Can exercise slow down the progression of multiple sclerosis? Multiple sclerosis, or MS, is a chronic, neurological disease characterized by damage to the myelin sheaths of nerve cells in the central nervous system, or CNS. Common symptoms of multiple sclerosis include pain, fatigue, vision loss and impaired coordination. Exercise is frequently recommended as a form of treatment for several types of injuries and/or conditions, including MS. While exercise has been determined to help improve the management of symptoms of multiple sclerosis as well as decrease the progression of the disease, further evidence is still required. The purpose of the following article is to demonstrate how exercise can affect disease progression of multiple sclerosis and improve quality of life in patients.
Contents
Abstract
It has been suggested that exercise (or physical activity) might have the potential to have an impact on multiple sclerosis (MS) pathology and thereby slow down the disease process in MS patients. The objective of this literature review was to identify the literature linking physical exercise (or activity) and MS disease progression. A systematic literature search was conducted in the following databases: PubMed, SweMed+, Embase, Cochrane Library, PEDro, SPORTDiscus and ISI Web of Science. Different methodological approaches to the problem have been applied including (1) longitudinal exercise studies evaluating the effects on clinical outcome measures, (2) cross-sectional studies evaluating the relationship between fitness status and MRI findings, (3) cross-sectional and longitudinal studies evaluating the relationship between exercise/physical activity and disability/relapse rate and, finally, (4) longitudinal exercise studies applying the experimental autoimmune encephalomyelitis (EAE) animal model of MS. Data from intervention studies evaluating disease progression by clinical measures (1) do not support a disease-modifying effect of exercise; however, MRI data (2), patient-reported data (3) and data from the EAE model (4) indicate a possible disease-modifying effect of exercise, but the strength of the evidence limits definite conclusions. It was concluded that some evidence supports the possibility of a disease-modifying potential of exercise (or physical activity) in MS patients, but future studies using better methodologies are needed to confirm this.
Keywords:disease activity, exercise therapy, physical activity, training
Introduction
Multiple sclerosis (MS) is a clinically and pathologically complex and heterogeneous disease of unknown etiology [Kantarci, 2008]. In 28 European countries with a total population of 466 million people, it is estimated that 380,000 individuals are affected with MS [Sobocki et al. 2007]. The disorder is progressive but more than 80% of all MS patients have the disease for more than 35 years [Koch-Henriksen et al. 1998], the number of years of life lost to the disease being 5 to 10 [Ragonese et al. 2008]. The fact that MS is a chronic, long-lasting and disabling disease makes MS rehabilitation an important discipline in maintaining an independent lifestyle and the associated level of quality of life [Takemasa, 1998]. Despite the fact that MS patients for many years were advised not to participate in physical exercise because it was reported to lead to worsening of symptoms or fatigue, it has become generally accepted to recommend physical exercise for MS patients during the last two decades [Sutherland and Andersen, 2001]. Exercise is well tolerated and induces relevant improvements in both physical and mental functioning of persons with MS [Dalgas et al. 2008]. It is an open question whether exercise can reverse impairments caused by the disease per se, or whether exercise simply reverses the effects caused by inactivity secondary to the disease. However, most likely exercise may reverse the effects of an inactive lifestyle adopted by many patients [Garner and Widrick, 2003; Kent-Braun et al. 1997; Ng and Kent-Braun, 1997; Stuifbergen, 1997]. Nonetheless, it has been suggested that exercise might have the potential to have an impact on MS disease progression by slowing down the disease process itself [Heesen et al. 2006; Le-Page et al. 1994; White and Castellano, 2008b]. In other disorders exercise has been shown to pose the potential to have an impact on brain function and, as recently summarized by Motl and colleagues, exercise in older adults with or without dementia leads to cognitive improvement relative to a control condition [Motl et al. 2011b]. Based on this and the few existing findings in MS patients, Motl and colleagues suggested that exercise may similarly improve cognitive functioning in MS patients. However, in MS it has not been reviewed whether physical exercise has a more general disease-modifying effect.
To gain more insight on this important topic, we therefore conducted a systematic literature search aiming at identifying studies linking exercise (or physical activity) to disease progression in MS patients or in the experimental autoimmune encephalomyelitis (EAE) animal model of MS. A secondary purpose of the review was to discuss possible mechanisms explaining this link if it does exist and to discuss future study directions within this field.
Methods
The included literature was identified through a comprehensive literature search (PubMed, SweMed+, Embase, Cochrane Library, PEDro, SPORTDiscus and ISI Web of Science) that was performed in order to identify relevant articles regarding MS and exercise up to 4 September 2011. The search was performed using the subject headings �exercise�, �exercise therapy�, �physical education and training�, �physical fitness�, �motor activity� or �training� in combination with �multiple sclerosis� or �experimental autoimmune encephalomyelitis�. No limitations regarding publication year and age of subjects were entered. If possible, abstracts, comments and book chapters were excluded when performing the search in the different databases. This search yielded 547 publications. A screening of these publications based on title and abstract revealed 133 publications relevant for further reading. The reference lists of these 133 publications were checked for further relevant publications that were not captured by the search. This resulted in further six publications and in a total of 139 closely read publications. Studies that turned out to be nonrelevant (n = 65), meta-analyses (n = 3), reviews (n = 22), conference abstracts (n = 8) and articles not written in English (n = 2) were excluded from the final analysis (see Figure 1). Relevant cross- sectional and longitudinal studies were included.
According to Goldman and colleagues measures thought to reflect disease progression (or activity) in MS can be evaluated with objective or subjective outcome measures [Goldman et al. 2010]. Objective measures include (1) clinical outcome measures such as the Expanded Disability Status Scale (EDSS) and Multiple Sclerosis Functional Composite (MSFC) and (2) nonclinical measures such as MRI. The subjective measures include (3) patient-reported measures thought to reflect disease progression or disability such as the Late-Life Function and Disability Inventory. Studies applying patient-reported measures that included a measure of physical activity were also included in this category. Furthermore, we added a category containing studies applying (4) the EAE animal model of MS as study population. Based on this framework the localized articles were divided into the following four groups (see Table 1):
�
disease progression evaluated with clinical outcome measures (n = 12);
disease progression evaluated with nonclinical measures (n = 2);
disease progression evaluated with patient-reported measures (n = 10);
disease progression evaluated in animal studies (n = 3).
Results
Disease Progression Evaluated with Clinical Measures
A number of studies evaluating structured exercise interventions lasting from 3 to 26 weeks have included clinical scales reflecting disease progression as an outcome measure. The applied clinical scales include the EDSS [Bjarnadottir et al. 2007; Dalgas et al. 2009; Fimland et al. 2010; Golzari et al. 2010; Petajan et al. 1996; Pilutti et al. 2011; Rodgers et al. 1999; Romberg et al. 2004; White et al. 2004], the MSFC [Pilutti et al. 2011; Romberg et al. 2005], the Guys Neurological Disability Scale (GNDS) [Kileff and Ashburn, 2005; van den Berg et al. 2006] and the Functional Independence Measure (FIM) [Romberg et al. 2005]. Studies applying the EDSS have generally not found any change after either endurance training [Petajan et al. 1996; Pilutti et al. 2011; Rodgers et al. 1999], resistance training [Dalgas et al. 2009; Fimland et al. 2010; White et al. 2004] or combined training interventions [Bjarnadottir et al. 2007; Romberg et al. 2004]. Only one study by Golzari and colleagues evaluating the effects of 8 weeks of combined training (3 days/week) reported an improvement in EDSS score [Golzari et al. 2010]. This finding was not confirmed in a long-term study (26 weeks) [Romberg et al. 2005] also evaluating the effects of combined training. In the study by Romberg and colleagues no effect on EDSS and FIM were found, but a small positive effect was seen in the MSFC. A few studies applied the GNDS with one reporting an improvement after 12 weeks of biweekly endurance training [Kileff and Ashburn, 2005] and one reporting no effects of 4 weeks endurance training completed 3 days a week [van den Berg et al. 2006].
In summary, structured exercise intervention studies of different exercise modalities lasting 3�26 weeks have generally found no effects on EDSS scores. A few exercise studies have shown positive effects when applying other clinical scales (MSFC and GNDS).
Disease Progression Evaluated with Non-Clinical Measures
Two studies by Prakash and colleagues have evaluated the effects of cardiorespiratory fitness on brain function and structure by applying (functional) MRI [Prakash et al. 2007, 2009]. One study [Prakash et al. 2007] investigated the impact of cardiorespiratory fitness on cerebrovascular functioning of MS patients. Twenty-four female participants with relapsing�remitting MS were recruited for the study and all participants went through fitness assessment (VO2 peak) and were scanned in a 3-T MRI system while performing the Paced Visual Serial Addition Test (PVSAT). Higher fitness levels were associated with faster performance during the PVSAT that could be related to greater recruitment of a specific region of the cerebral cortex (right inferior frontal gyrus [IFG] and middle frontal gyrus [MFG]) known to be recruited by MS patients during performance of PVSAT to purportedly compensate for the cognitive deterioration attributable to MS. In contrast, lower levels of fitness were associated with enhanced activity in the anterior cingulate cortex (ACC), thought to reflect the presence of a larger amount of conflict increasing the potential for error in lower fit MS participants. The authors interpreted the results as supporting aerobic training as an intervention to support the development of additional cortical resources in an attempt to counter the cognitive decline resulting from MS. Among a number of cognitive tests, only the Paced Auditory Serial Addition Test (PASAT) showed a weak correlation (p = 0.42) to VO2 peak leading the authors to suggest that fitness does not have an influence on measures of general cognitive functioning.
In another study by Prakash and colleagues the relationship between cardiorespiratory fitness (VO2 max) and measures of gray matter atrophy and white matter integrity (both of which have been associated with the disease process) were studied [Prakash et al. 2009]. A voxel-based approach to analysis of gray matter and white matter was applied on brainscans from a 3-T MRI system. More specifically it was examined whether higher levels of fitness in 21 female MS patients were associated with preserved gray matter volume and integrity of white matter. A positive association between cardiorespiratory fitness and regional gray matter volumes and higher focal fractional anisotropy values were reported. Both preserved gray matter volume and white matter tract integrity were associated with better performance on measures of processing speed. Recognizing the cross-sectional nature of the data, the authors suggested that fitness exerts a prophylactic influence on the structural decline observed early on, preserving neuronal integrity in MS, thereby reducing long-term disability.
In summary, (f)MRI studies suggesting a protective effect of cardiorespiratory fitness on brain function and structure in MS patients have started to emerge. However, the cross-sectional nature of the few existing studies limit conclusions regarding the existence of a causal relationship.
Disease Progression Evaluated with Patient-Reported Measures
A number of studies have addressed the relationship between exercise or physical activity and disease progression in large-scale questionnaire studies applying patient-reported measures.
In a large descriptive longitudinal survey study, Stuifbergen and colleagues examined the correlations between the change in functional limitations, exercise behaviors and quality of life [Stuifbergen et al. 2006]. More than 600 MS patients completed a number of questionnaires every year for a period of 5 years. The self-reported longitudinal measures were analyzed by applying latent curve modeling. The Incapacity Status Scale provided a measure of functional limitations due to MS, whereas the Health Promoting Lifestyle Profile II provided a measure of exercise behavior. At the first test point (baseline test) cross-sectional data showed a significant negative correlation (r = ?0.34) between functional limitations and exercise behaviors, suggesting that at the start of the study higher levels of functional limitations were associated with lower levels of exercise. Longitudinal data from the study showed that increasing rates of changes in functional limitations correlated with decreasing rates of change in exercise behaviors (r = ?0.25). In other words these findings are suggesting that increases in exercise behaviors correspond with decreased rates of change in functional limitations. No correlation between the initial degree of limitation and continuing rate of exercise was found which led the authors to suggest that persons with MS with varied levels of limitations might slow the trajectory of increasing limitations over the long term with consistent exercise participation.
A series of studies from Motl and colleagues have addressed the relationship between physical activity, symptoms, functional limitations and disability in MS patients. In a cross-sectional study [Motl et al. 2006] in 196 MS patients, the number of symptoms within 30 days (MS-related Symptom Checklist) and physical activity (Godin Leisure-Time Exercise Questionnaire and 7-day accelerometer data) were collected. After modeling data a direct relationship between symptoms and physical activity were found (r = ?0.24) indicating that a greater number of symptoms resulted in lower amounts of physical activity. However, the authors noted that the cross-sectional design precludes inferences about the direction of causality, and physical activity might affect symptoms as symptoms affect physical activity participation. When modeled this way a moderate inverse correlation between physical activity and symptoms was found (r = ?0.42) indicating fewer symptoms when the physical activity level is high. This led the authors to suggest the existence of a bi-directional relationship between physical activity and symptoms.
In a following questionnaire study Motl and colleagues examined physical activity (Godin Leisure-Time Exercise Questionnaire and 7 day accelerometer data) and symptoms (Symptom Inventory and MS-related Symptom Checklist) as correlates of functional limitations and disability (Late-Life Function and Disability Inventory) in 133 MS patients [Motl et al. 2007, 2008b]. A model based on the disablement model proposed by Nagi (1976) was tested as the primary model and this showed that physical activity and symptoms were negatively correlated (r = ?0.59) and those who were more physically active had better function (r = 0.4). Furthermore, those with better function had less disability (r = 0.63) which led the authors to conclude that the findings indicate that physical activity is associated with reduced disability (through an association with function) consistent with Nagi�s disablement model (Nagi 1976), but again the cross-sectional design limited definite conclusions on the direction of the relationships.
