Wednesday, December 31, 2008

Obesity genetics

Happy New Year to all of you. May your mantra of this year be "fitness". About me; i have completed the book i was writing last year on obesity. Hence i find the right oppertunity to write the first blog to be on obesity this year. Here it is
This following topic reviews gene-behavior interactions i.e. gene-diet + gene-physical activity interactions
The genetics of human body fat content (obesity) are clearly complex. Genetic and physiological analysis of rodents have helped enormously in pointing to critical molecules and cells in central nervous system and "peripheral" pathways mediating the requisite fine control over the defense of body fat (3). A vast body of research exists to demonstrate that obesity is a complex disorder with a strong genetic basis and a multifactorial etiology. Yet despite the overwhelming evidence that genes play an important role in the development of obesity, many people argue that the increasing prevalence of obesity is simply due to an abundance of palatable food and a dearth of opportunities for physical exercise (1).
According to one recent reviewed the literature indicating that natural alleles influence a substantial percentage of responses to nutrition and exercise in both humans and animal models (2). While activity and eating behaviors contribute substantially to the development of obesity, considering these to be the only etiologic factors is directly contradictory to what is now known about how eating and energy balance are regulated (1).
Human and animal studies are consistent with inferences from evolutionary considerations that the strengths of defenses against fat loss are greater than those against gain. Many of the genes participating in these pathways have reciprocal effects on both energy intake and expenditure, though different genes may have primary roles in respective responses to weight gain or loss. Such distinctions have important consequences for both research and treatment strategies (3). There is also a substantial amount of evidence that treatment responses to exercise and diet strategies may also be regulated by genes. Understanding gene-response relationships is the key to developing more efficacious intervention and prevention programs for obesity (1).
Gene-nutrient and gene-physical activity summary-genetics viewpoint.
The advent of high-density genome-wide scans in large numbers of human subjects for association analysis will revolutionize the study of the genetics of complex traits such as obesity by generating substantial numbers of powerful linkage signals from smaller genetic intervals (3).
Human genetic studies provide evidence that body weight response to over- and underfeeding and to exercise is associated with specific genes. Studies in animal models, primarily rodents, prove the genetic control of responsiveness to diet and exercise and provide the tools to examine specific mechanisms (2). Many of the genes implicated will not have been previously related to energy homeostasis (e.g., recent experience with FTO/FTM as described below), and will have relatively small effects on the associated phenotype(s). The mouse will again prove useful in determining the relevant physiology of these new genes (3).
Phenotypes related to energy intake and expenditure-which clearly are the major determinants of net adipose tissue storage-are not salient when individuals are in energy balance (weight stable); measurements obtained during weight perturbation studies are likely to provide more revealing phenotypes for genetic analysis (3).
New analytic tools will have to be developed to permit the necessary analysis of the gene x gene interactions that must ultimately convey aggregate genetic effects on adiposity. The body mass index (BMI) is a useful gross indicator of adiposity, but more refined measurements of body composition and energy homeostasis will be required to understand the functional consequences of allelic variation in genes of interest (3).
Gene-physical activity interactions: overview of human studies.
Physical activity level is an important component of the total daily energy expenditure and as such contributes to body weight regulation. A body of data indicates that the level of physical activity plays a role in the risk of excessive weight gain, in weight loss programs, and particularly in the prevention of weight regain.
Our understanding of the molecular processes controlling eating behavior, in particular, has accelerated exponentially in the last 10 years, and this is one area in which obesity genetics has made great progress. Our challenge is to understand more fully how genetic variation may interact with behavioral factors to influence the regulation of body weight and adiposity. Although exercise and diet strategies are used routinely for obesity treatment, there is a huge variability in how individuals respond to these interventions (1). Most studies dealing with potential gene-physical activity interaction effects use an exercise and fitness or performance model as opposed to an obesity-driven model. From these studies, it is clear that there are considerable individual differences in the response to an exercise regimen and that there is a substantial familial aggregation component to the observed heterogeneity (4).
Few studies have focused on the role of specific genes in accounting for the highly prevalent gene-exercise interaction effects. Results for specific genes have been inconsistent with few exceptions. Progress is likely to come when studies will be designed to truly address gene-exercise or physical activity interaction issues and with sample sizes that will provide adequate statistical power (4). Genetics has a substantial impact on responses to both diet and exercise. However, current knowledge does not allow individual diet and exercise recommendations. New resources and technologies, including cost-effective phenotyping for humans and whole genome sequencing in both humans and rodents, are needed (2).

