CRANIOSACRAL THERAPY

The Role of CranioSacral Therapy in Addressing Post-Traumatic Stress Disorder

By John Upledger, DO, OMM

Throughout human history, those who have undergone or witnessed traumatic events have oftentimes experienced ongoing and uncontrollable fear, anxiety, depression, and other life-altering emotions. It has only been in recent times, however, that these symptoms have gained recognition, validation, and a name.

In 1980, Post-Traumatic Stress Disorder (PTSD) was first officially recognized by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders, Volume III. Before 1980, the condition existed only as titles such as "shell shock," "battle fatigue," "dissociative amnesia" and "physioneurosis." It was the rather high incidence of PTSD in Vietnam veterans that finally prompted inclusion of the condition as a mental disorder in the DSM III.

Although combat veterans comprise a significant percentage of PTSD sufferers, combat should not be considered the singular cause of the disorder. It can result from any experience a person feels is life-threatening, terrorizing or totally degrading. It can also result from viewing horrible or terror-inducing events that happen to others, especially loved ones.

The symptoms of PTSD may occur days to years after the related event. Once begun, the symptoms occasionally go into remission and then return. The disorder we now call PTSD may continue to affect the victim for years, decades, or the balance of a lifetime. Though classified as a mental disorder, PTSD has distinct physical origins. In our years of research and treatment of PTSD, we have encountered numerous symptoms that respond well to hands-on CranioSacral Therapy. The following are seven of the more prevalent symptoms that the PTSD patient may endure, and how we approach managing such symptoms:

1. Insomnia can result when the joints of the head and neck become jammed due to extreme backward or forward bending of the head during a traumatic occurrence. CST is used to release these pressures and improve the efficiency of fluid outflow at the occipital-cranial base (base of the skull). When successfully applied, insomnia significantly improves.

2. Hypervigilance is a state of heightened awareness in which any surprise or unexpected noise causes an excessive response that the PTSD person cannot control. (This also contributes to insomnia.) We use CST and its offshoot, SomatoEmotional Release, to locate and release energy cysts (contained areas of stress) throughout the body.

We concentrate particularly on the reticular activating system (RAS) of the brain and spinal cord, which is responsible for the secretion of adrenalin and other stress hormones and biochemicals. When we can reduce this system's level of ready alertness, both hypervigilance and hyperresponsiveness are significantly alleviated.

3. Intrusive thoughts continually interrupt a PTSD victim's ability to concentrate, and may even prove intellectually disabling. CST and its offshoots are used to balance fluids and release restrictions on the right and left sides of the cranium, thus enhancing the circulation of both blood and cerebrospinal fluid. As a result, nutritional supplies to brain cells are improved and toxic waste products are removed. The brain areas that help control conscious thoughts are also revitalized and become more effective.

4. Flashbacks involve the mental re-experiencing of the horrific events that caused the PTSD initially. Each time they occur, they are just as terrifying to the person as the original experience. Unlike normal memories, they do not mellow with each recall, nor can the person experiencing them describe them in words. While this kind of response can be considered appropriate at the time of the original traumatic event, it certainly is not appropriate 10 years later in a different and probably safe setting.

Studies have shown that, in PTSD, the left hemisphere of the brain is less functional than the right, and the hippocampus - thought to be an important factor in memory control - is smaller on the left side than on the right. CranioSacral therapists work to equalize the mobility and fluid flows of both sides of the brain. They also pass a lot of energy from right to left, focusing on the left-side speech area (plenum temporale).

Using this approach, we have seen clients become able for the first time to describe the flashback event(s). As this ability improves, the flashback comes under control and the experience can be recalled voluntarily. Eventually, the power of the event fades and the flashbacks discontinue.

5. Panic attacks mark the beginning of PTSD, but they fade and discontinue as hypervigilance, intrusive thoughts and flashbacks are successfully treated.

6. Long-term fear results in a PTSD patient faced with a short-lived, scary episode. On the other hand, the non-PTSD person might well react with momentary fear to the same episode. This long-term fear becomes chronic anxiety. As with panic attacks, this too wanes as the CST takes effect.

7. Depression and suicidal thoughts are common in PTSD-afflicted individuals. Our treatment focuses specifically on releasing abnormal compression at three junctions: where the sphenoid bone and base of the occipital bone meet (floor of the cranial vault); where the joints where the first cervical vertebra and occipital bone unite (base of the skull); and where the lumbar and sacrum come together (lower back into tailbone). Once alleviated, depression lifts and suicidal ideations discontinue.

Using this approach in a study with 22 Vietnam veterans, we found that, at the end of two intensive weeks of treatment, all of them tested much lower on the depression scale. Even the administering psychologist had trouble believing the results of his own tests. It may be difficult to understand how something as light-touch as CranioSacral Therapy could effect meaningful change in an individual suffering from Post-Traumatic Stress Disorder. You are not alone. Those of us who practice the technique still marvel at the responses we often witness. The body is a remarkable mechanism, full of mystery and capable of untold feats of self-preservation and healing.

My hope is simply that this brief discussion helps you gain a better understanding of how CranioSacral Therapy works to aid the PTSD sufferer - and perhaps clears up some misperceptions about this disorder along the way.

PTSD is not an incurable mental disorder. Our research with Vietnam veterans has shown just the opposite, producing some of the most dramatic and encouraging results I have ever witnessed. This is just the tip of the iceberg. I hope you will join our efforts in the years to come, as we seek to eliminate PTSD from the trauma equation.

Training Effects

By Keith Eric Grant, PhD, NCTMB

A three-and-a-half million year-old footprint in East Africa, discovered by Mary Leakey, indicates that, at that time, our human ancestors had clearly diverged from the great apes.

The footprint is of a creature unquestionably standing on two legs. The adjustment from walking on all fours to walking upright encouraged reliance on vision and freed the front limbs for other work, like tool making and carrying. The weight of the body, previously supported by the front limbs, shifted to the legs and pelvis, which thickened to carry the weight of the upper body. This, in turn, refashioned childbirth, causing babies to be born immature.

- James Burke and Robert Ornstein

Humans exchanged difficult childbirth and a longer maturation period for versatile bipedal mobility; dexterity and expression with our arms; an upright environment; and the far-reaching vision that stimulated the development of minds that strive for beauty in movement. We are literally a species designed to adapt physiologically and neurologically to the movements we perform regularly.

Figure 1: Russian sports scientist N. Yakovlev's model of training and adaptation. After a workout, there is a recovery period followed by a period of super-compensation. The optimum time for the next workout is at the peak of super-compensation. Too early , and the body is still recovering; too late, and the benefits of the last workout are lost. The intensity of the workout also must be adjusted to achieve the optimum training effect indicated by the blue curve. The recovery period will also depend on factors such as nutrition, hydration and amount of sleep.We go through three identifiable stages when we learn a motor skill, such as massage or dance. We start learning in a verbal-cognitive phase, in which we derive information on position and direction from demonstration and verbal direction. Our movements typically are created by joining together bits and pieces of our existing movement "vocabulary." In the associative phase, we develop focused movement patterns and continue to perfect and adjust them through practice. In the autonomous phase, there is little need for constant monitoring, because movements are performed consistently, with precision and accuracy. We can turn our attention from the present task back to the surrounding environment.

