and forth between this interview and series of meetings, loads of paperworks and numerous phone calls. Once again we marveled on his multitasking capabilities which he has refined over the years.

Another quality that stayed with him through the years is his youthful appearance. We decided to start our interview from that point.

PHYSILIFE: Your looks haven’t changed since the past one and half decades sir. What is the secret?

Senthil Sir: Praise to Almighty. The secret is I love what I do; being a physiotherapist and always staying positive whatever might be the tidings.

PHYSILIFE: The physiotherapy profession meanwhile has changed considerably. How would you compare physiotherapy today with what it was when you started out?

Senthil Sir: I see a tremendous change in the field, a change that is positive, dynamic, and good.  A physiotherapist has evolved in to being his/her own master. The field of physiotherapy currently provides exciting, innovative and  invigorating environment for all physiotherapists.

“MBA students were posted under Senthil sir to learn management skills.”

For Senthil sir it’s always students first. During our time sir had organized a full blown conference with Rs. 1 registration fee, so that everyone can afford it. The doors of Senthil sir’s house are always open for the students. They become part of his extended family. The discussions off the classroom provide great nourishment for mind as well as stomach!

Sir’s management skills are legendary, so much so that at one time he was entrusted with the responsibility of 20+ courses, besides physiotherapy. Even MBA students were posted under Senthil sir to learn hands on management skills.

Einstein Jerome

(Former Student)

Physiotherapist & PhD Scholar

ESIC Model Hospital & Research Institute, Bangalore

(Govt. of India)

Administrator

Physiotherapy Jobs Portal

Executive Committee Member

Bangalore Physiotherapists Network

PHYSILIFE: The PHYSIOCON has now become one of the most popular events among the physio community. How did it start?

Senthil Sir: The spark for PHYSIOCON was ignited five years ago, when I thought it’s high time to honour our teachers, luminaries of physiotherapy field and to give opportunity to other physios to honour their teachers. By the grace of God annual PHYSIOCON event has become a huge success and PHYSIOCON 2017 has become one of the known events throughout the country.

PHYSILIFE: The PHYSIOCON 2017 is already making right noises. Tell us something about it? Is it too costly to attend?

Senthil Sir: The PHYSIOCON 2017 will be an exciting platform for the physiotherapy fraternity to come together  and exchange their views, latest professional practices, professional skills, innovative ideas, experiences and infuse dynamism in to ever changing physiotherapy field. PHYSIOCON 2017 is not going to be expensive.

PHYSILIFE: You got a wonderful response from the physiocon 2016. Did you expect such a high turnout?

Senthil Sir: Yes, we certainly expected a high turnout because of the fact that our sincere endeavour to create a platform for physiotherapy fraternity to come together and to carry the profession to new horizons has been appreciated by all.

PHYSILIFE: Tell us something about Dr. MG. Mokashi.  The present generation of physiotherapists do not get much opportunity to interact with him.

Senthil Sir: Dr. Mokashi sir is Godfather to me. I feel he is Godfather for the profession. He is the man of principles and known to adjust to the profession who is working constantly for the professional development in spite of his ill health. 

I had never seen a person who is so humble and cares for his students.  I remember when I was a student he picked me in his Bajaj scooter from Bombay Mulund East station to his house to teach me.  Like me many students stayed at his house and studied. As a father to all of us, he helped many students to pay their fees.

PHYSILIFE: The physiotherapy  council is long overdue, will it happen anytime soon?

Senthil Sir: Yes definitely it will happen. The IAP and all other associations joined by good willed people are working tirelessy and together to achieve this.

“The most humble person and a great mentor, Dr CK Senthil Kumar is not only an excellent professional person but a true human being in all respect. He has been a constant source of  inspiration and a torch bearer.”

Dr.Syed Muhammad Waris, PT

(Former Student)

Associate Director, Academics

London Academy of Sports and Health sciences, (LASHS) UK

PHYSILIFE: On a hind sight do you think we should have settled with RCI?

Senthil Sir: I strongly believe one should always keep moving as the time and situation warrants and looking back does not serve any purpose.

PHYSILIFE: If the council happens will it change the profession significantly for patients and physiotherapists?