Motl and colleagues then published a longitudinal (case report) study examining the relationship between worsening of symptoms and the level of physical activity throughout a 3- to 5-year period [Motl et al. 2008a]. The study showed that worsening of symptoms (interview) was significantly associated with lower levels of self-reported physical activity (International Physical Activity Questionnaire [IPAQ]) in a group of 51 subjects with MS. The study supports symptoms as a possible explanation for the rate of physical inactivity among MS patients but the direction of the cause and effect relationship could still not be established. Based on the results the authors suggest that managing symptoms might be important for the promotion of physical activity, but also that symptoms may be both an antecedent and consequence of physical activity.
After that Motl and colleagues published a cross-sectional study examining the correlation between physical activity and neurological impairment and disability in a group of 80 MS patients [Motl et al. 2008c]. Physical activity (7-day accelerometer day), impairment and disability (Symptom Inventory and self-reported EDSS) was measured and significant correlations were found between physical activity and both EDSS (r = ?0.60) and Symptom Inventory (r = ?0.56). The authors concluded that physical activity was associated with reduced neurological impairment and disability, but also stated that no causal relationship could be established due to the cross-sectional nature of the study.
Motl and McAuley then published a large-scale longitudinal questionnaire study examining the changes in physical activity (Godin Leisure-Time Exercise Questionnaire and 7-day accelerometer data) and symptoms (Symptom Inventory and MS-related Symptom Checklist) as correlates of changes in functional limitations and disability (Late-Life Function and Disability Inventory) [Motl and McAuley, 2009]. A total of 292 MS patients were followed for 6 months. Again a model based on the disablement model proposed by Nagi (1976) was tested as the primary model and this showed that change in physical activity was associated with residual change in function (r = 0.22) and change in function was associated with residual change in disability (r = 0.20). This led the authors to conclude that the findings indicate that change in physical activity is associated with change in disability (through an association with function) consistent with Nagi�s disablement model, but other models may be applied during analysis and a causal interpretation, therefore, still could not be adopted.
In a 6-month longitudinal study Motl and colleagues then tested the hypothesis that a change in physical activity (Godin Leisure-Time Exercise Questionnaire and International Physical Activity Questionnaire) would be inversely associated with a change in walking impairment (Multiple Sclerosis Walking Scale-12) in patients with relapsing�remitting MS [Motl et al. 2011a]. Data from 263 MS patients were analyzed using linear panel analysis and covariance modeling. Findings showed that a standard deviation unit change of 1 in physical activity was associated with a standard deviation unit residual change of 0.16 in walking impairment. These findings, therefore, support physical activity as an important approach, when trying to avoid walking impairments.
Finally, Motl and McAuley published a paper on longitudinal data (6 months) from 292 MS patients evaluating the relationship between a change in physical activity (7-day accelerometer data) and change in disability progression (Patient Determined Disease Steps Scale) [Motl and McAuley, 2011]. Panel analysis showed that a change in physical activity was associated with a change in disability progression (path coefficient: �0.09). This led the authors to conclude that a reduction in physical activity is a behavioral correlate (but not necessarily a cause) of short-term disability progression in persons with MS.
Recently, Tallner and colleagues evaluated the relationship between sports activity (Baecke Questionnaire � sports index) and MS relapses during the last 2 years (based on self-reports) in 632 German MS patients [Tallner et al. 2011]. Patients were divided into four groups based on their sports index. The study showed no overall differences between the four groups concerning the number of relapses within the last 2 years. However, the most active group had the lowermost mean and standard deviation of all groups. Consequently, these data suggest that exercise does not negatively influence relapse rate and the data further indicate that exercise actually reduce relapse rate.
In summary, patient-reported measures of the association between exercise or physical activity and disease progression (expressed as symptoms, functional limitations or disability) or activity (relapse rate) provide evidence of an association with more physical activity providing protection. However, due to the nature of the studies the causality of this association has not been established.
Disease Progression Evaluated in Animal Studies
Some obvious methodological difficulties exists in designing a human study clarifying whether or not exercise has an impact on disease progression in MS patients. Therefore, the question has been addressed in the EAE animal model of MS.
In a preliminary study by Le-Page and colleagues four groups of EAE rats were followed from day 1 to day 10 after injection with an agent inducing EAE [Le-Page et al. 1994]. The injection resulted in three different disease courses in the rats, namely acute (rats rapidly developed serious clinical signs and died without signs of recovery), monophasic (rats developed only one bout of disease followed by complete recovery) and chronic relapsing (CR-EAE, more than one bout of disease followed by remission). The CR-EAE disease course is characterized by the development of an initial acute paralytic attack 10�20 days after immunization with neuroantigens and the development of spontaneous relapses thereafter. A female and a male group of rats exercised and a female and male group served as control. Exercise consisted of running on a treadmill from day 1 to day 10 after injection. The protocol was progressively adjusted with the duration increasing from 60 min towards 120 min and the running speed increasing from 15 to 30 m/min. The study showed that in the exercised CR-EAE rats of both sexes the onset of the disease was significantly delayed compared with the onset in control CR-EAE rats. Also, the duration of the first relapse was significantly reduced in exercised CR-EAE rats compared with control rats whereas no effect was seen on the peak severity of the disease. No effects of exercise were observed in the acute and monophasic EAE rats. The authors concluded that endurance exercise during the phase of induction of EAE diminished lightly one type of EAE (CR-EAE) but also that exercise did not exacerbate the disease.
In a complementary study Le-Page and colleagues conducted further four experiments in the monophasic EAE model [Le-Page et al. 1996]. Experiments 1 and 2 showed that 2 consecutive days of intensive exercise (250�300 min/day) performed just after injection had a lowering effect on the course of the clinical signs of disease as compared with control rats. Also, the onset of the disease and the day of maximal severity were both delayed in the exercising rats, whereas no change was observed in disease duration. When the 2 consecutive days of exercise were performed before injection no effects were observed. In experiments 3 and 4 it was tested how 5 days of more moderate exercise at either constant (15�25 m/min for 2 hours) or variable speed (3 min at 2 m/min and then 2 min at 35 m/min for a total of 1 hour) affected the course of the disease and the clinical parameters. No effects were observed on the disease course and on the clinical parameters. The authors concluded that severe exercise contrary to more moderate exercise slightly influenced the effector phase of monophasic EAE, and confirmed that physical exercise performed before onset of EAE did not exacerbate the clinical signs.
More recently, Rossi and colleagues further explored the effects of physical activity on disease progression in the CR-EAE mice model [Rossi et al. 2009]. In this study one group of mice had their cage equipped with a running wheel on the day of immunization, while the control group had no running wheel. The amount of physical activity was not controlled and it was therefore the amount of voluntary physical activity in the running wheel that constituted the intervention. In a further experiment EAE mice in standard cages were compared with EAE mice in cages equipped with a blocked wheel. This was done to dissect the role of physical activity from that of sensory enrichment caused by the wheel itself, and showed not to influence the clinical course of the disease. During the initial phase (13 days after injection) of the disease the exercising mice ran spontaneously an average of 760 turns/day in the running wheel which dropped to 18 turns/day when motor impairment peaked (20�25 days after injection). The study showed that the severity of EAE-induced clinical disturbances was attenuated in both acute and chronic phases of EAE in the physically active mice, who consistently exhibited less severe neurological deficits compared with control EAE animals during a time period of 50 days after EAE induction. Furthermore, it was shown that both synaptic and dendritic defects caused by EAE were attenuated by physical activity.
In summary, aerobic exercise (or voluntary physical activity) has the potential to influence the clinical course of the disease in the EAE animal model of MS.
Participating in physical activities and exercise can be beneficial for anyone, especially for people with multiple sclerosis, or MS. Exercise can help ease multiple sclerosis symptoms, however, patients have to be careful with the amount of physical activity they engage in. Several research studies like the one discussed in this article have determined that physical activities and exercises can help improve symptoms as well as slow down the progression of multiple sclerosis. It’s essential to talk to a healthcare professional to discuss the details of each workout program in order to make the best of the benefits of exercise for MS. Dr. Alex Jimenez D.C., C.C.S.T.
Discussion
Recent evidence from studies applying nonclinical and patient-reported measures as well as from studies applying the EAE animal model of MS indicate a possible disease-modifying effect of exercise (or physical activity) but the strength of the evidence limits definite conclusions. Furthermore, these findings are not confirmed in intervention studies evaluating disease progression by clinical outcome measures. Despite the obvious associated difficulties future long-term exercise intervention studies in a large group of MS patients are needed within this field.
MS Disease Progression
Some major methodological problems arise when trying to measure MS disease progression. The ideal MS outcome measure would quantify irreversible sustained disease progression, but in MS this has proven difficult. The pleiotropic expression of MS makes it challenging to measure all facets of the disease and it may be necessary to focus on specific symptoms. Furthermore, great patient heterogeneity, population variability in the disease course and tempo of progression, subclinical MRI changes of uncertain impact on delayed disability progression, multifaceted neurological deficits with varied abilities for individual patients to compensate and patient comorbidities complicate things further [Goldman et al. 2010].
Clinical Outcome Measures
EDSS, MSFC and relapse rate are the standard clinical outcome measures for MS therapeutic trials and the most widely used measure of disease progression is the EDSS [Goldman et al. 2010]. Our literature review shows that exercise studies (resistance, endurance and combined training) applying EDSS generally do not report any change after an exercise intervention. In medical studies applying EDSS, large sample sizes and interventions lasting 2�3 years are typically required to measure changes in exacerbation rates between treatment and placebo [Bates, 2011]. This corresponds poorly to the short intervention periods (3�26 weeks) and the small sample sizes applied in most exercise studies. This is due to the overall low responsiveness and sensitivity to change of the EDSS as reported in a number of studies (for references see Goldman et al. [2010]). Also, the EDSS have been criticized for its noninterval scaling, emphasis on ambulation status and absence of adequate cognitive and visual components [Balcer, 2001]. Despite the emphasis on ambulation and that a recent meta-analysis concluded that exercise impacts walking positively [Snook and Motl, 2009], no changes were seen in the EDSS in most of the reviewed studies, indicating low scale responsiveness towards exercise interventions. In clinical trials the MSFC is claimed to be more sensitive to change than the EDSS [Goldman et al. 2010]. This suggestion is supported by the finding from one exercise study applying both the EDSS and the MSFC. In this long-term study (26 weeks) [Romberg et al. 2005] the effects of combined training on EDSS and MSFC were evaluated. Only the MSFC showed a significant effect which led the authors to conclude that the MSFC was more sensitive than the EDSS in the detection of improvement of functional impairment as a result of combined exercise. In future exercise studies evaluating disease progression it should therefore be considered to add the MSFC as a clinical outcome measure.
In addition to low scale responsiveness, short-term interventions and small sample sizes other explanations for the general lack of effects on clinical outcome measures can be hypothesized. Despite no clear pattern in the existing data, the type of exercise (e.g. endurance versus resistance training) may influence the effect captured by clinical scales. Also, most studies have evaluated mild to moderately impaired (EDSS <6) MS patients. Perhaps the clinical scales would be more sensitive to change in more severely impaired patients. Finally, findings can be biased if it is generally more physically fit patients that accept to be enrolled in exercise studies. If so, the baseline fitness level may be above average in these patients further lowering the possibility of a change on clinical scales with low responsiveness.
Only a few studies [Bjarnadottir et al. 2007; Petajan et al. 1996; Romberg et al. 2004; White et al. 2004] present clear data on relapse rate but due to the short intervention periods and the small sample sizes in most studies changes in the relapse rate, would not be expected to be evident. However, Romberg and colleagues found a total of 11 relapses (five in the combined training group and six in the control group) during a 6-month intervention period [Romberg et al. 2004]. Similarly, Petajan and colleagues (endurance training group four relapses and control group three relapses) [Petajan et al. 1996] and Bjarnadottir and colleagues (combined training group one relapse and control group one relapse) [Bjarnadottir et al. 2007] reported identical relapse rates in exercise and control groups. In the study by White and colleagues no participants experienced relapses during the 8-week intervention evaluating resistance training [White et al. 2004]. Recently, Tallner and colleagues collected self-report questionnaires on relapse rates and physical activity from MS patients to examine the relationship of different levels of sports activity and relapses [Tallner et al. 2011]. Based on these data the authors concluded that exercise had no significant influence on clinical disease activity. Taken together the few existing data do not indicate that any type of exercise increases relapse rate among MS patients. However, these data should be interpreted with caution due to the small number of participants (not stratified according to disease type or severity) and the short intervention periods in most studies. Consequently, future long-term studies with a large number of participants should, therefore, include relapse rate as an outcome measure.