In powering our movements, we have three different systems for obtaining energy that operate in a continuum. Immediate energy, for high-intensity movement lasting up to 20 seconds, comes from the production of adenosine triphosphate (ATP) from creatine phosphate. Anaerobic glycolysis provides energy for high-intensity exercise lasting 20-180 seconds. Finally, aerobic oxidation provides energy, quite literally, for the long run. With correct training, muscle cross-section and muscle strength increase. Our abilities to use oxygen (VO2 max) and process the lactate produced by glycolysis, also increase. One of the most dramatic effects of including anaerobic intervals in aerobic conditioning is an increase in the intensity of exercise performance for extended periods - our lactate threshold.

Some years back, Russian sports scientist N. Yakovlev devised a conceptual model that captured the concept of optimal training, both in intensity and repetitive timing, for maximum improvement (Figure 1). If we train too hard for our current conditioning and recovery rate, we head ourselves into deepening fatigue and, ultimately, breakdown. If we don't train hard enough, we obtain too little benefit. The right intensity of training allows us to recover fully and enter a period of super-compensation. If we train again during the maximum super-compensation period, we gain the greatest effect. If we wait too long, we lose the benefit of what we did before.

Figure 2: Exercise capacity and recovery capacity form a delicate balance. By normalizing hypertonicity, massage acts to increase recovery capacity. Increased recovery capacity allows for increased exercise capacity and a higher level of training.The benefits of massage come partly, I believe, in shortening the recovery time in Yakovlev's model. When recovery capacity is increased, exercise capacity can increase, yet stay in balance (Figure 2). Thus, we facilitate the gains of super- compensation. I believe the mechanisms for this lie in the interactions between the psychological and neurological. Daniel Arnheim noted both aspects of staying focused and relaxed in discussing injuries in dancers: The psychological aspect of injury prevention is as important to the dancer as is proper conditioning and nutrition. Dancers, like all people, have varying personalities and react to stress in unique ways. What sets dancers off as unique from other individuals is that they are artists seeking perfection in movement. The extent to which the dancer can withstand the psychological stresses imposed by the dance environment is determined by the dancer's total psychoemotional development and lifestyle, both past and present.

When considering injuries associated with psychogenic factors, one must consider muscular tension as a major cause in the dance field. Tension is defined as increased muscular contraction as a result of some emotional state or muscular work. Nervous tension is a syndrome that is characteristic of the so-called fast way of life of our times. It is associated with anxiety that comes from an undefined worry or fear. An overanxious dancer can have an extremely high level of unneeded muscular tension. The person who is outwardly anxious may be less flexible and less able to smoothly coordinate muscles. Organically, he or she may have an increased heart rate and blood pressure. The tense dancer is extremely susceptible to injury, and because of the increased muscular excitability, may over-respond to painful conditions.

We become part of the lifestyle structures of support to which an athlete and kinesthetic artist can turn when viewing massage as an interaction and communication. Beyond this, we can address the tension to which they might unconsciously cling. Among the wonders of our human embodiment is the astounding plasticity we have, which enables us to learn new kinesthetic skills, and adapt our bodies to their impassioned pursuit. Among the wonders of the massage we pursue is our ability to affect the training of those who come to us.

References

1. Abernethy, Bruce, Vaughan Kippers, Laurel Traeger Mackinnon, Robert J. Neal, and Stephanie Hanrahan, 1996: The Biophysical Foundations of Human Movement, Human Kinetics, ISBN 088011732X.
2. Anderson, Owen, 1998: Lactate Lift-Off, SSS Publishing Inc., Lansing, MI, ISBN 0-966-37260-3
3. Arnheim, Daniel D., 1991: Dance Injuries - Their Prevention and Care, 3rd ed., Dance Horizons, Princeton, NJ, ISBN 0-871-27146-X.
4. Burke, James, and Robert Ornstein, 1995: The Axemaker's Gift - A Double-Edged History of Human Culture, Grosset Putnam, NY, ISBN 0-399-14088-3.
5. Eyestone, Ed, 2001: Model Behavior, Runner's World, Sept. 2001, 32.
6. Knuttgen, Howard G., 2003: What is Exercise? - A Primer for Practitioners, Physician & Sportsmedicine, 31(3), www.physsportsmed.com/issues/2003/0303/knuttgen.htm.
7. Ylinen, Jari, and Mel Cash, 1988: Sports Massage, Stanley Paul, London, ISBN 0-09-173746-X.

Tendinitis Masquerading as Knee Joint Pain

By Ben Benjamin, PhD

Question: Which muscle tendon units often masquerade as medial, lateral or posterior knee ligament or joint injuries?

a. rectus femoris, vastus lateralis and vastus medialis
b.gastrocnemius, plantaris anda dductor magnus                                                             c. semitendinosis, semimembranosis, biceps femoris and gastrocnemius                                     d. all of the above

Answer: c - semitendinosis, semimembranosis, biceps femoris andgastrocnemius

The semitendinosis, semimembranosis, biceps femoris, popliteus and gastrocnemius are the muscle tendon units responsible for knee flexion. The semitendinosis and semimembranosis are located on the medial aspect of the knee, while the biceps femoris is located at the lateral aspect. Collectively known as the hamstrings, they work together to flex the knee. The superior portion of the gastrocnemius muscle tendon unit, located at the back of the knee, and the popliteus muscle also assist in the initiation of knee flexion.

The semimembranosis (1), semitendinosis (2) and biceps femoris (3).All of these tendinous attachments may become injured and give rise to a confusing type of knee injury. Pain felt medially, just posterior to the medial collateral ligament, may mean injury to the semimembranosis has occurred; pain at the medial upper tibia, or slightly behind the medial aspect of the knee in the tendon body, may indicate hamstring tendinitis of the semitendinosis; and pain at the head of the fibula, or slightly superior, may be caused by tendinitis of the biceps femoris.

Since this tendon attaches to the fibula head (the same bony prominence the lateral collateral ligament is attached to), it can be difficult to differentiate these injuries unless the practitioner is skilled at testing both ligaments and tendons. Superficial pain felt directly behind the knee may be caused by strain of the popliteus muscle or the gastrocnemius muscle at its broad upper tendon attachment.

Bear in mind that when a tendon is injured, no swelling or limitation in flexion and extension of the knee occurs. Swelling at the knee usually indicates a ligament injury, or injury to some structure within the joint capsule, such as the medial or lateral meniscus.

Continuing to educate ourselves in the most current information is vital in helping our profession grow in skill and stature. Identifying if a client has a superficial tendon or ligament injury (which can be treated with myofascial or friction massage techniques) is an important part of a therapist's education. On the other hand, trying to treat a client with knee pain caused by torn cartilage or a cruciate ligament tear (for which hands-on therapy will not help) will leave the client confused, frustrated and disappointed. Treating the wrong structure because of limited knowledge is an all-too-common error.

I continue to learn, and encourage you to do the same.

Increasing Physical Activity

Increasing Physical Activity in the Sedentary

Physical inactivity is so strongly associated with coronary artery disease, type 2 diabetes, and colon cancer that the American Heart Association has named physical inactivity an independent risk factor for coronary vascular disease.