Senthil Sir: I strongly believe that a council will have a tremendous positive effect on physiotherapy profession.

PHYSILIFE: You juggle between lots of responsibilities. How do you manage time?

Senthil Sir: I don’t manage time, time is managing me and I strongly believe in the ethos complete the work of the day and sleep peacefully.

PHYSILIFE: Before we finish please tell our young readers, is present era a good time to take up BPT?

Senthil Sir: The present era provides an excellent, invigorating and dynamic environment for any aspiring physiotherapist and it is an evergreen profession. I feel proud that the rise of my students and the professionalism what I maintained made my elder daughter Chrislin Jennifer to take up physiotherapy without any compulsion.

PHYSILIFE: What are your advises for a young physiotherapist who is just starting out?

Senthil Sir: I would like to suggest to young physiotherapists to always have the zeal to maintain highest level of professional ethics and competency at all times and always strive sincerely and wholeheartedly for the betterment of physiotherapy profession.

 

 

PENS: A New Analgesic Modality in Physiotherapist’s Arsenal

download (1)

Mrs. Ruby  Bose, 37, had an important family function  at her residence on Sunday. However, on Saturday during preparations of the function  she had a catch in her low back muscles. After the home remedies and  strong painkillers did not work the doctor sent her to  physiotherapy.

“She was never fond of needles”, her husband Dibyendu recollects, “but she didn’t really have a choice, she had to be fit for the gathering next day”. So when Dr. Das, PT informed her about a new procedure called PENS which can relieve her pain she agreed. And 15 minutes later became completely pain free.

“It was nothing short of a miracle. I mean I have taken physiotherapy before and they did help, but I never experienced complete pain relief in a single session” Ruby says.

So what is PENS? PENS stands for Percutaneous Electrical Nerve Stimulation. It is a combination of traditional physiotherapy modality, i.e. TENS with Dry Needling, a new age technique. To perform this the Dry Needling needles are inserted in the body first. Then the needles are connected with special resistor electrodes. These electrodes are in turn attached to a traditional battery operated low TENS machine.

PENS holds several advantages over TENS. First, the TENS is applied on the skin overlying the area of pain. TENS    impulses have to combat skin resistance and the resistance of the subcutaneous fat before they reach the source of pain. On the other hand PENS can be delivered specifically to the source of pain,  resulting in a much profound analgesia.

Secondly, both low TENS and Dry Needling releases endorphins in the CNS. Combining both together enhances each others effectiveness. By changing the frequency of impulses one can even tap into other neurotransmitter reserves, like GABA.

Third, because the skin resistance is bypassed it is much   easier to get muscle contractions via PENS as compared to TENS. The rhythmic pumping action helps to remove the metabolic waste products in the vicinity and also works to bring down the muscle spasm. This breaks the Pain-Spasm-Pain cycle and helps in early return to activity. This also means PENS is effective not only for analgesia but also in  resolving the pathology.

Fourth, PENS helps to stimulate both A-Delta and A-Beta fibers, which activate different parts of pain gate.

The effects of PENS are thus impossible to achieve by any other means. When used with strong clinical reasoning PENS often produce results which are in patient’s own words, “nothing short of a miracle”.

(Some names have been changed to protect identity)

Persistent low back pain: 6 questions to ask yourself

Burning red pain80% of all people suffer from (LBP) low back pain at least once in their lifetime. So, if you are having one, no big deal. But if your back pain continues beyond reasonable time (say, about 6 weeks) or recurs frequently, then something must be wrong with your health habits. To find out what, you should ask yourself these questions:

#1 Am I sitting the wrong way?

A slouch sitting on a badly designed chair for a long time produces considerable amount of LBP. Sit straight with butts deep inside the seat so that your thighs are completely supported. your feet should be supported too, instead of hanging in the thin air, so adjust the chair height or get a foot rest. It is best to add a cushion in the lumbar area (the hollow of your back opposite the umbilicus). A rolled up towel works fine, but if you are the spending type then you can order the McKenzie roll.

Invest in a good ergonomic chair if you are on a sitting job, mind you, the costliest is not the best, so look for user review or expert opinion while choosing one.

#2  Am I bending too much?