Nonclinical Measures
Application of MRI has revolutionized the diagnosis and management of patients with MS [Bar-Zohar et al. 2008]. In regard to clinical trials, MRI offers several advantages over the accepted clinical outcome measures for MS, including an increased sensitivity to disease activity and a better association with histopathology findings. Also, MRI provides highly reproducible measures on ordinal scales, and the assessment of MRI can be performed at the highest degree of blinding [Bar-Zohar et al. 2008]. Consequently, a surrogate MRI measure reflecting disease progression such as lesion activity (gadolinium-enhanced lesions and new or enlarged T2-hyperintense lesions) or disease severity (total T2-hyperintense lesion volume, total T1-hypointense lesion volume and whole-brain atrophy) [Bermel et al. 2008] may reduce the required sample sizes needed to evaluate the effects of exercise therapy on disease progression considerably. Until now only two cross-sectional studies have evaluated the effects of exercise (expressed as the current cardiorespiratory fitness level) on different MRI measures limiting the conclusions that can be drawn from this type of study. However, the promising findings do encourage the inclusion of MRI as an outcome measure, in future longitudinal trials evaluating the effects of exercise on disease progression.
Patient-Reported Measures
Patient-reported measures of the association between exercise or physical activity and disease progression (expressed as symptoms, functional limitations or disability) provide evidence of an association with more physical activity providing protection. However, the nature of the studies does not allow conclusions on the causality of this association. In the group of studies applying patient-reported measures we decided to include not only measures of exercise, but also measures of physical activity. It is acknowledged that a measure of physical activity is not necessarily a surrogate measure of exercise, but the many interesting findings from particularly the group of Motl and colleagues caused this. In a recent paper, based on their own studies, Motl and colleagues concludes that recent research has identified physical activity as a behavioral correlate of disability in MS. This made the authors suggest, that physical activity might attenuate the progression of what they call �mobility disability� by improving physiological function in persons with MS, particularly those who have achieved a benchmark of irreversible disability (EDSS >4) [Motl, 2010]. It might be more cost effective to offer the more disabled (EDSS >4) MS patients exercise therapy, but it must be noted that most exercise studies do not indicate that a relationship between the degree of training adaptation and neurological disability exist. In fact, studies indicate that MS patients with an EDSS score below 4.5 experience the largest improvements after a period of endurance training as compared with more disabled MS patients [Ponichtera-Mulcare et al. 1997; Schapiro et al. 1988] or that no differences exists [Petajan et al. 1996]. It must be noted that none of these studies were powered to evaluate the effects of exercise in MS patients with different levels of disability. However, a recent study by Filipi and colleagues specifically evaluated whether 6 months of resistance training improves strength in MS patients with different levels of disability (EDSS 1�8) and concluded that all individuals with MS, despite different disability levels, showed parallel improvement in muscle strength [Filipi et al. 2011]. This leads to the suggestion, that exercise may be equally important during the early phases of the disease, also in regard to impact on disease progression.
An important advantage of applying patient-reported measures is the opportunity to collect data from large sample sizes in longitudinal studies. Furthermore, it seems important to collect data on patient perspective when evaluating the effects of exercise on disease progression. Future studies including patient-reported measures should also include clinical and/or nonclinical outcome measures if possible.
Animal Studies
Our review showed that aerobic exercise (or activities) has the potential to influence the clinical course of the disease in the EAE animal model of MS. The obvious question is whether or not the findings from the EAE animal model of MS can be extrapolated to humans. At the moment no clear answer can be given to this question. A recent review summarized whether the current disease-modifying treatments are justified on the basis of the results of EAE studies. Here it was concluded that although EAE is certainly an imperfect mirror of MS, many clinical, immunopathological and histological findings are impressively replicated by animal models, making EAE invaluable in elucidating the basic immunopathological mechanisms of MS and providing a testing ground for novel therapies [Farooqi et al. 2010]. Consequently, a direct transfer of findings into human subjects cannot be made, but testing of difficult hypotheses can start here. Also, it should be noted that in EAE you cannot control the relative exercise intensity since no maximal exercise test (such as a VO2 max test) can be performed. As a consequence the applied relative exercise intensity may differ between animals. This is also why it is very difficult to evaluate the effects of aerobic exercise on aerobic capacity in EAE. Nonetheless, the EAE model offers a number of advantages compared to human studies. In addition lower costs, easy control with adherence to the intervention and controlled environmental and genetic factors the EAE model also allows evaluation of possible mechanisms located in the central nervous system (CNS), which should have attention in future studies. Another review stated that the genetic heterogeneity, which is so critical in the MS population, is only reflected when multiple different models of EAE are studied in parallel [Gold et al. 2006]. This aspect should also be incorporated in future studies.
Possible Mechanisms
Several mechanisms have been proposed as a possible link between exercise and disease status in MS. Some of the most promising candidates include cytokines and neurotrophic factors [White and Castellano, 2008a].
Cytokines. Cytokines play an important role in the pathogenesis of MS and are a major target for treatment interventions. In particular, interleukin (IL)-6, interferon (IFN)-? and tumor necrosis factor (TNF)-? have a prominent role in the process of demyelination and axonal damage experienced by persons with MS [Compston and Coles, 2008].
Changes in the concentrations of certain cytokines, in particular IFN-? and TNF-?, have been associated with changes in disease status in MS, and elevated concentrations of pro-inflammatory Th-1 cytokines (such as TNF-?, IFN-?, IL-2 and IL-12) may contribute to neurodegeneration and disability [Ozenci et al. 2002]. This has led to the suggestion that exercise may counteract imbalances between the pro-inflammatory Th1 cytokines and the anti-inflammatory Th2 cytokines (such as IL-4 and IL-10) by enhancing anti-inflammatory mechanisms, and thereby potentially be able to alter the disease activity in MS patients [White and Castellano, 2008b].
In MS both the acute and/or chronic effects of resistance [White et al. 2006], endurance [Castellano et al. 2008; Heesen et al. 2003; Schulz et al. 2004] and combined training [Golzari et al. 2010] on several cytokines have been evaluated. A study by White and colleagues reported that resting levels of IL-4, IL-10, C-reactive protein (CRP) and IFN-? were reduced, while TNF-?, IL-2 and IL-6 levels remained unchanged after 8 weeks of biweekly resistance training [White et al. 2006]. These results suggest that progressive resistance training may have an impact on resting cytokine concentrations and, thus, could have an impact on overall immune function and disease course in individuals with MS. However, the study was not controlled and only 10 participants were included obviously limiting the strength of the evidence. Heesen and colleagues evaluated the acute effects of 8 weeks of endurance training on IFN-?, TNF-? and IL-10 and compared this to both a waitlist MS control group and a group of matched healthy subjects [Heesen et al. 2003]. After completing 30 minutes of endurance training (cycling) an increase in IFN-? were induced similarly in all groups while trends towards smaller increases in TNF-? and IL-10 were observed in the two groups of MS patients. Based on these data the authors concluded, that no deviation in pro-inflammatory immune response to physical stress could be demonstrated in MS patients. These findings, therefore, supports that a single bout of endurance training can influence the cytokine profile at least for a period of time in MS patients. In another publication from the same study Schulz and colleagues were not able to demonstrate any differences between the resting level or the acute IL-6 response after 30 minutes of endurance exercise in the MS training group (8 weeks of bicycling) and the MS control group [Schulz et al. 2004].
A study by Castellano and colleagues evaluated the effects of 8 weeks of endurance training (cycling, 3 days/week) on IL-6, TNF-? and IFN-? in 11 MS patients and 11 healthy matched controls. In MS patients both resting IFN-? and TNF-? was elevated after endurance training whereas no changes were observed in healthy controls [Castellano et al. 2008]. Like in the study by Heesen and colleagues [Heesen et al. 2003], Castellano and colleagues also studied the acute effects of a single bout of endurance training and similarly found no differences when compared to the healthy controls, but in this study no increase in IFN-? and TNF-? were observed in any of the groups contrasting the findings by Heesen and colleagues.
In the most recent study Golzari and colleagues performed a randomized controlled trial (RCT) evaluating the effects of 8 weeks of combined endurance and resistance training on IFN-?, IL-4 and IL-17 [Golzari et al. 2010]. The study showed significant reductions in the resting concentrations of IFN-? and IL-17 in the exercise group, whereas no changes were seen in the control group, but no group comparisons were made.
In summary, no clear pattern can be seen in the reported cytokine responses to exercise probably reflecting large methodological differences between the studies (study type, type of exercise intervention, time of measurements, standardizations, etc.) and a low statistical power which is critical due to the great variation in this type of measurements. Nonetheless, a single bout of exercise have been reported to influence a number of (pro-inflammatory) cytokines in MS patients and also chronic changes in the resting concentration of several cytokines have been reported after a training period. Furthermore, the response seems to be comparable to that of healthy subjects. Cytokines, therefore, may link exercise and disease progression in MS, but large-scale future RCTs have to evaluate this further.
Neurotrophic factors. Neurotrophic factors are a family of proteins that are thought to play a role in preventing neural death and in favoring the recovery process, neural regeneration and remyelination throughout life [Ebadi et al. 1997]. Some of the more well-characterized neurotrophic factors include brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) [White and Castellano, 2008b].
Gold and colleagues evaluated the acute effects of a single exercise bout (30 min cycling at 60% VO2 max) on NGF and BDNF in 25 MS patients and compared this with a group of matched healthy controls [Gold et al. 2003]. The study showed that baseline concentrations of NGF were significantly higher in MS patients compared with controls. Thirty minutes after exercise a significant increase was observed in BDNF while a trend towards an increase in NGF was observed. However, the changes did not differ from the changes observed in the healthy subjects. This made the authors conclude that moderate exercise can be used to induce neutrophin production in subjects with MS possibly mediating the beneficial effects of physical exercise. In a study from the same group Schulz and colleagues evaluated the effects of biweekly cycling for 8 weeks on BDNF and NGF in a RCT in MS patients [Schulz et al. 2004]. The study showed no effects on the resting concentration and on the response to acute exercise after the intervention period, and only a trend towards lower resting NGF levels was found. Castellano and White also evaluated whether 8 weeks of cycling (three times a week), would affect serum concentrations of BDNF in MS patients and in healthy controls [Castellano and White, 2008]. In contrast to the findings of Gold and colleagues, resting BDNF was lower at baseline in MS patients as compared with controls, but no difference (a trend) between groups was found after 8 weeks. In MS patients BDNF concentration at rest was significantly elevated between weeks 0 and 4 and then tended to decrease between weeks 4 and 8, whereas resting BDNF concentration remained unchanged at 4 and 8 weeks of training in controls. Also, the response to a single bout of exercise was evaluated showing a significant reduction in BDNF 2 and 3 hours after exercise in both groups again contrasting with the findings by Gold and colleagues. The authors concluded that their findings provided preliminary evidence showing that exercise may influence BDNF regulation in humans.
In summary contrasting findings on the effects of exercise on neurotrophic factors exists in MS patients, making more studies warranted. However, findings do imply that exercise may influence several neurotrophic factors known to be involved in neuroprotective processes.
Conclusions
It cannot be clearly stated whether exercise has a disease-modifying effect or not in MS patients but studies indicating this do exist. Future long-term intervention studies in a large group of MS patients are therefore needed to address this important question.
Acknowledgments
The authors would like to thank research Librarian Edith Clausen for a substantial contribution to the comprehensive literature search.
Footnotes
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
UD has received travel grants and/or honorary from Biogen Idec, Merck Serono and Sanofi Aventis. ES has received research support and travel grants from Biogen Idec, Merck Serono and Bayer Schering and travel grants from Sanofi Aventis.
Multiple sclerosis, or MS, is a chronic disease identified by symptoms of by pain, fatigue, vision loss and impaired coordination caused by damage to the myelin sheaths of nerve cells in the central nervous system, or CNS. Exercise has been demonstrated to help improve the management of symptoms of multiple sclerosis as well as decrease the progression of the disease, although further evidence is still required, the article above summarizes these outcome measures. The purpose of the article above demonstrates how exercise can change the progression of multiple sclerosis and improve overall health and wellness. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. �
De Quervain’s Tenosynovitis, also called �washerwoman sprain,� is a condition of the hand that typically affects people who do continuous, fast, repetitive movements. The patient can experience a sudden onset of the condition or it can be gradual, beginning with tenderness in the thumb area and slowly progressing. It can restrict activity, but it doesn�t have to be a long-term disability. Chiropractic care can help relieve the symptoms of De Quervain�s Tenosynovitis and the hand can return to normal function.
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What Is De Quervain’s Tenosynovitis?
De Quervain’s Tenosynovitis is a condition affecting the thumb side of the wrist. It is a very painful condition that makes many everyday activities difficult or impossible. Many activities like playing golf, lifting a child, garden work, and racket sports can worsen the condition.
What are the Symptoms ofDe Quervain’s Tenosynovitis?
There are several distinctive symptoms of De Quervain�s tenosynovitis which include:
Pain near or at the base of the thumb
Difficulty moving or controlling the thumb and wrist when doing activities that involve pinching or grasping
Swelling near or at the base of the thumb
A �catch� or �sticking� sensation when moving the thumb
If the condition is allowed to progress or goes untreated it can involve the forearm and entire thumb, causing pain and swelling in those areas. The pain and symptoms can be exacerbated by movements that involve the wrist and thumb. The symptoms can last for a long time, weeks or even months.
What causes De Quervain’s Tenosynovitis?