But an amazing majority of people (60% of the population) still are inadequately active or completely inactive. More sedentary lifestyles, with more of the population working at desks and spending leisure time without exercising, contribute to deaths due to coronary heart disease, type 2 diabetes and colon cancer.

Regular vigorous, structured exercise programs appear to be too demanding of the average person�s time and commitment. This study reports on an alternative that may produce results comparable to physical fitness programs.

Sedentary, but otherwise healthy men (116) and women (119) aged 35 to 60 were randomly assigned to a traditional structured exercise program or a more moderate "lifestyle" physical activity program. The lifestyle participants accumulated 30 minutes of moderate-intensity activity, such as brisk walking and climbing stairs, on most or all days of the week. Physical as well as behavioral challenges were addressed.

Over 24 months, the subjects were evaluated to see if the lifestyle program helped overcome activity barriers with moderate-intensity physical activity as part of their daily routine. The results showed that both groups had significant and comparable improvements in physical activity and cardiorespiratory fitness, blood pressure and percentage of body fat.

Conclusions: This study should encourage sedentary and out-of-shape individuals by providing evidence that "lack of time, lack of social support, inclement weather, disruptions in routine, lack of access to facilities, and dislike of vigorous exercise" need not condemn them to ill health and risk of life-shortening disease. Patients should be counseled to engage daily in moderate-intensity activity that this study shows could have significant health benefits on a par with high-intensity workouts.

Increasing Patients� Physical Activity: Traditional Care vs. Interactive Counseling

Patients often report that they want their physicians to provide more information about physical activity. Practitioners are likely to counsel patients with known diseases, but generally do not provide regular counseling on physical activity.

Few studies have evaluated the efficacy of primary care counseling for physical activity. The Activity Counseling Trial (ACT), sponsored by the National Heart, Lung, and Blood Institute, was created to examine three different patient education and counseling approaches related to physical activity.

Cardiorespiratory fitness and self-reported physical activity, measured using a 7-day Physical Activity Recall, were evaluated for 874 inactive subjects in the 2-year ACT study. All subjects were given physical activity targets based on national recommendations. The investigators divided subjects into three groups to evaluate the effects of different physical activity counseling interventions. The first group was termed the "advice" care group in which patients received physician advice and written educational materials. Group two, the "assistance" group, received the same as the advice group, plus interactive mail and behavioral counseling at office visits. The third group, the "counseling" group, received all of the above plus regular telephone counseling and behavioral classes.

Cardiorespiratory fitness was significantly higher in women at 24 months in the assistance and counseling groups than in the advice group. Men in all groups demonstrated higher cardiorespiratory fitness, but there were no dramatic differences between the groups at the end of the study; therefore men in all groups improved. Both men and women reported increases in physical activity, but there were no observed differences between groups.

Increased patient interaction may be more effective for increasing physical activity in women. Advice, assistance, and counseling all appear to improve fitness levels in both sexes.

Note: This is the second research paper reviewed in this issue that highlights the importance of a doctor being actively involved in behavior modification of patients for issues pertaining to prevention and wellness. 

Encouraging Physical Activity Pays Off

The benefits of physical activity have long been known to have a positive impact on health, including improving quality of life and reducing the risk factors associated with cardiovascular disease, diabetes, obesity, osteoporosis and depression.

Patients who have been counseled on physical activity by general practice physicians have shown an increase in levels of physical fitness and activity; however, no health benefits have been associated with the activity.

This study sought to determine whether physical activity could improve a patient's quality of life over 12 months without evidence of adverse side-effects. Researchers studied 800 patients (of 40 New Zealand and United Kingdom general practice physicians in rural and urban areas) between the ages of 40-79, who showed evidence of sedentary lifestyles. Patients in the study received the "green prescription," an intervention program in which physicians counseled patients on developing physical fitness goals, combined with support from a local sports foundation that encouraged patients via phone calls and quarterly newsletters.

The study determined the green prescription intervention in general practice is effective in increasing patients' physical activity and improving quality of life without adverse side-effects. Patients in the intervention group increased their leisure exercise an average of 34 minutes per week - significantly more than the control group. In addition, patients in the intervention program self-rated their general health, vitality and bodily pain significantly better than patients in the control group. A trend toward decreasing blood pressure was found; however, no significant changes in the risk of coronary heart disease were noted.

Note: This study, and the previous one, demonstrate that in sedentary individuals, exercise can be positively encouraged and lead to beneficial effects on weight loss and quality of life. This information should be helpful in counseling patients on weight loss; it seems that as long as they are exercising and modifying their diets, benefits should be noted.

Physical Activity

Physical Activity Helps Prevent Vascular Atherosclerosis

Endothelium dysfunction has been proposed as a possible contributor to cardiovascular damage. Endothelium, the thin lining of arterial walls, plays a primary role in the modulation of vascular tone and structure through the production of nitric oxide.

Nitric oxide in turn acts to protect vessel walls from developing atherosclerosis and thrombosis.

Evidence that physical exercise can improve endothelium-dependent vasodilation led to the current investigation. The study population included 12 young and elderly sedentary subjects (average age: 26.9 and 62.9 years, respectively) and 11 young and 14 elderly matched athletes (average age: 27.5 and 66.4 years, respectively). Athletes included long-distance runners, triathletes and cyclists; sedentary subjects performed no regular exercise.

Apart from age, the four study groups were similar in terms of blood pressure, body mass index, and plasma total cholesterol and glucose levels. However, young and elderly athletes had decreased resting heart rate, increased high-density lipoprotein (HDL) and decreased low-density lipoprotein (LDL) levels compared with sedentary subjects. Results also showed that blood vessel function was also quite similar in elderly athletes compared with younger sedentary subjects, suggesting the value of physical activity in protecting the inner lining of the blood vessels. The authors speculated that the mechanism behind these results is most likely "the restoration of nitric oxide availability consequent to prevention of production of oxidative stress."

Daily Walking Reduces Risk of Hypertension

Previous studies have shown an inverse relationship between physical activity and hypertension, especially with respect to consistent vigorous exercise. However, little research has thoroughly investigated the direct impact of walking on blood pressure, despite the fact that brisk walking is part of the recommended treatment protocol for patients with hypertension (especially in Japan, where walking to work constitutes a primary form of exercise).

The subject group for this study included 6,017 Japanese men (35-60 years of age) with blood pressure less than 140/90 and no history of hypertension or diabetes at baseline.

Questionnaires were used to gather data on physical activity (work-related and leisure-time), the length of the walk to work, and other variables such as alcohol intake and smoking habits. Blood pressure was measured using a standard mercury sphygmomanometer, with pressure of at least 160/95 designating hypertension. 



Results: Men whose walk to work lasted 21 minutes or more had a decreased risk of incident hypertension compared with those whose walk lasted 10 minutes or less. This association was maintained after adjusting for age, body mass, alcohol consumption, smoking status, blood pressure, fasting plasma glucose level, and other physical activity variables (i.e., frequency of leisure-time physical activity). The authors recommend walking to work as a means to reduce blood pressure, concluding that "even persons who drive to work or use public transportation may benefit from parking or leaving their transportation more than a 20-minute walk from the office."