Frequency of flexion (forward bending) is a known risk for LBP. in fact a study has shown if you control forward bending early in the morning there is significant improvement in the low back pain. So, next time use a broom with a log handle, tie the shoelace with the foot over the stool, bend the knees instead of stooping when you pick up something from the floor. In short, stop forward bending as much as possible.

#3 Are my daily activities taking a toll on my back?

Are Sundays/leisure days better than a working day? if yes, then most probably your ADLs (Activities of Daily Living) are over stressing your back. Remember, there are two ways to perform any work, the wrong way: when you hurt your back and the right way, when you protect it. If your job involves sitting for prolonged time without much movement, lifting and carrying heavy objects, riding two wheelers or operating machines that vibrates a lot then you should take frequent rest in between and exercise.

#4 Am I performing correct exercise?

First, are you exercising at all? Studies have shown sedentary lifestyle is a known risk factor for back pain. So, if you do any physical activity you are positioned better prevent LBP.

If you are already suffering from LBP then depending on your type of pain you need to perform specific exercises. There is no single exercise prescription that cures them all, so consult a good physio who will show you the correct set of exercises. While in most cases a properly designed exercise regime is sufficient to get rid of low back pain, a wrong set of exercise may have disastrous effect on the back pain.

#5 Am I suffering from an underlying disease?

While most back pains are mechanical in nature (overload related) a variety of systemic diseases are associated with low back pain, ranging from forms of arthritis to cancer to kidney stone. The hallmark of a mechanical back pain is it changes intensity with body posture. Still, when in doubt, always seek professional help.

#6 Am I suffering from stress?

Stress can both produce back pain and delay the recovery. Negative emotions like depression, anxiety, anger, tension etc have far reaching implications on health issues like back pain than we commonly realize. If this is the case for you then don’t ignore it. There are number of ways to de-stress, you need to choose what suits you.

Top 7 reasons for not getting the desired results of workout

Frustrated woman on exercise ball
Not satisfied with your progress in the gym? May be you are making one of these mistakes.

1.     Not maintaining correct form

Form is of greatest importance when you are executing an exercise move. Many of us sacrifice form/posture to get more repetition or to be able to work with greater resistance. This only produces poor result, as instead of working the target muscles you end up working other muscles, in simple words, you are cheating yourself. An example of this would be using the hand support on your knees in squat. Another example is sagging the back during push up.

2.     Letting gravity do half of your work

when you are lifting a weight (e.g. biceps curl with a dumbbell), or working against gravity (standing up from a squat), your muscles got to work. But to get an efficient work out you must use your muscles during the lowering down phase also, by controlling the speed. If you allow the gravity to take the weight down then you are getting only half of the workout.

3.     Not getting enough workout

Do you find your work out too easy?  May be your exercise plan is inadequate. May be you are into the same regime too long and your body has become accustomed to that routine. To get improvement in any exercise program you must overload your body. A good exercise routine should produce tolerable levels of fatigue when you finish it. A general guideline to proper exercise load for muscle building is when you are performing 3-4 sets of 6-12 repetitions per set, and you are exhausted after every set. A minimum 3 days of exercise is needed per week.

4.     Getting too much of exercise

This is the opposite scenario when your body can not handle the amount of overload. The body needs to recover from the previous workout session before you start the next one. Are you in a hurry to get into shape? Overzealous workout can only give you injury, and tiredness throughout the day. Plan a balanced workout routine.

5.     Exercising only for strength

Many of us go to gym just to work with heavy weight, that too, for the upper body. Please remember, fitness has 4 components, strength, suppleness (flexibility), speed and stamina, and they are interdependent to eachother. If you workout only for strength or only for a part of the body then gains from your workout will not be substantial.

6.     Not having a healthy lifestyle

This is pretty commonplace, and the one that really spoils all your hard work in the gym. An unbalanced diet with excess oil and carbs, no established food routine, haphazard sleep cycle, smoking, too much of alcohol and stress can negate your gains from the gym.

 

7.     Not enjoying your workout

It may sound funny but people who get maximum benefit from their workout are also the one who enjoy their workout immensely. The bodily changes of exercise are largely dependent upon the neuro-hormonal factors which are directly related with your mood. Find some workout form that excites you, challenges you in a positive way and motivates you to do your level best. There are infinite options available. One will surely suit you.