The exact cause of De Quervain�s Tenosynovitis is not known, but the condition is commonly associated with chronic overuse of the wrist. There are tendons that connect the wrist and lower thumb, enabling movement like grasping, gripping, pinching, and wringing. The tendons slide through a sheath as they facilitate the movement. Over time, the sheath can swell and thicken which inhibits the amount of the tendon�s movement. When the movements are repetitive, it can cause irritation of the sheath, resulting in inflammation.
Who is at Risk for De Quervain’s Tenosynovitis?
Research has identified several groups that are at risk for developing De Quervain�s Tenosynovitis:
30 to 50 years of age with a higher concentration statistically around 40
Female
African ethnicity or descent
Pregnant
Caring for a child or baby
Works at a job that involves repetitive wrist and hand motions
This condition has typically been considered to be one that affects people who are middle-aged. However, with the popularity of texting, many young people experience symptoms of De Quervain�s. In one study, more than half of students who texted extensively were labeled positive for De Quervain�s.
What are the Treatments for De Quervain’s Tenosynovitis?
Treatment for De Quervain�s Tenosynovitis include:
Resting the affected thumb and wrist
Bracing or immobilization
Ice to the affected area
Anti-inflammatory medications like ibuprofen and naproxen
If standard treatment is not effective it may be necessary to seek medical attention. If the condition is severe or chronic, the doctor may inject corticosteroid directly into the tendon sheath. Surgery for De Quervain�s is not common, but it may be deemed necessary in order to release the thumb. The speed of healing and the�degree of normal use of the thumb depends on the treatment chosen and if the activity that exacerbates the condition is stopped.
Can Chiropractic Help De Quervain’s Tenosynovitis?
A chiropractor may recommend rest, ice, and bracing for a patient with De Quervain�s Tenosynovitis. Upon reviewing the patient�s lifestyle and habits, he or she may also advise ergonomic changes, modification of activity, and reduce exposure to positions that exacerbate the symptoms. Soft tissue therapies may be used to quickly bring relief to the soft tissue, minimizing the inflammation and pain. As the pain decreases, the chiropractor will recommend specific strengthening and stretching exercises that involve the wrist, thumb, and forearm.
With regular care and modification to activities, the condition can be healed and full mobility of the thumb and wrist can be restored.
Daniel Alvarado, owner of PUSH Fitness, in order to participate in his activities that are physical, he depends on his health. After fighting with shoulder pain during the course of several months, Daniel Alvarado went to visit Dr. Alex Jimenez, chiropractor, to receive shoulder pain rehabilitation. Chiropractic care is a treatment for subluxations, which might be causing symptoms, or an alternative treatment option used to cautiously help restore any misalignments. Dr. Alex Jimenez assisted Daniel Alvarado to enhance his strength, flexibility, and freedom through using spinal adjustments and manual manipulations. Daniel Alvarado was able to come back to his daily physical tasks after receiving shoulder pain rehabilitation together with Dr. Alex Jimenez, chiropractor. Daniel Alvarado highly recommends Dr. Alex Jimenez because he is the non-surgical pick for shoulder pain.
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Note generations of the tracheal-bronchial tree, lobes, segments, and fissures. Note secondary pulmonary lobule (1.5-2-cm)-the basic functional unit of lungs observed on HRCT. Note important structural organization of the alveolar spaces with communications in between (pores of Kohn & canals of Lambert) that permit air drift and by the same mechanism allow exudative or transudative fluid to spread through the lung and stopped at the fissure. Note the anatomy of the pleura: parietal that is a part of the endothoracic fascia and the visceral that forms a lung edge � pleural space in between.
Mediastinum: surrounded by the pleura and the lung. Accommodates major structures contains numerous lymph nodes (see diagramme showing mediastinal nodes and their involvement in Lymphoma
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General Approach to Investigating Chest Complaints
Decubitus views right and left: help to evaluate subtle pleural effusion, pneumothorax and other pathology
Normal CXR PA & Lateral views. Ensure good exposure: T-spine discs and vessels through the heart are visualized on PA view. Count 9-10 right posterior ribs to confirm adequate inspiratory effort. Begin a thorough survey using the following approach: Are There Many Lung Lesions A-abdomen/diaphragm, T-thorax wall, M-mediastinum, L-lungs individually, Lungs-both. Develop a good search pattern
1) Airspace disease aka alveolar lung disease? Filling of the lung’s alveoli, acini and subsequently the entire lobe with fluid or substance of any composition (blood, pus, water, proteinaceous material or even cells) Radiographically: lobar or segmental distribution, airspace nodules may be noted, tendency to coalesce, air bronchograms and silhouette sign present. Batwing (butterfly) distribution noted as in (CHF). Rapidly changing over time, i.e., increase or decrease (days)
2) Interstitial disease: infiltration of pulmonary interstitium (alveoli septum, lung parenchyma, vessel walls, etc.) by for example by viruses, small bacteria, protozoans. Also infiltration by cells such as inflammatory/malignant cells (e.g., lymphocytes) Presented as an accentuation of lung interstitium with a reticular, nodular, mixed reticulonodular pattern. Different etiologies: inflammatory autoimmune diseases, fibrosing lung disease, occupational lung disease, viral/mycoplasma infection, TB, sarcoidosis lymphoma/leukemia and many other.
Recognizing different patterns of pulmonary disease can help with DDx. Mass vs. Consolidation (left). Note different patterns of pulmonary disease: airspace disease as lobar consolidation indicative of pneumonia, diffuse consolidation indicative of pulmonary edema. Atelectasis (collapse and volume loss). Interstitial patterns of pulmonary disease: reticular, nodular or mixed. SPN vs. Multiple focal consolidations (nodules) likely representing mets infiltrates vs. septic infiltrates
A = intraparenchymal
B = pleural
C = extrapleura
Recognize important location of chest lesions
Important signs: Silhouette sign: help with localization and DDx. Example: Bottom left image: radiopacity in the right lung, where is it located? Right MM because the right heart border that is adjacent to right middle lobe is not seen (silhouetted) Air bronchograms: air containing bronchi/bronchioles surrounded by fluid
Chest Trauma
Pneumothorax (PTX): air (gas) in the pleural space. Many causes. Complications:
Tension PTX: continuous increase of air in the pleural space that rapidly compresses mediastinum and lung rapidly reducing venous return to the heart. It can be fatal if not treated rapidly
Spontaneous PTX: primary (young adults (30 -40) especially tall, thin men. Additional causes: Marfan�s syndrome, EDS, Homocystinuria, a – 1 -antitrypsin deficiency. Secondary: older pts with parenchymal disease: neoplasms, abscess, emphysema, lung fibrosis and honeycombing, catamenial PTX d/t endometriosis and others.
CXR: note visceral pleural line aka lung edge. An Absence of pulmonary tissue/vessels beyond the visceral pleural line. Subtle pneumothorax can be missed. On erect position, air rises and PTX should be sought at the top.
Rib fractures: v.common. Traumatic or pathological (e.g., mets, MM) Rib series x – rays are not very useful because CXR and/or CT scanning are more important to evaluate posttraumatic PTX (bottom left) lung laceration and another major path
Infection
Pneumonia: bacterial vs. viral or fungal or in the immunocompromised host (e.g., Cryptococcus in HIV/AIDS) Pulmonary TB
Pneumonia: community-acquired vs. hospital-acquired. Typical bacterial pneumonia or Lobar (non-segmental) pneumonia with purulent material filling the alveoli and spreading to the entire lobe. M/C organismStreptococcus Pneumonia or the Pneumococcus
Others: (Staph, Pseudomonas, Klebsiella esp. in alcoholics potentially leading to necroSIS/lung gangrene) Mycoplasma (20-30s) aka walking pneumonia, etc.
Clinically: a productive cough, fever, pleuritic chest pain sometimes hemoptysis.
CXR: confluent airspace opacity confined to the entire lobe. Air bronchograms. Silhouette sign help with location.
Viral: Influenza, VZV, HSV, EBV, RSV, etc. presents as interstitial lung disease that can be bilateral. May lead to respiratory compromise
Atypical pneumonia and Fungal Pneumonia: Mycoplasma, Legionnaire’s disease, and some fungal/Cryptococcus pneumonia may present with interstitial lung disease.
Pulmonary abscess: an infectious collection of purulent material in the lungs that often necrotizes. May lead to significant pulmonary and system complications/life-threatening.
On CXR or CT: round collection with thick borders and central necrosis containing air-fluid level. DDx from empyema that distorts the lung and pleural-based
Rx: antibiotics, antifungal, antiviral agents.
Pneumonia needs to be followed up with repeat CXR to ensure complete resolution
Lack of radiographic improvement of pneumonia may represent declined immunity, antibiotic resistance, underlying lung carcinoma or other complicating factors
Pulmonary TB
Common infection worldwide (3rd world countries). 1 in 3 persons worldwide is affected by TB. TB is caused by Mycobacterium TB or Mycobacterium Bovis. Intracellular bacillus. Macrophage plays a key role.
Primary Pulmonary TB & Post-primary TB. Requires repeated exposure through inhalation. In most immunocompetent hosts, the active infection does not develop
TB presents as 1) cleared by the host, 2) suppressed into Latent Tuberculosis Infection (LTBI) 3) cause active disease TB. Patients with LTBI are not spreading TB.
Imaging: CXR, HRCT. Primary TB: pulmonary airspace consolidation (60%) lower lobes, lymphadenopathy (95%- hilar & paratracheal), pleural effusion (10%). The Spread of primary TB most likely in immunocompromised and children.
Milliary TB: pulmonary and system complication dissemination that can be fatal
Post-primary (secondary) or reactivation infection: Mostly in the Apices and posterior segments of the upper lobes )high PO2), 40%-cavitating lesions, patchy or confluent airspace disease, fibrocalcific. Latent features: nodal calcifications.
Dx: Acid-fast bacilli (AFB) smear and culture (sputum). HIV serology in all patients with TB and unknown HIV status
Rx: 4-drug regimen: isoniazid, rifampin, pyrazinamide, and either ethambutol or streptomycin.
Pulmonary Neoplasms (primary lung cancer vs. pulmonary metastasis)
Lung cancer: m/c cancer in men and 6th most frequent cancer in women. Strong association with carcinogens inhalation. Clinically: late discovery, depending on the location of the tumor. Pathology (types): Small cell (SCC) vs. Non-small cell carcinoma
Small cell: (20%) develops from neuroendocrine aka Kultchitsky cell, thus may secrete biologically active substances presenting with paraneoplastic syndrome. Typically located centrally (95%) at or near the mainstem/lobar bronchus. Most show poor prognosis and unresectable.
Non-small cell: Lung adenocarcinoma (40%) (M/C lung cancer), M/C in women and non-smokers. Others: Squamous cell (may present with cavitating lesion), Large cell and some others
Plain film (CXR): new or enlarged focal lesion, widened mediastinum suggestive of lymph node involvement, pleural effusion, atelectasis, and consolidation. SPN-may represents potential lung cancer especially if it contains irregular borders, feeding vessels, thick wall, in the upper lungs. Multiple lung nodules are likely to represent metastasis.
Best Modality: HRCT with contrast.
Other chest neoplasms: Lymphoma is v. common in the chest especially in mediastinal and internal mammary notes.
Overall M/C pulmonary neoplasms are a metastasis. Some tumors show a higher predilection for lung mets, e.g., Melanoma, but any cancer can metastasize to the lungs. Some mets referred as �Cannonball� metastasis
Rx: radiation, chemotherapy, resection
Pulmonary edema: a general term defines abnormal fluid accumulation outside vascular structures. Broadly divided into Cardiogenic (e.g., CHF, mitral regurgitation) and Non-cardiogenic with a multitude of causes (e.g., fluid overload, post-transfusion, neurological causes, ARDS, near drowning/asphyxiation, heroin overdose, and others)
Causes: increased in Hydrostatic pressure vs. decreased in oncotic pressure.
Imaging: CXR and CT: 2-types Interstitial and Alveolar flooding. Imaging presentation depends on stages
In CHF: Stage 1: redistribution of vascular flow (10- 18-mm Hg) noted as �cephalization� of the pulmonary vasculature. Stage 2: Interstitial edema (18-25-mm Hg) Interstitial edema: peribronchial cuffing, Kerley lines (lymphatics filled with fluid) A, B, C lines. Stage 3: Alveolar edema: airspace disease: patchy consolidations developing into diffuse airspace disease: Batwing edema, air bronchograms
Rx: 3 main goals: Initial O2 to keep O2 at 90% saturation
Next: (1) reduction of pulmonary venous return (preload reduction), (2) reduction of systemic vascular resistance (afterload reduction), and (3) inotropic support. Treat underlying causes (e.g., CHF)
Lung atelectasis: incomplete expansion of pulmonary parenchyma. The term “collapsed lung” is typically reserved for when the entire lung is collapsed
1) Resorptive (obstructive) atelectasis occurs as a result of complete obstruction of an airway (e.g. tumor, inhaled objects, etc.)