Hayashi T, Tsumura K, Suematsu C, et al. Walking to work and the risk for hypertension in men: the Osaka Health Survey. Annals of Internal Medicine 1999:130, pp21-26.

Coronary Heart Disease and Physical Activity in Women

Heart disease is the leading cause of death among women in the United States. A decrease in physical activity is one of the risk factors for this disease. Women who are physically active have been shown to have lower coronary heart disease (CHD) rates than inactive women.

However, it is uncertain as to whether the association differs by intensity of activity or in women at high risk for CHD. This study examines the relationship between CHD and physical activity in women, specifically related to light-to-moderate walking activity and varying pace. A group of 39,372 healthy female health professionals aged 45 years or older enrolled throughout the United States for a three-year period, with a four-year follow-up period. Recreational activities, such as walking and stair climbing, were reported at study entry. Correlation of CHD with energy expended on all activities, vigorous activities, and walking, was measured.

The study participants were observed for an average of 5 years and within that time 244 confirmed incidents of CHD occurred. The findings of this study showed that:

* Active women had a lower body mass index than inactive women.

* Active women showed healthier behavior patterns (e.g., lass likely to smoke, consumed a healthier diet).

* Women with higher levels of activity were less likely to have hypertension, diabetes mellitus and elevated cholesterol.

* Active women were less likely to develop CHD.

* Women who walked at least one hour per week at a 'usual' pace experienced half the CHD risk of women who did not walk regularly.

* Walking pace or intensity was not considered as important as the amount of walking per week (i.e. walk at least 1 hour per week at a light to moderate pace produced protective effects).

Conclusion: This study shows that light-to-moderate activity may be associated with lower CHD rates in women. At least one hour of walking per week predicted lower risk. These findings also held true even for those patients who were overweight, had increased cholesterol levels, or were smokers.

How Physical Activity Helps Prevent Cancer

Previous studies provide evidence that exercise can help prevent a variety of cancers; data suggests that the link between exercise and colon cancer may be particularly strong.

A study involving 63 men and women (42-78 years of age) with a history of colonic polyps (a potential precursor to colon cancer) investigated the potential influence of leisure-time physical activity and low body mass index (BMI) on levels of prostaglandin E2 in rectal mucosa.

High prostaglandin levels have been shown to be associated with the development of colon cancer.

Self-administered questionnaires assessed leisure-time physical activity per week, and levels of prostaglandin E2 were measured by examining rectal biopsy tissue samples taken eight weeks apart.

Prostaglandin levels increased with higher weight, higher BMI, and lower levels of leisure-time physical activity. An increase in BMI from 24.2 to 28.8 kg/m2 resulted in a 27% increase in prostaglandin levels, whereas an increase in physical activity from 5.2 to 27.7 MET-hours per week (one MET-hour being roughly equivalent to an oxygen uptake of 3.5ml/kg of body weight per minute) decreased prostaglandin levels by 28%.

Conclusion: Increasing physical activity and reducing body mass index may decrease the risk of colon cancer. These findings add support to previous evidence suggesting the protective value of physical activity against cancer and other chronic diseases.

Frequent, Vigorous Exercise Reduces Accumulation of Visceral Fat

Visceral fat, or fat that surrounds the abdomen and other internal organs, is considered a significant contributor to a variety of weight-related health problems, including heart disease, type 2 diabetes, and metabolic syndrome.

Regular exercise is known to provide a wide range of health benefits, including weight loss and reduction of total body fat. Despite this evidence, few studies have examined the direct effects of exercise programs on changes in visceral fat levels.

In this randomized, controlled study, 175 sedentary adults ages 40 to 65, all considered overweight or mildly obese, and all with mild to moderate dyslipidemia, were assigned to participate in a control group for 6 months, or to one of three exercise groups (low amount/moderate intensity, equivalent to walking 12 miles per week; low amount/vigorous intensity, equivalent to jogging 12 miles per week; or high amount/vigorous intensity, equivalent to jogging 20 miles per week). Computed tomography scans were performed pre- and post-study to analyze changes in visceral fat, subcutaneous abdominal fat, and total abdominal fat.

Results: "In the control group, visceral fat levels increased by 8.6%, which was statistically significant. Visceral fat levels did not change significantly in either of the low-amount exercise groups. The high-amount exercise group experienced an average decrease in visceral fat of 6.9%, which was significant. Only the high-amount exercise had any change in subcutaneous abdominal fat amount, which decreased in this group by 7.0%."

"Taken together, the data suggest a clear dose-response relationship between exercise amount and changes in visceral fat," the authors concluded. The authors also emphasized that "even a relatively modest exercise program, consistent with the activity recommendations from the Centers for Disease Control and American College of Sports Medicine, prevented significant increased in visceral fat," and recommended that "until we are able to prevent weight regain after short-term dieting success, a greater emphasis toward prevention should be a major goal in the U.S."

Senior Health

Back Symptoms Affect Function in the Elderly

Age and health burden have been associated with back symptoms and functional limitations in previous studies; however, little data addresses how back symptoms impact overall physical disability, the proportion of disability attributable to back symptoms, or the association between site-specific back symptoms and functional limitations in people older than age 70.

In a study designed to determine the relationship between back symptoms and limitations in performing specific functional activities, 1,007 surviving members (ages 70-100) of the Framingham Heart Study provided information on whether they experienced pain, aching or stiffness in any joints on most days. Subjects also identified the location of their problem by selecting its location from a picture of the back regions that clearly defined the neck, upper back, midback and lower back.

Subjects were also asked about whether they had any difficulty performing one or more of nine functional skills: standing in one place for approximately 15 minutes; walking one-half mile; stooping, crouching or kneeling; lifting a 10-pound object off the floor; putting on socks or stockings; getting in and out of a car; pushing or pulling a large object (i.e., a living room chair); reaching or extending the arms above shoulder level; and writing, handling

or fingering small objects. Functional limitation when performing any of the nine activities was determined if the subject stated that he or she experienced considerable difficulty performing the activity or was unable to perform it altogether. The proportion of the study population with a particular functional limitation that they attributed to back symptoms was also determined.

Results: Most subjects reported problems performing at least one functional activity, and limitations were more than twice as common in those with back symptoms than those without such symptoms. Back symptoms accounted for a significant proportion of functional limitations (43%-63% of limitations), particularly for activities such as standing in one place for approximately 15 minutes and pushing or pulling a large object. The association between back symptoms and functional limitations proved stronger in women than in men.

Edmond SL, Felson DT. Function and back symptoms in older adults. Journal of the American Geriatrics Society December 2003;51(12):1702-09.

www.americangeriatrics.org

Recognizing Neurologic-Based Pain in the Elderly

Pain in the elderly population is often attributed to chronic musculoskeletal conditions such as osteoarthritis. Health care practitioners must remain wary of other conditions that may cause widespread pain, particularly if such pain has neuropathic features (allodynia, hyperpathia or hyperalgesia).

This article presents a case report of an elderly patient presenting with widespread pain attributed to thalamic pain syndrome, otherwise known as central post-stroke pain (CPSP). Discussion of the basic characteristics of neuropathic pain and testing techniques are presented to help clinicians identify patients presenting with this condition. Included in the case report is a discussion of the patient�s:

* chief complaint;
* mental status examination;
* physical examination;
* diagnostic imaging and laboratory test results;
* differential diagnoses; and
* treatment options.