AN OVERVIEW OF WEIGHT REDUCTION TECHNIQUES

 

 

eric chopin

The guy above is Eric Chopin, winner of 2006 reality TV show, The Biggest Loser season 3. He had lost almost 100 kgs during the tenure of the show. If you want to lose weight too, and searching for ways, this article will discuss all the popular options available.

The energy balance

To understand weight reduction process better, let us spend a moment on the energy balance. The food we take gives us calories (energy) which are burnt (utilised) for every physiological and metabolic function. If the calorie intake and calorie output remains equal, then we have an even energy balance. If the calories we burn are less than the calorie we eat then we have a positive energy balance, i.e. excess calories. The excess calories are converted to fat and stored in our body. In order to reduce weight we need a negative energy balance, means higher calorie expenditure than we eat. In that case the difference in calorie will come from stored fat.

The bus analogy

The food we consume travels through the curvy passage of our food pipe can be compared with a bus that moves through the road from terminus (Mouth) to destination (No prize for guessing where!) The passengers pay the bus money whereas the food gives us calories during the course of the travel.

An even energy balance would be when the cost of running the bus is equal to the money earned from the passengers. No profit, no loss.

A positive energy balance is when the money earned is more than running cost. Money is saved like fat. Every bus owners dream, but every obese person dreads this situation.

A negative energy balance is when money earned is less than running cost. Money that is previously saved has to be given away in order to run the bus. This is what we need to achieve, a massive and sustained loss in the business!

Now we will see how a negative energy balance can be induced in each station as the bus travels.

 

Mouth: The starting point

jaw wiring
     Jaw wiring surgery

 

If you can reduce the number of passengers, the earnings will be low.

This is achieved by diet restriction. Also, in olden days surgeries were performed to wire the jaws together temporarily to drastically reduce the food intake! Appetite suppressing drugs also work in this aspect.

Restricting the no. of seats in the bus: restrictive surgeries

bariatric
    Implanted balloon device

If the seats in the bus reduce, so will the profit. For this stomach size is reduced. This can be achieved a number of ways, like actual surgical shortening of stomach, placing a band around the stomach, or putting a balloon inside the stomach to occupy the space inside.

Malabsorptive surgeries: Taking a shorter route

BPD: Biliopancreatic diversion
  BPD: Biliopancreatic diversion

Suppose a bus suddenly decides to take a bypass route. What will happen? The passengers who were supposed to get down in between will no longer pay. The earning will take a beat. Same thing is achieved with malabsorptive procedures, where a surgically created ‘shortcut’ prevents the food to be absorbed. E.g biliopancreatic diversion.

Increasing the without ticket passengers

Interesting proposition, isn’t it? Simply means eat food, but don’t take the calories. It can be done in two ways. First, eating the foods which does not yield much of calories, e.g. green leafy veggies, cucumber, tomatoes etc. Second, use of means which interfere with the normal digestive mechanism, which is commonly done using medication.

Exercise: Increasing the cost to company

Imagine you exchange the economic engine of a run of the mill bus with the engine of AC Volvo. What will happen? The riding will be smooth, there will be more power, but .. the fuel efficiency will decrease drastically. Same thing happens when one starts exercising. The excess calories spent during exercise helps to create a negative energy balance that results in loss of weight.

Rob’em off

So you made a huge profit in your bus business. Have a lot of money stored in your locker, and one fine morning you are robbed off all the cash. This is analogous  liposuction and related cosmetic surgeries, where excess body fat is removed from the body.

If you can’t make it, fake it!

sauna
Sauna bath reduces weight by dehydration

Suppose the bus is doing great business, but you do not want to pay tax for it, what will you do? You will fake a loss. This is done with weight reduction too. Where people fool others (or themselves) with the reduction of body water, instead of fat mass. That is plain and simple dehydration, which will be eventually gained. The ways to do so are by steam bath, using drugs which increase urination, drinking abysmally small quantity of water etc. Remember, tax evasion can land you in jail whereas water depletion will land you in hospital.