2) Passive (relaxation) atelectasis occurs when contact between the parietal and visceral pleura is disrupted (pleural effusion & pneumothorax)
3) Compressive atelectasis occurs as a result of any thoracic space-occupying lesion compressing the lung and forcing air out of the alveoli
4) Cicatricial atelectasis: occur as a result of scarring or fibrosis that reduces lung expansion as in granulomatous disease, necrotizing pneumonia, and radiation fibrosis
5) Adhesive lung atelectasis occurs from surfactant deficiency and alveolar collapse
6) Plate-like or discoid often developed after following general anesthesia
7) Imaging features: lung collapse, migration of lung fissures, deviation of the mediastinum, rising of the diaphragm, hyperinflation of adjacent unaffected lung
Mediastinum: pathology can be divided into those that result in a focal mass or those that result in diffuse disease involving the mediastinum. Additionally, air may track into the mediastinum in pneumomediastinum. Knowledge of mediastinal anatomy helps the Dx.
Pulmonary emphysema: loss of normal elastic tissue/elastic recoil of the lung with the destruction of capillaries and alveolar septum/interstitium.
Destruction of lung parenchyma due to chronic inflammation. Protease-mediated destruction of elastin. Air trapping/airspace enlargement, hyperinflation, pulmonary hypertension, and other changes. Clinical: progressive dyspnea, irreversible. By the time the forced expiratory volume in 1 second (FEV1 ) has fallen to 50% the patient is breathless upon minimal exertion and adapts to lifestyles.
COPD is the third leading cause of global death. Affects 1.4% of adults in the US. M:F = 1 : 0.9. Pts 45 years and older
Causes: Smoking and a-1-Antitrypsin deficiency (divided into centrilobular (smoking) and panacinar.
Imaging; signs of hyperinflation, air trapping, bullae, pulmonary hypertension.
Truide Torres recibe atenci�n quiropr�ctica con el Dr. Alex Jimenez por su dolor en el nervio ci�tico. La ci�tica es una colecci�n de s�ntomas caracterizados por dolor lumbar que se irradia a trav�s de los muslos hacia las piernas, rodillas y pies. El dolor del nervio ci�tico puede afectar uno o ambos lados de las extremidades inferiores. Truide Torres luch� para participar en sus actividades f�sicas diarias debido a sus s�ntomas de ci�tica. A trav�s de ajustes espinales y manipulaciones manuales, el Dr. Alex Jimenez restaur� cuidadosamente la alineaci�n original de su columna, aliviando sus s�ntomas dolorosos. Truide Torres recomienda al Dr. Alex Jimenez y su personal como la opci�n no quir�rgica para la ci�tica.
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Nos complace presentarle a la Cl�nica Premier de Atenci�n de Lesiones y Bienestar de El Paso.
Nuestros servicios est�n especializados y enfocados en lesiones y en el proceso completo de recuperaci�n. Nuestras �reas de pr�ctica incluyen Bienestar y nutrici�n, Dolor cr�nico, Lesiones personales, Cuidado de accidentes automovil�sticos, Lesiones en el trabajo, Lesi�n en la espalda, Dolor en la espalda baja, Dolor en el cuello, Tratamiento de migra�a, Lesiones deportivas, Ci�tica severa, Escoliosis, Discos herniados complejos, Fibromialgia, Cr�nica Dolor, manejo del estr�s y lesiones complejas.
Como Cl�nica de Rehabilitaci�n Quiropr�ctica y Centro de Medicina Integrada de El Paso, nos enfocamos apasionadamente en el tratamiento de pacientes despu�s de lesiones frustrantes y s�ndromes de dolor cr�nico. Nos enfocamos en mejorar su capacidad a trav�s de programas de flexibilidad, movilidad y agilidad dise�ados para todas las edades y discapacidades.
Queremos que viva una vida que se cumpla con m�s energ�a, actitud positiva, mejor sue�o, menos dolor, peso corporal adecuado y educaci�n sobre c�mo mantener esta forma de vida. He hecho una vida cuidando a cada uno de mis pacientes.
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Are you struggling with your symptoms of MS on a regular basis? Multiple sclerosis, or MS, is a disease where the human body’s own immune system attacks the fatty myelin coating which surrounds and insulates nerve cells, a process called demyelination. Common symptoms of multiple sclerosis include fatigue, muscle spasms, walking problems, and tingling sensations and numbness.
According to various research studies, improved strength, flexibility, and mobility from participating in physical activities and exercises help decrease the risk of bone fractures and other ailments in people with MS. One research study also indicates that improper nutrition and a lack of physical activity and exercise are the most frequent risk factors for people with multiple sclerosis.
Another research study on the benefits of exercise for multiple sclerosis was printed by researchers from the University of Utah in 1996. The participants of the research study developed a more positive mindset, increased their strength, flexibility, and mobility, experienced less fatigue, improved their bowel, bladder, and cardiovascular function, and developed fewer symptoms of depression.
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Exercises for Multiple Sclerosis
A fitness program ought to be designed under medical supervision and may be adjusted as MS symptoms change. Patients with MS should engage in physical activities and exercises several times each week and avoid workouts for extended periods of time. Patients with MS can still do tasks around the home. Examples of everyday tasks include cooking, gardening, and�other household tasks.
Exercises that can help manage MS symptoms include:
Yoga. This type of physical activity/exercise features becoming aware of your breathing to help relax your body and mind. Benefits of yoga include enhancing the human body’s alignment, improving your own balance. Yoga also teaches you relaxing techniques, like meditation, which you could use during a magnetic resonance imaging, or MRI scan, or receiving an injection.
Tai Chi. This Chinese martial art teaches you how to breathe, relax and slow down your movements. Furthermore, Tai Chi can also help improves your balance, further helping to manage and support muscle tone, as well as help relieves stress.
Water exercises. Physical activities/exercises performed in water require less effort. This helps people with MS move in ways that they would otherwise not be able to perform properly. Benefits of water exercises include muscle relaxation, enhanced flexibility, better movement, improved strength, and reduced pain. These concentrate on improving aerobic resistance.
Healthcare professional used to recommend that people with MS avoid exercise entirely for fear of aggravating their symptoms. Now, evidence indicates that regular exercise not only improves quality of life for people with MS, but it might also help alleviate symptoms and decrease the risk of complications in the future. Exercise can be beneficial for anyone, even for people with multiple sclerosis.
According to many healthcare professionals, physical activity and exercise are one of the most essential elements of treatment for multiple sclerosis or MS. While many patients with MS often avoid exercise, thinking it will aggravate their symptoms, research studies have demonstrated that exercise can actually help improve symptoms. As described in the following article, physical activity can help improve strength, mobility, and flexibility. Furthermore, physical activity can have various other health benefits for MS, including improved bowel and bladder function as well as enhanced mood and decreased fatigue. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Getting Started with Exercise for MS
Kathleen Costello, a nurse practitioner and associate vice president of medical care for the National Multiple Sclerosis Society, recommends seeking the support of a healthcare professional, such as a chiropractor or physical therapist, to determine which physical activities or exercises would be beneficial for patients with MS. Benefits of exercise for multiple sclerosis include:
Less Fatigue
Various kinds of physical activities and exercise can improve fatigue. This is a frequent complaint among individuals with MS. A research study on yoga for people with MS discovered that yoga is as superior as other kinds of exercise in lowering fatigue. Another research study discovered that eight months of water exercise decreased fatigue and improved quality of life in women with MS.
Better Mood
Moderate-intensity exercise, such as brisk walking, dancing, or bicycling, has been shown in several research studies to enhance mood in people who are depressed. One research study discovered that the benefits also apply to adults with neurological disorders, including multiple sclerosis, especially when physical activity guidelines are met. The Centers for Disease Control and Prevention currently recommends that adults get at least 150 minutes, or 2 hours and 30 minutes, of moderate-intensity physical activities or exercises each week, in addition to including at least two workout routines involving muscle strengthening exercises for MS.
Better Bladder Control
Among the research studies on the benefits of exercise in people with MS, one review found that 15 months of aerobic exercise helped to enhance bowel and bladder function in people with MS. A small pilot research study published in the Journal of Alternative and Complementary Medicine in 2014 discovered that a yoga program also afforded better bladder control among individuals with MS.
Stronger Bones
Weight-bearing physical activities and exercise, such as walking, running, or using an elliptical machine, can help strengthen bones and may protect against osteoporosis, a bone-thinning disease that raises the possibility of fracturing bones. A lot of people with MS, or multiple sclerosis, are at risk of developing osteoporosis due to a combination of factors, including:
Low blood levels of vitamin D, the nutritional supplement that works with calcium to protect bone health
A history of taking corticosteroids, drugs used to treat MS flares that can lead to low calcium levels in the bloodstream
Mobility difficulties, which might make a person least likely to engage in different forms of exercise
Low body weight
At the same time, people with MS occasionally have balance conditions which make them more vulnerable to falling, a significant cause of broken bones. Finding a means to take part in exercises and physical activities which can help strengthen the bones is therefore important for preserving bone density and helping to prevent fractures, especially in people diagnosed with MS.
Weight Management
If symptoms of MS result in decreased physical activity or exercise, among one of the consequences, may include weight gain, which can make it even harder for you to get around. The use of corticosteroids can also lead to weight gain. Engaging in physical activities or exercise can help slow down or stop weight gain. Regular exercise can also benefit people who are underweight. Along with other benefits described above, physical activity or exercise may also increase appetite in people who are underweight.
For a lot of people, MS means changes in the physical activities or exercises they can perform and in how they will be able to execute them, however, it doesn’t imply that their lifestyle will come to a standstill. Work with your healthcare professional to discover the actions that suit you best and the assistive devices that could keep you moving with MS. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex JimenezR
Additional Topic Discussion:�Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. �
We live in a stressful world. Life happens; it moves so fast. Pressures coming at you from all directions. Eventually, it catches up with you, and it�s your body that bears the brunt of it. Tension is your body�s way of telling you that it is under stress � probably too muchstress.
It�s hard to escape stress in today�s society so if you find that you are exhibiting physical symptoms of stress, it might be time to make some changes. If tension headaches are one of those symptoms, you�re in good company � about 90% of adults in the US have headaches. Many of them are tension headaches.
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Symptoms of Tension Headaches
Tension headaches are distinctive and can be very painful. The good news is, they are rarely an indication of a more serious condition � other than a stressful lifestyle. Some of the most common symptoms of tension headaches include:
Muscle tightness in the neck, jaw, and shoulders � may also be sore.
A Headache that originates at the back of the head and moves forward over the top and sides.
Sleep problems.
Squeezing pain or dull pressure in the head may also be described as a tight band or vice around the head.
Trouble eating.
Pain or pressure on both sides of the head equally.
Sometimes tension headache symptoms can occur prior to a migraine. In other words, a tension headache can turn into a migraine headache and may be considered a migraine trigger.
Causes of Tension Headaches
The actual cause of tension headaches is not known. Researchers have some idea of potential triggers, but recent advancements in medicine have debunked the belief that they are caused by the tightening of muscles in the scalp, shoulders, neck, and jaw. Scientific tests show that then a person has a tension headache, muscle tension does not increase. Newer theories indicate that a likelier cause involves changes neurotransmitters (chemicals in the brain) which includes serotonin. This is similar to a migraine.
While researchers do not know the exact levels of neurotransmitter fluctuations, they do have evidence that it activates the brain�s pain pathways. The tightness in the muscles could be part of the physiological changes that trigger the fluctuations in neurotransmitters, or the neurotransmitter fluctuations could cause muscle tightness.
Some common triggers of tension headaches include:
Stress
Clenching the jaw
Alcohol or drugs
Overexertion
Certain medications (even some medications for headaches which can cause rebound headaches)
Keeping your head in one position for too long (like using a cell phone or computer)
Depression
Fatigue
Grinding teeth
Neck or head injury (even old injuries)
Sleeping in a cold room or in an awkward position.
Arthritis
Anxiety
Hormonal changes
Sleeping on a worn-out mattress or the wrong pillow
Dehydration
Skipping meals
Eye strain
Certain foods can also be triggers for tension headaches. Additives and preservatives in prepared foods, even high sodium, can cause a headache.
Sinus and allergy problems can also accompany or lead to tension headaches.
Tension Headache Treatment
Over the counter and prescription medication may be recommended for tension headaches, but a good portion of the treatment involves lifestyle changes. Relaxation techniques, dietary changes, and exercise are all common treatments for tension headaches. Patients may be advised to stop smoking, limit alcohol consumption, or avoid certain foods.
Many patients find that keeping a headache journal is very useful in pinpointing triggers. There are several headache tracking apps that you can install on your smartphone and use them to get a better handle on your headaches.
Chiropractic for Tension Headaches
Chiropractic is a very effective, natural treatment for tension headaches. In addition to recommended lifestyle changes, the chiropractor may also make adjustments to realign the vertebrae and spine. The chiropractor may also use massage and other treatments that encourage relaxation of the muscles and relieve stress. He or she will use spinal manipulation of the neck and upper back to bring the body back into alignment, relieving not only the pain but the tension as well.
Participating in regular physical activities and exercises is essential towards maintaining overall health and wellness, however, for approximately 400,000 people in the United States living with multiple sclerosis, exercise can have several benefits worth knowing about. Healthcare professionals used to recommend that patients with multiple sclerosis, or MS, should avoid engaging in physical activities and exercises to prevent aggravating their symptoms. However, research studies suggest that exercise can improve the quality of life of individuals with multiple sclerosis. The purpose of the article below is to demonstrate the effects of exercise in MS.