The author emphasizes the role of the chiropractor in correct diagnosis and referral and continued chiropractic support and follow-up in the form of musculoskeletal treatment for residual discomfort. He also stresses the importance of this case report in illustrating nonmusculoskeletal conditions that may present as musculoskeletal pain.

Specific Risk Factors Predict Functional Decline in Elderly Women

It has been estimated that more than 20% of Americans aged 65 and older live with a disability. Functional declines in the elderly have been associated with age and socioeconomic status, but modifiable risk factors have yet to be determined - a shortcoming that may have prompted this study.

A volunteer sample of 6,632 community-residing women was recruited to identify modifiable predictors of functional decline.

Functional decline was defined as inability over a four-year interval to perform one or more of five "vigorous" activities (household chores; heavy housework; shopping; climbing stairs; or walking 2-3 blocks), or one or more of eight "basic" activities (getting in/out of bed; turning faucets on/off; getting in/out of a car; dressing oneself; washing and drying entire body; bending down; preparing one's own meals; or lifting a full cup/glass to one�s mouth).

Of the 10 potential risk factors studied, eight proved significant predictors of functional decline in terms of ability to perform at least one of the five vigorous activities or one of the eight basic activities. The authors present a clinically useful prediction tool for functional decline based upon the following eight modifiable risk factors:

* slow gait (< 1 meter per second on a 6 meter course);
* use of short-acting benzodiazepines;
* geriatric Depression Scale rating of > 6;
* exercise levels lower than 448 kcal per week;
* obesity measured as body mass index > 29;
* weak grip strength (< 15 kg average);
* use of long-acting benzodiazepines; and
* visual acuity worse than 20/40.

Conclusion: Functional decline may be attributable to specific risk factors responsive to short-term intervention. The authors suggest that by "using eight modifiable predictors that can be identified at a single office visit, clinicians can identify older women at risk for functional decline."

Sarkisian CA, Liu H, Gutierrez PR, et al. Modifiable risk factors predict functional decline among older women: a prospectively validated clinical prediction tool. Journal of the American Geriatrics Society, Feb. 2000:48, pp170-78.

Involvement in Activities Improves Function in Elderly

It is estimated that 250,000 hip fractures occur in the United States each year, affecting primarily Caucasian females between the ages of 85 and 95. Most do not regain their previous level of functioning, and many become permanently institutionalized in nursing homes.

Twenty women who were admitted to a rehabilitation facility after suffering hip fractures were separated into two groups for study purposes. The first group (10 subjects) received intervention based on a biomechanical approach. This model asserts that improvement in physical function will result in improvement in overall function, as assessed by predetermined outcomes such as strength and flexibility. The second group of 10 subjects received intervention based on occupational adaptation. This model focuses on the improvement of the patient based upon parameters of daily activities (i.e., cooking, cleaning, sewing, etc.) and the adaptation program made with each individual patient.

Results showed no significant difference in improvement of patients receiving biomechanical intervention compared with those receiving adaptation intervention. However, both groups improved during the course of care, suggesting that a sense of involvement in the rehabilitation process and participation in activities of interest are therapeutic.

Buddenberg LA, Schkade JK. Special feature: a comparison of occupational therapy intervention approaches for older patients after hip fracture. Topics in Geriatric Rehabilitation, June 1998;13(4), pp52-68.

Pain Management and Disability in the Elderly

As the number of people 65 years of age and older increases, the need for appropriate pain-management strategies becomes more critical. Although a high proportion of the elderly population reports musculoskeletal pain and physical disability, very little research has examined the potential association between the two.

Eight hundred and eighty-seven community-dwelling senior citizens in Ontario, Canada completed a postal questionnaire which assessed the presence of musculoskeletal pain (self-reported pain in joints, muscles or bones) and the amount of difficulty performing three or more routine activities (eating, walking, reaching, gripping, etc.)

Of the study participants, 644 (72.7%) reported musculoskeletal pain, and 500 (56.5%) were classified as having a physical disability. A significantly higher percentage of patients reporting pain were identified as having a disability, compared to patients who reported no pain (68.6% vs. 24.1%).

These results emphasize the need for competent management of pain and its underlying causative disorders. The valuable information in this article can be used to develop educational and preventative programs designed to promote more active and healthy lives in the geriatric community.

Scudds RJ, Robertson JMcD. Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens. Pain, April 1998;75, pp229-35.

Management of Chronic Pain in the Elderly

Pain is recognized as a complex experience derived from sensory stimuli and influenced by individual memory, expectations and emotions. In older people, arthritis, bone and joint disorders, degenerative back dysfunction, and other chronic conditions can cause debilitating pain and frustration.

This position paper by the American Geriatric Society outlines clinical practice guidelines for managing chronic pain in the elderly population. Recommendations for appropriate case management are presented in a comprehensive, concise format focusing on:

* pain assessment and classification;
* conservative intervention techniques;
* exercise recommendations;
* pros and cons of pharmacologic therapy; and
* the importance of patient education.

Included throughout the paper are informative tables, charts, records and scales that can be utilized in clinical practice. Classifying chronic pain in pathophysiologic terms can help determine prognosis and an appropriate course of care. The information presented in this paper can serve as a valuable tool for clinicians managing geriatric patients.

AGS Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons.Journal of the American Geriatric Society, 1998;46, pp635-51.

 Exercise /Benefits

Regular Exercise Shows Benefits -- Even After Sedentary Lifestyle

The benefits of exercise have been well-documented over the years. Numerous studies have shown that exercise can help reduce incidences of disease, promote weight loss, and improve mental health.A recent study set out to examine if exercise during the senior years has benefits in people who were previously sedentary. 

Canadian researchers investigated two groups of previously sedentary healthy adults, ages 55-75 years at baseline. One group remained sedentary during the study, while the other group initiated and engaged in regular exercise consisting of 30- to 45-minute aerobic sessions, three times a week, for a minimum of 46 weeks a year over the 10-year study period. Investigators evaluated the participants for fitness levels, metabolic risk factors for cardiovascular disease, and comorbid conditions. 

At the conclusion of the study, researchers examined data for 161 participants in the active group and 136 participants in the sedentary group. According to the study, "The active group showed a significantly lower prevalence (11%) of the metabolic syndrome than the sedentary group (28%) at 10 years." The sedentary group also had a 13% decrease in fitness over the 10-year study period, while the exercise group showed a small increase in fitness levels. HDL, or "good" cholesterol, showed a 9% increase in the exercise group, compared to the sedentary group that showed an 18% decrease in HDL. The active group also had "fewer comorbid conditions, and fewer signs and symptoms of cardiovascular disease," than their sedentary counterparts.

Petrella RJ, Lattanzio CN, Demeray A, et al. Can adoption of regular exercise later in life prevent metabolic risk for cardiovascular disease? Diabetes Care 2005;28:694-701.

Evidence That Exercise May Help Reduce Depression

A 1997 study found that mild to moderate major depressive disorder ranked second behind ischemic heart disease in terms of years of life lost due to premature death or disability. National estimates indicate that less than one-fourth of individuals with MDD seek treatment, and only one in 10 receive adequate treatment, perhaps because of the social stigma attached with such treatment.

While exercise may be an effective treatment for MDD, primarily because it can be recommended to most individuals and does not carry a negative social stigma, insufficient evidence establishes its efficacy.

This study was designed to test whether exercise is a beneficial treatment for mild to moderate MDD, and to determine the dose-response relation of exercise and reduction in depressive symptoms.

Eighty adults diagnosed with mild to moderate MDD were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure (7.0 kcal/kg/week or 17.5 kcal/kg/week) and frequency (three days/week or five days/week), or to a placebo control group that participated in flexibility exercises three days a week). The primary outcome measure was the score on the 17-item Hamilton Rating Scale for Depression (HRSD).

After 12 weeks, the group expending 17.5 kcal/kg/week (consistent with public health recommendations) had the lowest scores on the HRSD, while the placebo control group had the highest scores. Average HRSD scores at 12 weeks were 47% lower than at baseline. The authors conclude: "Aerobic exercise in the amount recommended by consensus public health recommendations was effective in treating mild to moderate MDD. The amount of exercise that is less than half of these recommendations was not effective."

Dunn AL, Trivedi MH, Kampert JB, et al. Exercise treatment for depression. Efficacy and dose response. American Journal of Preventive Medicine 2005;28(1):1-8.

Women: Exercise Quantity, Not Intensity, May Be Key

Federal guidelines encourage a minimum of 30 minutes of moderate-intensity exercise most days of the week; earlier guidelines suggested vigorous exercise for at least 20 minutes three or more times per week.

The debate between the relative benefits of moderate vs. vigorous exercise is ongoing. Additionally, the effect of time spent sitting or sedentary is unclear.

The incidence of coronary and total cardiovascular events was compared in 73,743 women ages 50-79 based on total time spent: doing any physical activity; walking; vigorously exercising; and sitting. Activity was determined by questionnaires, and classified as mild, moderate or vigorous. Over 5.9 years of follow-up in the Women�s Health Initiative Observational Study, 345 of these women were diagnosed with coronary heart disease and 309 with strokes.

The more physical activity completed (or energy expended) by subjects, the less likely they were to suffer coronary/cardiovascular events, regardless of race, weight or age. Subjects who walked or performed vigorous exercise 2.5 hours or more per week reduced their total risk for cardiovascular events by approximately 30%, while those who spent more time sitting each day had an increased risk. Although walking and vigorous exercise produced similar reductions in risk for cardiovascular events, a brisker pace when walking and less time spent sitting daily additionally reduced risk.

"Although vigorous exercise should not be discouraged for those who choose a higher intensity of activity, our results indicate that moderate-intensity exercise confers substantial health benefits for postmenopausal women," the authors conclude. 

Men: Exercise Quality Important

Men who exercise at high intensity cut their risk for coronary heart disease (CHD) nearly in half, compared to sedentary individuals. Yet risk reduction has been shown for higher and lower exercise intensities, and for varying levels of energy expenditure.

Therefore, the optimal type of exercise for men wanting to reduce CHD risk is unclear.

A sample of 44,452 men, ages 40-75 and participating in the Health Professionals' Follow-up Study, completed multiple questionnaires from 1986-1998 assessing diet, lifestyle, medical history and exercise performed. Walking/hiking; jogging; bicycling; tennis; swimming; rowing; calisthenics; outdoor work; weight training; and racquetball were considered as types of exercise.

Although higher physical activity levels translated into dose-dependent reductions in CHD (men with the greatest amount of activity reduced their risk 30%, compared to sedentary men), higher exercise intensity also lowered risk 17% more than low intensity exercises. Activities that offered significant reductions in CHD risk were listed as:

* weight training (23% reduction);

* rowing (18% reduction); and

* running (42% reduction).

A faster walking pace was found to reduce CHD risk more than a slower pace, regardless of time spent walking. Traits most common in active men included: weighing less; eating less fat and more fiber; drinking more alcohol; taking vitamin E; and not smoking. The authors encourage increasing aerobic exercise intensity and total volume of activity, and adding weight training when appropriate, to reduce CHD risk in male patients.

Tanasescu M, Leitzmann MF, et al. Exercise type and intensity in relation to coronary heart disease in men. Journal of the American Medical Association 2002:288(16), pp. 1994-2000.http://jama.ama-assn.org

Continuous, Intermittent Exercise Equally Effective

Public health efforts to encourage exercise have often included the recommendation to devote 30 continuous minutes per day to aerobic exercise, which is not an option for those with physical or time constraints.

As a result, the American College of Sports Medicine and the Centers for Disease Control changed existing guidelines to suggest a more practical approach: that 30 minutes of total moderate physical activity - continuous or intermittent - should be performed most days of the week. The effectiveness of these new guidelines has not accurately been tested, in terms of cardiovascular fitness and weight loss.

This study compared multiple variations of a 30-minute, monitored exercise program on aerobic fitness (as measured by oxygen uptake) and weight loss in college-age women. Forty-eight overweight women were divided into four groups: no exercise (the control group); 30 minutes continuous exercise per day; two 15-minutes sessions of exercise per day; and three 10-minute sessions per day. Measures of fitness, weight loss, skinfold thickness, and body circumference (hip, waist, thigh, upper arm) were taken at baseline and after 12 weeks of exercise training on a stationary bicycle.

Results: All three exercise groups demonstrated significantly increased fitness and significantly decreased weight and body measurements after 12 weeks. The results were similar between all three exercise groups. The control group did not demonstrate any significant changes. The authors concluded that exercise participation did not vary between exercise groups, with regards to average number of exercise days per week.

Exercise may have similar effects on weight loss and aerobic fitness whether performed in one long bout or several cumulative short sessions. This study implies that offering the alternative of multiple short workouts to some patients may not effectively increase their participation, however.

Schmidt WD, Biwer CJ, Kalscheuer LK. Effects of long versus short bout exercise on fitness and weight loss in overweight females. Journal of the American College of Nutrition 2001:20(5), pp. 494-501.

 Exercise/diabetes

Recommending Exercise for Patients With Diabetes:

Diabetes mellitus affects an estimated 150 million people worldwide, including 16 million Americans; according to estimates, by the year 2025, the number of patients suffering from the condition will exceed 300 million.

Type 1 diabetes, which afflicts 10% of sufferers, is characterized by insulinopenia, requiring that patients take insulin for survival.
This overview of type I diabetes provides the clinician with an introduction to its etiology and how it is diagnosed, then explores the influence of exercise on patients with the condition, including the many general effects of a consistent exercise regimen:

* improving glucose tolerance by augmenting insulin sensitivity;
* decreasing muscle capillary basement membrane thickening and arterial pulse volume recordings;
* increasing lean body mass and work capacity;
* improving overall weight management;
* reducing serum total cholesterol, low-density lipoprotein (LDL) and very low-density lipoprotein levels (VLDL), while raising high-density lipoprotein (LDL) levels; and
* increasing cardiac function.

Numerous management strategies and guidelines for exercise are included and can be obtained from the Internet, along with steps clinicians should take in evaluating patients with type I diabetes (prior to recommending any exercise regimen); specific considerations in terms of diet, exercise intensity and duration, and energy requirements; and potential risks and complications.