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Abstract
Multiple sclerosis (MS) is the most common chronic inflammatory disorder of the central nervous system (CNS) in young adults. The disease causes a wide range of symptoms depending on the localization and characteristics of the CNS pathology. In addition to drug-based immunomodulatory treatment, both drug-based and non-drug approaches are established as complementary strategies to alleviate existing symptoms and to prevent secondary diseases. In particular, physical therapy like exercise and physiotherapy can be customized to the individual patient’s needs and has the potential to improve the individual outcome. However, high-quality systematic data on physical therapy in MS are rare. This article summarizes the current knowledge on the influence of physical activity and exercise on disease-related symptoms and physical restrictions in MS patients. Other treatment strategies such as drug treatments or cognitive training were deliberately excluded for the purposes of this article.
Keywords:Multiple sclerosis, Physical therapy, Exercise, Prevention of sequelae, Personalized treatment
Background of MS
MS is a chronic inflammatory disease of the CNS, which causes multifocal demyelination along with astrocytic gliosis and variable axon loss in the brain and spine. MS is one of the most common causes of non-traumatic disability in young adults and approximately 1-2.5 million people around the world are estimated to be affected, depending on the publication [1,2]. Women are more likely to develop the disease than men (female:male ratio approximately 2-3:1). MS usually manifests between the age of 20 to 40 years, rarely much earlier during childhood, or in old age. The disease course is usually relapsing-remitting with progression into a secondary progressive form after a varying period of time or primary progressive right from the start. The precise etiology of MS still remains unclear. A combination of environmental and genetic factors which lead to autoimmune reactions against CNS-structures which in turn result in CNS tissue damage and neurological impairment is assumed to be the most likely pathomechanism [2,3].
Depending on the localization and characteristics of the morphological changes in both white and gray brain matter, different symptoms and signs may occur, such as visual impairment, dysarthria and dysphagia, spasticity, paresis, coordination and balance impairment, ataxia, pain, sensory impairment, bladder, bowel and sexual dysfunction [3-7]. Fatigue, emotional and cognitive changes are also frequently present in MS [8-13]. These symptoms, often in combination with a lack of confidence in one’s own capabilities and abilities to manage the symptoms, lead to impaired functional capacity and subsequently reduced physical and sporting activity as well as reduced quality of life [14-18]. As in other conditions with reduced mobility, in MS the lack of physical activity can lead to secondary sequelae such as obesity, osteoporosis, and/or cardiovascular damage which in turn pose a serious threat to patients as they increase the risk of further complications like thrombosis, pulmonary embolisms, upper respiratory or urinary tract infections, or prominent decubital ulcers [15,16,19].
According to the autoimmune etiopathology, immunomodulatory drugs such as interferon-? or glatiramer acetate are the treatment of choice. If these drugs are not sufficiently effective, escalation therapy with immunosuppressive substances (mitoxantrone), monoclonal antibodies (natalizu-mab) or the recently approved sphingosinphosphat receptor modulator fingolimod may be required (Figure 1) [20-22].
Definitions
For the purpose of this article the terms movement, physical activity, exercise, physical function, physical therapy, physiotherapy and sport will be used according to the following definitions (Tables 1 and 2): In terms of the motor system, the term “movement” includes an actively or passively induced change in the position of the body. Regular exercise and physical activity are decisive factors in a person’s quality of life by sustainably improving health and wellbeing and preventing diseases at all stages of life. As opposed to sport, in which the focus is on physical achievement, competition and fun, physical activity encompasses any type of physical movements, which consume energy, regardless of the underlying motivation. The term “health-enhancing physical activity” includes both leisure-time activities (e.g. sport) and everyday activities (e.g. climbing stairs). The intensity of the activity is categorized according to the metabolic equivalent (MET; 1 MET corresponds to the oxygen uptake of an adult whilst sitting = 3.5 ml (men) and 3.2 ml (women) O2/kg/min) into light (<3 MET), moderate (3-6 MET) and vigorous (>6 MET). In contrast to general physical activity, exercise encompasses the planned performance of systematically repeated movements to accomplish skills, maintain and strengthen physical condition, and improve performance. Athletics, more specifically, aims to improve general flexibility and includes endurance training to maintain performance over longer periods of time at a high level and strength training to increase muscle strength. The terms endurance and aerobic training, as well as resistance and strength training, are often used synonymously. Physical function encompasses “a series of increasingly integrated steps, with the highest level consisting of the most advanced activities of daily life (ADL), the fulfillment of societal roles and the pursuit of recreational activities” [16]. The term “physiotherapy” includes manual skills, that are appropriately supplemented by remedies like water, heat, light, or electricity and aims to restore functionality and conscious perception of the human body. Active and/or passive training programs are part of physiotherapeutic methods. On the contrary “physical therapy” is rather used as an umbrella-term, comprising different kinds of physical activity like exercise, (functional) training, physiotherapy, and rehabilitation.
Symptomatic Treatment of MS: Aiming at a Personalized Modification of Symptoms and Outcome
Drug-based and non-drug-based symptomatic treatment approaches for MS complement each other. Drug-based approaches which are referred to in comprehensive reviews [21,22] are beyond the scope of this article. Apart from counseling and nursing care, non-drug strategies encompass physical therapy like physiotherapy, logopedics, occupational therapy including living and mobility aids, sociotherapy and psychotherapy (Figure 1). These measures can be applied multimodally, meaning that several approaches are combined in a patient’s treatment strategy and should generally complement drug therapy [4,23,24]. Physical therapies are developed depending on the individual symptoms and positively affect several factors at the same time. Importantly, apart from reducing symptoms, enhancing mobility, improving quality of life and conferring as much independence as possible, for example by functional training of ADLs, such as washing, eating, drinking, dressing, and performing household chores, symptomatic therapies may prevent potentially life-threatening secondary diseases [15,25]. Physical therapies can be applied in almost every stage of disease — from the first onset of symptoms to highly impaired patients and palliative conditions. In contrast to physiotherapy, exercise is not part of commonly used therapies offered to MS patients; however, it might be a promising and cost-effective tool to improve various functions in patients with MS.
Exercise in MS Patients: Effects on Clinical Parameters (Table 3)
Impairment of MS patients like spasticity or paresis is primarily a consequence of disease progress (morphological changes), but it can be aggravated by reduced physical activity [14,26]. Exercise has been shown to improve various aspects of the physiological profile of MS patients; in particular, inactivity-related impairment can be alleviated by exercise [26]. However, recommendations on exercise for patients with MS have to face a number of limitations: Although there is a large number of studies on which recommendations have been based, many of these studies have limitations, including small sample sizes, lack of an appropriate control group, unblinded design, and failure to distinguish between different courses and stages of the disease. In fact, only occasionally a randomized controlled and blinded study design is applied. Training regimes are often not standardized, and the interventions are hardly sufficiently described. The comparability of studies is furthermore limited by variable treatment duration extending over a short period of weeks up to few months, different treatment frequency and different treatment intensity. Long-term effects of the respective interventions are rarely reported [14,27-31]. Furthermore, the effects of exercise have been studied almost exclusively in MS patients with slight or moderate impairment (score on the expanded disability status scale (EDSS) less than 7) [14]. To our knowledge,only one recently published study examined highly impaired MS patients with an EDSS of 5-8 [32].
In summary, despite the often insufficient methodological quality of the studies and the insufficiently described training regimes [14,29,33] most of these studies including exercise programs of resistance (e.g. progressive resistance exercise, walking mechanics), endurance (e.g. bicycle ergometry, arm or arm-leg ergometry, aquatic exercise, treadmill walking) as well as combined training provided evidence for a benefit of exercise in MS patients [14,15,28,29]. These training programs are referred to in more detail below. All training programs have been well tolerated by the patients. Nearly 100% of inpatient participants and 59-96% participants of home-based trials completed without occurrence of adverse events [34-38].
Endurance Training
Moderate endurance training resulted in improved muscle strength of both lower and upper extremities and some functional measures like walking speed, fatigue, and quality of life [14,15,17,28,29,31,34]. Some authors reported beneficial effects in chair transfer [14,39], gait, stair climbing, and timed up and go test (standing up from a chair, walking 3 m, turning around and seat again) [14,35,40]. But, as described above, varying and contradictory results were found. For example, some authors reported marked improvements in aerobic capacity, measured by maximal oxygen uptake (VO2-max), [14,41,42], whereas others did not observe significant improvements [14,43,44].
The same applies to fatigue as there is some evidence for an improvement of fatigue by endurance training [30,35,45], whereas other studies missed the level of statistical significance [14,28,35] or did not reveal any differences at all [27,46,47].
Contradictory data have been reported on various items of health related quality of life like vitality [14,48], social functioning [14,44,48], mood [14,42,44], energy [14,42], anger [14,41], sexual function [14], bladder and bowel function [41], and depression [14,41].
One group analyzed the effect of a 6 months outpatient aerobic training program in MS patients with mild to moderate disability (EDSS 1-6) and observed a trend for larger benefits in more severely disabled than in less affected patients, but the study is limited by the small sample size of 19 patients of which only 11 patients completed the study [42]. Therefore, these results have to be handled with care and further studies are required.
Resistance Training
Resistance training is known to enhance muscle strength in healthy people. In MS patients there is also evidence for improving muscle strength [35,40]. Furthermore, beneficial effects on walking speed, stepping endurance, stair climbing, timed up and go test, self-reported disability, and self-reported fatigue have been described in MS patients as well as significant improvements in gait disturbances, measured by Dynamic Gait Index [35,49].
There are different forms of resistance training. One form, for example, constitutes progressive resistance exercise (PRE), which according to Taylor et al. comprises the following three principles: “1. perform a small number of repetitions with relatively high loads until muscle fatigue is reached, 2. allow sufficient rest between exercise for recovery, and 3. increase the load as the ability to generate muscle force development” [40].
Cakit et al. examined the effect of PRE by means of cycling progressive resistance training and lower-limb strengthening, both combined with balance exercise in a prospective randomized controlled trial of 45 MS patients [35]. After 8 weeks, patients in the two training groups performed better with respect to 10 m walking test, duration of exercise, and timed up and go test than patients in the control group who received no intervention. Moreover, the training groups showed evidence for superior effects on balance, fatigue, depression, and fear of falling.
Taylor et al. investigated the effect of a 10 week PRE program on maximal muscle force, muscle endurance, functional activity, and overall psychological function in MS patients [40]. The authors reported significant improvements of arm strength, leg endurance, and fast walking speed, and a trend towards improvement in the 2-min walk-test and day-to-day life function.
Besides PRE, other training forms like strategies to promote proper gait mechanics, focusing on weight bearing, weight shifting, and body positioning, or weightlifting are used [49]. For example, Pilutti et al. examined the effect of resistance exercise in six severely disabled patients (EDSS 5-8) with progressive MS (five patients with primary progressive, one patient with secondary progressive disease course) by means of a 12 week course of body-weight supported treadmill training performed three times weekly for 30 min [32]. The patients improved in terms of training intensity treadmill walking speed and required body weight support as well as in physical and mental subscales of a quality of life questionnaire. Fatigue was not reduced.
Combined Endurance and Resistance Training
Only a few authors examined the effect of combined resistance and endurance training in MS. Small improvements both in muscle strength and gait velocity have been described [14,34,50]. Interestingly, in a comparatively large study on 95 MS patients, Surakka et al. observed significant training effects after six months of combined resistance and endurance training only in women, but not in men, which might be explained by a 25% higher exercise activity in women [50]. Furthermore, Romberg et al. reported significant improvements in walking speed and upper extremity endurance following six months combined exercise training, whereas lower extremity strength, VO2-max, static balance, and manual dexterity did not improve [34].
In 2005, the Cochrane Collaboration published a first systematical review on the effects of exercise on ADL and health-related quality of life (HRQoL) and the effects of physical therapy on various symptoms in MS patients [33]. Only controlled, randomized clinical studies on adult MS patients not experiencing an exacerbation at the time were included. Six studies, of which four have so far only been published as an abstract, analyzed the effects of physical therapy (rehabilitation, physiotherapy, exercise, functional training, independent home-based training, aquatic exercise) on several disease-related variables compared to a control group that had not received any physical therapy [36,39,41,51-53]. Three other studies compared the results of two different physical therapy programs. In summary, muscle strength, movement (changing and maintaining posture, walking, moving around, timed transfer, walking cadence), and exercise tolerance tests (modified graded exercise test, VO2-max, and physiological cost index) all showed substantial improvement. Mood parameters (fear, depression) showed only moderate improvement and EDSS, fatigue, cognitive parameters and ADL remained unchanged [18,37,48].
Asano et al. assessed the methodological quality of selected randomized controlled trials (RCT) of exercise interventions in MS carried out from 1950 to 2007 [29]. They found evidence for positive effects of exercise on physical and psychosocial functioning and quality of life, but highlighted a great need for high quality RCTs in this field.