The authors emphasize that caring for diabetes patients requires that all clinicians be responsible for education about blood glucose self-monitoring; proper exercise prescription; appropriate dietary and insulin management plans; pre-participation clearance; and ongoing education. With respect to exercise, they note: "Exercise has risks and benefits that must be understood so that participation yields a safe, enjoyable outcome. ..."

Recommending Exercise for Hypertensive Patients

Hypertension, defined as blood pressure (BP) of 140/90 mm Hg or greater, affects approximately 50 million Americans. Mild-to-moderate increases in BP can dramatically amplify risk for stroke, renal disease, and left ventricular hypertrophy; extreme elevations in BP can raise risk for these conditions even more.

Nonpharmacologic interventions, such as exercise programs, can serve as comprehensive therapy for some patients and adjunctive therapy for others.

All current hypertension treatment guidelines recommend exercise as an adjunctive therapy for mild hypertension, although drug treatment is recommended in addition to exercise in severe cases. Exercise reduces BP; low-density lipoprotein (LDL) cholesterol levels; insulin resistance/ glucose intolerance; and body weight. This paper states that aerobic exercise and diet-induced weight loss are the most effective and physiologically desirable means to achieve a decrease in atherosclerosis, which leads to coronary artery disease.

Since the authors propose that all patients with controlled hypertension should participate in exercise, this review offers tips on how to prescribe exercise to patients of various ages, weights, and hypertension levels. Some of the key points of the review:

* Patients should have a thorough physical and cardiac evaluation before beginning an exercise program.
* Extreme hypertension patients (BP of 180/105 mm Hg or more) should only begin exercise training after medication controls their BP.
* Sudden cardiac death is the most dangerous complication related to exercise therapy in hypertension patients, but the risk is "very minimal."
* Graded exercise stress tests (GXTs) are useful for measuring the magnitude of BP response to exercise, rate of recovery, and arrhythmias.
* Aerobic exercises, including walking and running, are the preferred endurance exercises for hypertension patients. Swimming is a good alternative for obese, injured, asthmatic, or otherwise impaired individuals. Tai chi chuan has been shown to safely reduce BP, but no large, randomized trials have validated its effects.
* Vigorous, rhythmic exercises - such as sprinting, rowing, and downhill skiing - should be discouraged in hypertensive patients. High-altitude sports in general should be discouraged because of additional risk for elevated BP from cold and reduced air pressure.
* Low-to-moderate exercise training intensity may be more effective than intense regimens for hypertensive patients; heart rate should fall within 50-70% of predicted maximum during exercise. Regimens will likely take one to three months to significantly reduce BP, but must be maintained thereafter for indefinite results.

Note: This paper is excellent for clinicians seeking to incorporate more active health promotion strategies for their patients. Available for free on the Internet at the address below; several links to helpful articles and exercise tables also are provided.

Chintanadilok J, Lowenthal DT. Exercise in treating hypertension: Tailoring therapies for active patients. The Physician and Sportsmedicine 2002:30(3). Available free atwww.physsportsmed.com.

 Recommending Exercise May Benefit Patients with Knee Osteoarthritis

Reducing pain and disability are the predominant goals of exercise therapy for patients with osteoarthritis (OA). Exercise programs in this regard focus on improving muscle strength, joint stability, range of motion and aerobic fitness, and making corrections of the walking pattern when necessary.

The authors of this study note that previous treatment guidelines and published studies on exercise therapy for OA fail to "satisfy the current methodologic requirements for literature reviews." The authors addressed this perceived shortcoming by including recently published randomized, controlled clinical trials and by applying updated review methodologies to their analysis.

A comprehensive literature search of the Medline (Jan. 1966 to Sept. 1997), Embase (Jan. 1988 to Sept. 1997), Cinahl (Jan. 1982 to Sept. 1997) and the Cochrane Controlled Trial Register databases revealed 11 trials, six of which met at least 50% of the authors� validity criteria: randomized studies of treatment of OA of the hip or knee in which exercise therapy was utilized in one or more treatments.

Analysis of the available literature showed beneficial short-term effects from exercise therapy in patients with OA of the knee, but less so in OA of the hip. These benefits were small to moderate when assessing self-reported disability, including observed disability in walking, and moderate to great in terms of patient's global assessment of the effect of exercise. The authors caution that the small number of quality studies "restricts drawing firm conclusions," and call for further research to support their recommendation.

Van Baar ME, Assendelft WJJ, Dekker J, et al. Effectiveness of exercise therapy in patients with osteoarthritis of the knee. Arthritis & Rheumatism, July 1999:42(7), pp1361-69.

Recommending Exercise

Lifelong Exercise Might Prevent Heart Failure in Aging Hearts

Heart failure associated with aging generally occurs when there is a stiffening of the heart muscle, which causes pressure that in turn resists blood flow into the heart. As a result, the heart�s main pumping chamber, the left ventricle, cannot pump blood throughout the body in a normal capacity; this can eventually lead to complete diastolic heart failure.

Researchers from the University of Texas Southwestern Medical Center in Dallas compared the function of the left ventricle in 12 healthy but sedentary senior citizens, 12 senior Masters athletes, and 12 young, sedentary adults (average age 29) to determine if aging was the primary cause of left ventricle failure, or if physical inactivity was also partly to blame.

Results: Researchers found that sedentary hearts were stiffer than those of the Masters athletes; moreover, the function of the athletes' hearts was virtually the same as that of the younger study participants - something that came as a surprise to the researchers. "We found that older, sedentary individuals' hearts were 50 percent stiffer than the Masters athletes, which we expected," said researcher Benjamin Levin, MD, professor of internal medicine at the university. "What we didn't expect was that the hearts of these senior athletes were indistinguishable from those of the healthy younger participants."

"A sedentary lifestyle during healthy aging is associated with decreased left ventricle compliance, leading to diminished diastolic performance. Prolonged, sustained endurance training preserves ventricular compliance with aging and may help to prevent heart failure in the elderly," the researchers concluded.

Zadeh AA, Dijk E, Prasad A, et al. Effect of aging and physical activity on left ventricle compliance. Circulation, 2004; 110:1799-1805.

Exercise Lessens Prostate Trouble?

Most older men suffer lower urinary tract symptoms resulting from prostatic enlargement caused by benign prostatic hyperplasia (BPH).

Because sympathetic nervous system activity, which is decreased by physical activity, is associated with increased smooth-muscle tone and prostatic symptoms, the researchers conducting this study assessed whether exercise leads to a reduction in lower urinary tract symptoms.

The subjects were nearly 4,000 men 40 to 75 who were free of diagnosed cancer, including prostate cancer both at baseline (1986) and during follow-up.

The subjects were observed for incidence of

surgery for BPH between 1986 and 1994, during which time more than half the subjects did undergo BPH surgery.

The results of the study showed that physical activity was inversely related to total BPH risk. Men who walked two to three hours per week had a 25 percent lower risk of total BPH and the lower urinary tract symptoms associated with BPH.

Chiropractors who advise their patients regarding exercise and nutrition may wish to suggest that, based on the results of this study, exercise is a safe and easy method for decreasing the frequency of lower urinary tract symptoms.

Platz EA, Kawachi I, Rimm EB, et al. Physical activity and benign prostatic hyperplasia. Archives of Internal Medicine, Nov. 23, 1998;158(21), pp2349-56.

[See also the summary of the Wilt et al. study of Saw Palmetto for Benign Prostatic Hyperplasia, on page 7 of this issue of CRR.]

Exercise: Optimal Options for Heart Patients

Regular physical activity under a doctor's direction is a key element of heart patients' efforts to manage their disease. Individuals who have had heart attacks, balloon angioplasty or bypass surgery, or who are affected by heart disease in other ways, must take many steps to improve their health.

Exercise, in addition to the other changes they make in the behavior and nutrition, can make them more confident, less depressed and less stressed. It can even lower their risk of dying and improve their overall sense of well-being.

This article recommends an optimal program of aerobic exercise of at least 30 minutes three times a week. It is written to and for patients and carefully explains how they can gradually build to higher levels of activity and tells them how to monitor the impact of their exercise. It also outlines how strength and flexibility exercises can contribute to improved heart health. Throughout, it provides guidelines and discusses cardiac warning signs that can indicate that the patient is overdoing it. The article includes a "Complete Heart-Care Package" of healthy steps patients can take to reduce their risk of further heart problems.

Note: Doctors of chiropractic will find the information in this article of use to them and their patients with heart problems. It is an easy-to-follow regimen in the spirit of the practical approach to wellness, prevention and rehabilitation. This is an excellent lay person's 2-page handout.

Exercise Reduces Stroke Risk?

It is plausible, physiologically, for physical activity to decrease stroke risk. However, epidemiological studies have produced mixed findings. Furthermore, few studies have examined specific kinds and intensities of activities.

The purpose of this study was to examine the association between walking, climbing stairs, participation in sports and recreational activities and stroke risk.

The purpose of this study was to examine the association between walking, climbing stairs, participation in sports and recreational activities and stroke risk.

This study of 11,130 men was drawn from individuals tracked in the Harvard Alumni Health Study, an ongoing study of the predictors of chronic diseases among men matriculating as undergraduates at Harvard University between 1910 and 1950. 

The current study included men 43 to 88, with a mean age of 58 who were free of cardiovascular disease or cancer.

Physical activity was found to be associated with decreased risk of stroke in men, including older men. With levels of energy expenditure up to 3000 kcal/wk, risk declined steadily. Beyond this, the association weakened. The data indicated that walking &#8804; 20km/wk was associated with significantly lower risk, independent of any other physical activity components. Climbing stairs and activities of at least moderate intensity were related to lower risk. But light-intensity activities were unrelated to stroke risk. Furthermore, men who participated in recreational activities experienced lower stroke rates than those who only walked or climbed stairs but did not engage in recreational activities. 

Recommend Exercise to Fight Osteoarthritis

Arthritis is the most common disability in the United states, and osteoarthritis the most common form of arthritis, affecting an estimated 33% of the population age 60 and older. Declines in muscle strength, aerobic fitness and functional capacity may be important risk factors in the acceleration of the disease process.

A sensible, moderate exercise program can indirectly protect osteoarthritic joints in a number of ways:

* Stretching and range-of-motion exercises can improve mobility and reduce joint fatigue and mechanical stress.

* Resistance training can strengthen muscle around the affected joints, which improves shock absorption, stabilizes the joints, and reduces stresses that tend to accelerate cartilage degeneration.

* Any exercises promoting healthy weight loss will also reduce stress on weight-bearing joints (especially the knees).

Included is a discussion of potential exercise variations/methods which may be most appropriate for combating the effects of osteoarthritis. Many patients can achieve substantial benefits from a well-designed, sensible exercise regimen. Chiropractors can play a key role by educating patients on the value of exercise in pain management and providing training suggestions and encouragement.

Exercise Each Day Keeps Gallstones Away

Gallstone formation has been linked to blood-sugar intolerance and excess insulin levels. A study of 45,813 men (aged 40 to 75) assessed physical activity; incidence of gallstone disease; dietary, alcohol and smoking habits; medication use; and occurrence of diagnosed medical conditions other than gallstone disease, over an eight-year period.

Vigorous physical activity showed a distinct inverse relationship with the risk of gallstone disease. After adjustment for possible confounding factors, each increase in physical activity of 25 metabolic equivalents (METs) per week was associated with a distinct reduction in risk. One MET was defined as the energy expended by sitting quietly, equivalent to an oxygen uptake of 3.5 ml/kg of body weight per minute. Activities that required six or more METs per hour were classified as vigorous; those that required less than six METs per hour were considered nonvigorous.

Conclusions: Physical activity, especially rapid walking, jogging or hiking, may decrease risk for symptomatic gallstone disease by improving blood-sugar utilization. The overall level of activity, rather than the particular form of exercise, may be the main determinant of risk. 

Moderate-Intensity Exercise Reduces Diabetes Risk

Vigorous exercise is known to improve insulin sensitivity, and is also associated with a lower risk of non-insulin-dependent diabetes mellitus. A survey of Caucasian, African American and Hispanic men and women (aged 40 to 69) found that energy expended by both vigorous and nonvigorous exercise (i.e., brisk walking) was associated with significantly higher levels of insulin sensitivity.

In 1,467 subjects with glucose tolerance ranging from normal to mild non-insulin-dependent diabetes, an intravenous glucose tolerance test assessed insulin sensitivity.

Mean insulin-sensitivity levels showed a positive improvement from both vigorous and nonvigorous physical activity after adjustments for potential mediators, body-mass index, and waist-to-hips ratio. Results were similar for subgroups of sex, ethnicity and diabetes. These findings lend further support to current public health recommendations for increased nonvigorous exercise (i.e., 30 minutes per day of moderate-intensity physical activity) which may decrease the risk of diabetes. 

Regular Exercise Shows Benefits -- Even After Sedentary Lifestyle

The benefits of exercise have been well-documented over the years. Numerous studies have shown that exercise can help reduce incidences of disease, promote weight loss, and improve mental health.

A recent study set out to examine if exercise during the senior years has benefits in people who were previously sedentary.

Canadian researchers investigated two groups of previously sedentary healthy adults, ages 55-75 years at baseline. One group remained sedentary during the study, while the other group initiated and engaged in regular exercise consisting of 30- to 45-minute aerobic sessions, three times a week, for a minimum of 46 weeks a year over the 10-year study period. Investigators evaluated the participants for fitness levels, metabolic risk factors for cardiovascular disease, and comorbid conditions.

At the conclusion of the study, researchers examined data for 161 participants in the active group and 136 participants in the sedentary group. According to the study, "The active group showed a significantly lower prevalence (11%) of the metabolic syndrome than the sedentary group (28%) at 10 years." The sedentary group also had a 13% decrease in fitness over the 10-year study period, while the exercise group showed a small increase in fitness levels. HDL, or "good" cholesterol, showed a 9% increase in the exercise group, compared to the sedentary group that showed an 18% decrease in HDL. The active group also had "fewer comorbid conditions, and fewer signs and symptoms of cardiovascular disease," than their sedentary counterparts.