Exercise in MS Patients: the Impact of Body Temperature on Disability
In 1890 the German ophthalmologist Wilhelm Uhthoff (1853-1927) first described visual impairment and paresis occurring after physical activity. Because the patients’ body temperature was not recorded, Uhthoff assumed that the described symptoms were caused by the physical activity itself and not by the resulting increased body temperature. Consequently, MS patients were advised not to engage in exercise [14-16,19,46,54,55]. In fact, 60-80% of MS patients experience a reversible (re)occurrence or aggravation of neurological symptoms in situations with increased body temperature, for example during vigorous physical activity, fever, or a hot bath [14-16,46,54,55]. As a reference to the first description, the eponym “Uhthoff’s phenomenon” has been coined. The underlying cause is thought to be a temperature dysregulation due to dysautonomia with subsequent temperature-dependent impairment of the conduction velocity of partially demyelinated axons [15,16,54,56]. Not until about 1937, numerous systematic investigations revealed the correlation between increased body temperature and aggravation of disability.
Another argument for MS patients to avoid exercise was the assumption that a “waste” of energy might aggravate fatigue and reduce ADLs [14] which however has never been confirmed. Furthermore, a detrimental effect of physical activity itself on CNS structures or an activity-mediated increase of the relapse rate has never been demonstrated [15,57].
Exercise in MS Patients: Effects on the Immune System
It is well known that exercise may influence susceptibility to common infectious diseases like upper respiratory tract infections in different directions [58]. Whereas vigorous physical activity such as competitive sport can lead to an increased susceptibility to infections, moderate exercise may contribute to their prevention [15,19,57-59].
On the immune cell level, physical strain in healthy subjects has been demonstrated to initially increase the peripheral lymphocyte count which subsequently falls to below the initial level after cessation of the physical activity [19,60,61]. The resulting lymphocyte reduction was short-lasting with a maximum duration of 3-24 h [19,58,60] and was shown to be more prominent in Th1 cells than in Th2 cells [61-63]. As Th1 cells primarily secrete pro-inflammatory cytokines like IFN-?, IL-2, and TNF-? whereas Th2 rather secrete anti-inflammatory cytokines such as IL-4, IL-5 and IL-10, exercise can promote a shift from a Th1-mediated pro-inflammatory to a rather anti-inflammatory Th2-mediated cytokine milieu [58,60] which is of particular interest because an imbalance of Th1- and Th2-cells is considered relevant in MS pathogenesis [62].
Since established immunomodulatory drugs such as IFN-? or glatiramer acetate exert similar effects on the immune system, drug treatment and physical activity may complement each other in terms of modulating the immune system. The only short lasting effects of exercise on the immune cell level argue for regular and frequent training intervals.
The effect of exercise on cytokine production and response is less clear and often contradictory [44,60,62,64], which can in part be explained by different populations studied, different training protocols and/or different readout parameters and paradigms. For example, Heesen et al. found similar resting serum concentrations of IFN- ?, TNF- ? and IL-10 in trained and untrained MS patients [62], whereas White et al. reported reduced resting plasma concentrations of IL-4, IL-10, C-reactive protein (CRP) and IFN- ? and a tendency for decreased TNF- ? in MS patients upon eight weeks of PRE. Muscle contractions are thought to stimulate secretion of IL-6 [44,65]. Likewise, contradictory data have been published on the effect of exercise on immunoregulatory IL-6 in MS patients [44,64].
Given the neurodegenerative component of MS, the effect of physical activity, particularly of exercise on nerve growth factors is of particular importance. In rodents, exercise has been shown to stimulate the release of brain-derived neurotrophic factor (BDNF) [66], insulin-like growth factor 1 (IGF-1) [67-69] and vascular endothelial growth factor (VEGF) [70], all of which support cell proliferation, synaptic plasticity, neuroprotection, and neurogenesis in both physiological and neuroinflammatory conditions [67,71-74]. Also in humans exercise seems to modify the secretion of neuroactive proteins [14,67]. In both healthy participants and MS patients 30 min of moderate ergometry-based exercise increased the concentrations of BDNF and nerve growth factor (NGF) [59,75]. Increased hippocampal BDNF concentrations have been measured upon moderate exercise [67]. Since the hippocampus is crucially involved in learning and memory tasks and modulation of mood, these findings might connect exercise with slowing of cognitive impairment and stabilization of affect in MS patients [67]. An increased secretion of IGF-1 has so far been demonstrated in healthy people after exercise [76-78]. IGF-1 as an important factor in development supports cell survival, brain growth and CNS myelination. During later phases of life IGF-1 might play a role in neuroprotection and synaptic and cognitive plasticity [67]. Furthermore, exercise increased the activity of antioxidant enzymes, which might support the role of exercise in neuroprotection [67].
Exercise in MS Patients: Effects on Morphology and Imaging Findings
Repetitive activation of the motor programs strengthens the cortical engrams and causes neuroplastic and adaptive processes like improved motor unit activation and synchronization of firing rates. In contrast periods of inactivity are associated with opposite effects [35,49,79].
Although data on the effect of physical activity on brain structural parameters are sparse, some evidence indicates that physiotherapy and regular fitness training counteract the structural degeneration of brain tissue in patients with relapsing-remitting MS and possibly have a neuroprotective impact. Both grey and white matter atrophy occurs already in early stages of relapsing-remitting MS [80]. However, patients with a higher level of aerobic fitness were shown to have a comparatively larger local volume of grey matter in the right post-central gyrus and midline cortical structures including the frontal medial and the anterior cinguli gyrus and the precuneus somatosensory cortex than unfit patients. Furthermore higher fitness levels were associated with greater recruitment of cortical regions whereas lower fitness levels were associated with enhanced anterior cingulated cortex activity [81]. These data should however be treated with caution as they based on a small sample of 24 female MS patients with a wide range in disability (EDSS 0-6) and disease duration (1-18 years).
MS patients have been shown to have more brain areas, often bilaterally, activated when performing motor and cognitive tasks compared to healthy controls, possibly as an expression of neuroplasticity [82-92]. The degree of ipsilateral activation appears to correlate with the disease course and severity [85,88,93] and is considered to reflect cortical adaptive reorganization processes [82,85,86]. For example, in MS patients with primary progressive disease course movement-associated cortical activation involved “nonmotor” areas like the insula and several multimodal cortical regions in the temporal, parietal, and occipital lobes in addition to the “classic” areas of motor planning and execution regions (including the supplementary motor area and the cingulate motor area) [93]. Morgen et al. reported that thumb movements of untrained MS patients elicited a more prominent activation of the contralateral dorsal premotor cortex in fMRI than in healthy controls [85] which in contrast to healthy controls was not attenuated upon repetitive thumb movements.
In MS patients the corpus callosum is typically affected. Besides callosal lesions detected by standard MRI sequences, diffusion tensor imaging sequences show ultrastructural damage, reflected by a reduced fractional anisotropy and increased mean diffusivity [79,94-98]. Interestingly, in a small study comprising 11 MS patients and healthy controls, Ibrahim et al. described a significant increase of fractional anisotropy and mean diffusivity in the corpus callosum after a two months physiotherapy program of 2 h per week, suggesting that physiotherapy may influence the brain microstructure in MS [79]. In summary, some data suggest, that effects of exercise in MS patients may be reflected by morphological changes in the CNS which may be detectable by advanced imaging techniques. However, existing data are not yet sufficient to unequivocally prove an impact of exercise on brain structure in MS.
Personalized Exercise in MS Patients: General and Specific Recommendations
At the start of the 1990’s the German Federal Health Monitoring System’s general recommendation of performing a specific health-related training program at least three times a week was replaced by a more global perspective, namely the integration of everyday physical activities. In the situation of MS patients with an often reduced everyday activity, regular exercise is particularly important. Apart from improving muscle strength, exercise is intended to improve endurance, muscle tone and posture stability, the degree of flexibility, and endurance should involve both the agonists and antagonists [15,35]. A physical training program needs to be tailored to the individual needs and symptoms of a patient. Factors to be considered include the course and stage of disease, the degree of disability, age, concomitant diseases and sequelae. Importantly, it has to be ensured that the patient is not overstrained [14-16].
Compared to healthy people MS patients have a reduced aerobic capacity [14,26,38], decreased muscle strength, retarded rate of muscle tension development, reduced muscle endurance and impaired balance [14,15,36,99-101]. A relationship between gait speed and strength parameters has been postulated [102]. Petajan and White illustrated the level of muscular fitness and physical activity of MS patients in two “pyramids”: passive range of motion (ROM) forms the basis of the muscular fitness pyramid and can minimize the risk of contractures when practiced regularly [16]. The next step in the pyramid comprises active flexibility and resistance exercise against or without gravity to maintain muscle integrity, for example to enable the patient carrying out essential daily functions. A well-rounded program of muscle strengthening exercise represents the top of the muscular fitness pyramid [16]. ADLs form the basis of the physical activity pyramid, followed by built-in inefficiencies, active recreation, and structured aerobic training programs. Again, design, frequency, and intensity of training programs have to be tailored to the individual patient. Weight-supported exercises like ergometry and water exercise are particularly recommended for patients with motor deficit or balance disturbances [16].
No specific recommendations for exercise treatment exist that are universally valid. However, general therapeutic recommendations can be defined. Since exercise programs have not sufficiently been investigated in more severely disabled patients, these recommendations are restricted to MS patients with a maximum EDSS score of 7 [14,15,34,38]. Any new exercise program should be initialized by a physiotherapist or exercise physiologist familiar with the disease [14]. A brief history including impairments in particular within daily activities should be elicited [16]. Regardless of the type of exercise, training programs should be uncomplicated and comprehensible to the patients. If necessary, it might be advisable to explain training programs in an illustrated or written form [15]. Patients should be supervised until they can perform the program adequately and independently [14-16,26]. Exercise programs should specifically target weaker muscles, and should preferably encompass multisegmental complex movements [15,35]. The intensity should be increased only slowly, and not to the point of pain [15]. Special care should be paid to peripheral nerves; particularly overstretching should be avoided [15]. Training sessions are recommended to start at a low level, include a light warm-up, progress according to the patients’ clinical state and specific problems, and finally reach light to moderate intensity [14-16,26]. 10-15 min of daily stretching to maintain and improve flexibility of muscles and tendons [15] and recovery time between training sessions of 24-48 h are recommended [15]. Immobilized patients or those with severe clinical symptoms should be individually assisted. Some authors advise that cardiopulmonary function and VO2-max should be assessed prior to treatment start since MS patients may have reduced heart rate responses in graded exercise testing, possibly as an expression of cardiovascular dysautonomia [15,16], although this probably can hardly be implemented in the daily routine. Regarding endurance training and according to the American College of Sports Medicine, White and Dressendorfer recommend using the actual heart rate response to graded exercise testing for finding the ideal target heart range for training [15]. No symptoms should appear and “moderate intensities” ought to be strived, for example by means of the Borg scale of perceived exertion, which ranges from 6 to 20 (6 means “no exertion at all”, 20 means “maximal exertion”). For moderate intensities ranges from 11 to 14 are aspired [15,103]. Depending on the symptoms and the training program, exercises should be performed at home, individually, with a training partner, or with a training group, and may include training equipment such as elastic bands, additional weights and pulley systems. Due to its social support a training group seems to be favorable in terms compliance and motivation [16,28]. To achieve similar effects in home-based training programs, patients should be closely supervised, for example by visits or telephone calls [16,28]. Most importantly, the training sessions have to be performed regularly [14-16,26].
Some special recommendations regarding exercise training for MS patients have been published. However, it has to be emphasized that these recommendations mostly represent personal experiences made by the authors and are not always supported by high standard clinical trials. Dalgas et al., for example, recommended endurance training of approximately 10-40 min duration, with an initial training intensity of 50-70% of VO2-max corresponding to 60-80% of maximum heart rate [14]. According to Dalgas et al., resistance training is recommended to initially comprise 8-15 repetitions which can then be increased over several months. The training should start with 1-3 sets, later 3-4 sets with a 2-4 min break between sets and should be performed two or three times per week. For heat-sensitive patients and those who regularly develop Uhthoff’s phenomenon exercise training in the morning or in water at temperatures of 27-28�C could be preferable since body temperature is physiologically lower early in the day and heat generated by physical activity is quickly dissipated in water [15,16]. Alternatively, cooling before exercise and/or during physical activity for example by cold packs may help to prevent Uhthoff’s phenomenon [15,16,55]. Also, resistance instead of endurance training could be preferable for heat-sensitive patients [14].
Multiple sclerosis, or MS, is a chronic, generally progressive disease caused when the immune system damages the sheaths of nerve cells in the brain and spinal cord. For many years, doctors recommended patients with MS to avoid engaging in any form of physical activity or exercise, however, recent research studies have found that staying active can be beneficial for MS symptoms. Common symptoms associated with multiple sclerosis include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Physical Therapy Approaches to Prevent or Alleviate Individual Target Symptoms and Signs in MS
Fatigue
Fatigue, defined as an extreme physical and mental tiredness inadequate to the preceding demand, is a frequent, often very debilitating symptom in MS, which is generally difficult to treat [8-10,15,35,104-106]. Approximately 75-90% of all MS patients experience fatigue during disease progression [8,10,16] and some MS patients end up in a vicious circle: out of a wish to reduce fatigue they decrease physical activity which over time reduces endurance, muscle strength, and quality of life and may enhance fatigue, which then thus in turn further limits physical activity and social life [9,42,49]. Apart from cooling, moderate exercise, particularly aerobic training, seems to have a positive effect on fatigue [30,35,45]. Because fatigue often increases over the day, training sessions should be performed in the morning and must not overexert the patient [104]. Special supports like participation in a training group or attending psychological support to increase motivation for continuation of training over time could be advantageous in patients suffering from fatigue [16]. Energy saving strategies are also applied, in which the patient learns to prioritize and to perform everyday tasks with a minimum of exertion [4,16,27]. Although a beneficial effect of moderate exercise on fatigue has been described by some authors [14,28,35,41], effects are usually insufficient to achieve significant improvements in current fatigue scales [17,35,45,47,50]. Other studies completely failed to detect any improvements [33]. One explanation for contradicting results can be found in the use of different fatigue scales, which focus on physical symptoms, or in attendant sleep disturbances such as insomnia, sleep-related breathing disorders, restless legs syndrome, periodic limb movement disorder [104-106]. In conclusion, there is some however not unequivocal evidence for low to moderate beneficial effects of moderate exercise on fatigue.
Spasticity
With a lifetime prevalence of about 90% spasticity is frequent in MS and has a potential to significantly reduced quality of life [104]. It leads to limitations in the range and normal pursuit of movements, results in malpositioning of the joints, and is often accompanied by pain [24]. Controlled studies on exercise and physiotherapy for MS-related spasticity are rare; however some evidence for improvements has been reported [104].
Physical therapy measures include active and passive exercise (e.g. targeted positioning of the patient, passive exercise using motorized cycles, active treadmill exercise) which can be assisted by a training partner or training equipment such as elastic bands. Physiotherapeutic techniques according to Bobath or Vojta and proprioceptive neuromuscular facilitation (PNF) are among the treatments applied. None of these measures has been proven to be superior [104,107]. It is most important to carry them out regularly and with a sufficient intensity [4,104]. Light stretching of the affected muscle groups with duration of approximately 20-60 s should be performed prior to and after exercise [15].
Pareses
Pareses lead to various physical disabilities, such as difficulty in walking and fine-motor dysfunction. A relationship between gait speed and muscle strength in MS patients has been shown [14]. As no drug treatment for pareses exists and antispastic drugs such as baclofen may also lead to a worsening of existing pareses, physical and occupational therapy techniques are the sole treatment option. Because of reduced impact of gravity aquatic training allows patients with even severe pareses of the lower extremities to perform standing and moving exercises [15,16]. A standing frame can help patients who are unable to stand, to train torso, limb, and respiratory muscles and protects against cardiovascular dysregulation. For immobilized patients, passive range of motion exercises proximal to the paralyzed region is recommended [15,16]. Various studies have shown a significant improvement of muscle strength due to exercise [33,35,40,101]. Furthermore, some authors reported beneficial effects in walking speed, stepping endurance, stair climbing, and timed up and go test [35,40,49]. In summary, evidence suggests that exercise is beneficial in the treatment of MS-related pareses, however again, only few, partially inconsistent data are available. Moreover, the effects of exercise have been studied almost exclusively in MS patients with mild or moderate impairment.
Coordination and Balance Dysfunction
Abnormalities in balance control are frequent symptoms in MS patients, which restrict patients in their daily living activities and increased risk of falls [5]. Balance skills like standing and walking, as well as the patients’ perception of their own balance are important to assess [5]. The sitting position of cycling training is advantageous for unsteady patients [15,16]. Only a few studies investigated the influence of exercise programs on balance and coordination in MS and very few have chosen these variables as the primary outcome parameter. Catteneo et al., for example, investigated the effect of balance training in 44 MS patients in a randomized controlled trial [5]. Two treatment groups received particular balance rehabilitation for three weeks, a third (control) group participated an unspecific training program. In both treatment groups, a reduction of the number of falls and an improvement in clinical tests of static balance (Berg Balance Scale) and dynamic balance (Dynamic Gait Index) could be detected. However, in self-assessment scales patients did not report significant improvements [5]. Another controlled study did not support a beneficial effect of exercise training on static balance [34].
Cognitive and Mood Disturbances
Depending on the disease course and stage 45-70% of MS patients are affected by cognitive impairments like reduced information processing speed, attentional deficits, and episodic memory deficits [12,13,24,104,108] and 60-70% experience mood disturbances [13,109,110]. Some evidence for a positive correlation between aerobic exercise and cognition and brain function in healthy people has been described [81]. In MS patients, beneficial effects of regular physical activity and exercise on mood [18,32,35,48] and quality of life [14,15,28,34] have been repeatedly reported. Valid data on the effect on cognitive function are hardly available.
Conclusion and Outlook
Several lines of evidence suggest that MS patients benefit from regular physical activity and exercise high-quality clinical, imaging and physiological parameters. However, the quality of so far realized clinical trials on exercise training in MS do not always satisfy the requirements of a high standard study. Moreover, because of different treatment paradigms and endpoints, data are often hardly comparable. Thus, many questions remain still unanswered. In consequence, there is a great need for standardized high quality and well described studies that address both short and long-term effects of exercise on clinical and paraclinical parameters in MS patients with different disease courses and different grades of disability.
Conflicts of Interests
The authors declare that they have no competing interests.
Acknowledgements
This work was supported by the DFG (Exc 257).
For the estimated 400,000 people in the United States living with multiple sclerosis, participating in physical activities and exercises can have tremendous health benefits. Although healthcare professionals advocated the limitation of exercise for patients with MS, many research studies like the one above have demonstrated that exercise can help improve multiple sclerosis symptoms, enhancing a patient’s quality of life. For people with MS, their life doesn’t have to come to a standstill. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. �
If you are currently thinking about the ketogenic diet, then you might be asking yourself, is the keto diet right for you? While you may have already heard about the benefits of the ketogenic diet, you might still be wondering about whether if it is worth it to completely change your diet to take advantage of these benefits.
The keto diet has many benefits, from weight loss and improved physical health to mental clarity and enhanced physical performance. In the following article, we will dive into the details of some of the ketogenic diet health benefits. These benefits can help with the particular health goal you may be attempting to attain.
Contents
Ketogenic Diet and Weight Loss
In comparison to low-fat dieting, a low-carb diet can deliver superior results within a shorter time period in terms of weight loss, and the management of cholesterol, and blood pressure. If you want to shed weight, the ketogenic diet plan provides the following benefits and will get you closer to attaining your objective. There can be many reasons for this, including:
Low-carb and ketogenic diets are more satisfying with their low carb content and higher quantities of fats and protein.
Going onto a low-carb diet usually makes you lose extra water weight.
Most individuals can undergo weight loss fairly quickly, especially within the first week�of beginning a ketogenic diet.
Increased HDL Cholesterol
Together with the high consumption of saturated fats and other healthy fats, the ketogenic diet may help raise HDL cholesterol and enhance triglycerides levels. Both of these are�considerably significant towards promoting heart health.
Ketogenic Diet and Physical Health
Acne
Following the ketogenic diet has been demonstrated to also be able to help reduce inflammation and lesions of the skin like those found in acne. This is believed to occur due to the effects of ketosis, or the state in which the cells use ketones instead of glucose for energy.
IBS Support
Moreover, several research studies have also associated a link between the reduced consumption of glucose, or sugar, and an improvement in symptoms of irritable bowel syndrome, or IBS. As a matter of fact, one research study demonstrated that following a ketogenic diet may improve bowel movement habits and help reduce abdominal pain, improving quality of life in people with IBS.
Ketogenic Diet and Physical Performance
Balanced Energy Levels
Do not be surprised if you’re ready to stop drinking coffee every day after adapting to the keto diet. Achieving and maintaining ketosis involves benefits like no day slumps, no mood swings, and reducing changes in energy levels that you might experience otherwise.
In addition, you’ll likely find it much easier to remain longer periods of time without feeling hungry. This is what ultimately helps with weight loss, steady blood sugar levels, and extended periods of fasting, which is one of the best ways to get into ketosis.
Enhanced Workouts
Adjusting to the ketogenic diet may take time, however, once your body gets used to burning fat for fuel rather than sugar, or glucose, from carbohydrates, you will likely notice a difference in your physical performance and endurance, such as more energy and focus for workouts. This makes sense because being in ketosis “instructs” the entire human body to burn fat for fuel more efficiently.
The most important first step in case you start the ketogenic diet and notice limitations in your physical performance is to give your body some time to adapt from utilizing carbohydrates as its primary fuel to utilizing ketones as a source of energy. For individuals who participate in a lot of physical activities and exercise as well as athletes may benefit from a cyclical or targeted ketogenic diet.
Fat Loss / Muscle Gain
The amount of protein intake on a ketogenic diet makes it excellent for building muscle mass. Results might seem to come more gradually than for someone fueling their workouts but that is usually because you’re building lean mass together with fat reduction. By way of instance, when documenting a keto fast for four days, the individual gained 2.4 lbs of muscle with 1.1 lbs of fat reduction.
Ketogenic Diet and Mental Clarity
Several research�studies have demonstrated that a ketogenic diet may have the ability to support mental clariy as well as help boost productivity, support better memory, and also, have positive effects in regard to moderate cognitive impairment.
Neurological Support
Early usage of the ketogenic diet has been used as a treatment for reducing seizures in people with epilepsy, especially children. Additionally, it has been shown to benefit people with Parkinson’s disease, Alzheimer’s disease, and other neurodegenerative disorders. This is likely because ketone bodies created through the keto diet can have neuroprotective effects.
Weight loss is one of the most well-known advantages of the ketogenic diet, however, this nutritional plan can have many other health benefits. By reducing the consumption of carbohydrates, the cells will go into a state of ketosis and instead utilize ketones created from fats, providing a steadier supply of energy than that of glucose, or sugar. Furthermore, research studies have also demonstrated the ketogenic diet’s possible role in disease prevention, such as for people with epilepsy. Dr. Alex Jimenez D.C., C.C.S.T. Insight
The benefits of the ketogenic diet are essential, not just for weight loss, but for overall health and wellness. When you are eating more fats and proteins with fewer carbohydrates, you are more likely to end up eating fewer calories. With this, you also don’t experience a change of energy levels but instead maintain a level of energy that lets you remain focused on your everyday tasks.
Regardless of the health goal you have in mind, the ketogenic, or keto, offers many benefits to improve your quality of life. Being aware of the proper foods you should eat on the keto diet is also important. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion:�Acute Back Pain
Back pain�is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Injuries and/or aggravated conditions, such as�herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief. �
Exercise is an essential part of good health. It can help with weight loss and plays a crucial role in preventing many chronic health conditions like hypertension, diabetes, and heart disease. Regular exercise has also been shown to help with depression and anxiety. There is just something about getting your body moving and your blood pumping. It is what nature intended; as humans, we are supposed to be active. The more active you are, the better you will look and feel � and the healthier you will be.
There are many different types of exercise out there, though. It seems that everyone has �system� or some slick, branded fitness routine that is guaranteed to work. The thing is, the old-fashioned way is best. Cardio, the type of exercise that raises your heart rate and gets your blood pumping is categorized by aerobic and anaerobic. Understanding the similarities and differences will help you round out your workout for better results.
Contents
What is Aerobic Exercise?
Aerobic exercise involves low to high-intensity physical exercise. The movements are oxygen infused, relying on the oxygen to meet the demands of the activity. Typically, exercises that are light to moderate intensity fall under aerobic:
Walking
Cycling
Swimming
Rowing
Jogging
Running
These activities can be performed for longer. Many experts advise that an aerobic exercise workout is better when done for an extended period; at least 18 to 20 minutes. For instance, a person can walk on a treadmill for 20 to 30 minutes, then cycle for the same amount of time. This is sufficient for raising the heart rate and increasing metabolism.
Aerobic exercise was first introduced in the 1960s by doctor and Air Force Colonel, Kenneth Cooper. He created the Cooper Institute in 1970, which focused on preventive medicine, centered around education and research. The workout became very popular in the �70s and �80s as a class workout but over time has expanded to become a significant part of gym workouts all over the world.
What is Anaerobic Exercise?
Anaerobic exercise is high-intensity physical exercise. Where aerobic build endurance, anaerobic is more like a sprint, building power, speed, and strength. It increases muscle mass and improves performance. It lasts from several seconds to around 2 minutes. Engaging in physical activity for longer than 2 minutes becomes more aerobic. Types of anaerobic exercise include:
Jump rope
Cycling sprints
Running Sprints
Swimming sprints
Heavyweight training
Anaerobic activities are often interspersed with aerobic activities in interval training for maximum effect.
Levels of Intensity
Aerobic and anaerobic exercise can be combined to create a highly effective workout. It can involve increasing the intensity of an aerobic exercise, or it can mean changing from an aerobic activity to an anaerobic activity.
For instance, you may jog for five minutes, then sprint for two, and jog for five more minutes. Another option is to switch up the activities. Walk on a treadmill for seven minutes, do a cycle sprint for two minutes, row for seven minutes, and jump rope for two minutes. The combinations are endless, and you can customize it for your favorite exercises or accommodate physical limitations.
Health Benefits
Aerobic and anaerobic exercise has been shown to help prevent certain types of cancer, like breast cancer and colon cancer with just 30 to 60 minutes of moderate intensity exercise a day. Exercise has also been shown to prevent osteoporosis, diabetes, depression, cardiovascular disease, obesity, and it even improves cognitive function.
Find ways to incorporate some aerobic and anaerobic exercise into your fitness routine at least several times a week. It is how you get healthy, stay healthy, and feel better.
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