1. Bray MS; Obesity (2008) 16, S72-S78; doi:10.1038/oby.2008.522.
Warden CH, Fisler JS; Obesity (2008) 16, S55-S59; doi:10.1038/oby.2008.519.
Chung WK, Leibel RL;Obesity (2008) 16, S33-S39; doi:10.1038/oby.2008.514.
Rankinen T, Bouchard C;Obesity (2008) 16, S47-S50; doi:10.1038/oby.2008.516.

Sunday, December 28, 2008


How is psoriasis defined?
Psoriasis is a chronic inflammatory skin condition which affects approximately 1-3% of the worlds population (1). It appears as red plaques covered with silvery scale that flakes away from the skin. Psoriatic plaques are often found on the elbows, scalp and knees but can also affect other parts of the body such as the face, feet and mucous membranes. Psoriasis is not contagious, nor is it caused by an allergy. However, the tendency to develop the condition can be genetically transmitted.Psoriasis causes itching in 60% to 70% of cases (2).
What are the different types of psoriasis?
Psoriasis may appear at any age, but there are two peak onset periods; during childhood/early adulthood (early onset psoriasis) and after age 40 (late onset) (1). There is strong evidence for a genetic predisposition to psoriasis, in particular to childhood psoriasis. It is estimated that 71% of patients with childhood psoriasis have a positive family history (2). There are multiple forms of psoriasis and they are often distinguished based on the location and appearance of the lesions. The presence and distribution of psoriatic plaques is highly variable; some people suffer from a single plaque of psoriasis on a specific part of their body, whereas others suffer from psoriasis all over their bodies. Psoriasis is accompanied by itching in 60% to 70% of cases (3). There is to date no permanent cure for psoriasis and eruptions often recur. However, most treatments are related to significant improvements in quality of life.
(1) Schon, N Engl J Med, 2005; Greaves, N Engl J Med, 1995.
(2) Sampogna, Br J dermatol, 2004.

Classification of psoriasis according to type of lesion?

Some dermatologists believe that the term "psoriasis" in fact covers six or seven different conditions, which in the future may be distinguished from each other and treated separately. The effect of the drugs that are available today (e.g. local and systemic treatments) is to clear the psoriatic plaques and to prevent relapse.

Psoriasis is classified according to the type of lesion into the following subgroups
Plaque psoriasis (which is the same as psoriasis vulgaris)
Guttate psoriasis
Nummular psoriasis
Pustular psoriasis
Erythrodermic psoriasis
Psoriasis arthritis
Plaque psoriasis (psoriasis vulgaris)
Psoriasis vulgaris is the clinical term for plague psoriasis. Vulgaris means “common” and psoriasis vulgaris is the most prevalent form of psoriasis affecting 95% of people with psoriasis. Lesions are clearly demarcated and may be surrounded by a clear ring. The condition can appear on various parts of the body and lesions vary depending on the body part affected.

Plaques vary in size and number and they can be both thin and thick, Scratching results in the appearance of fine droplets of blood. The colour pf the plaques may vary in intensity, being redder towards the edge of a plaque than at the centre.

The plaques are often found symmetrically on the outer arms and legs, especially on both elbows and/or both knees, but any part of the body can be affected.

The plaques sometimes appear in certain shapes, and they are always clearly demarcated (it is easy to see where it starts and ends). It is sometime refered to as psoriasis circinata (from the Latin circum) where lesions are ring shaped.
Guttate psoriasis
Small, round, scattered lesions are typical of guttate psoriasis or psoriasis guttata. Instead of extensive, thick plaques, this type of psoriasis presents with small red scaly dots which look like drops of water sprinkled over the body. Guttate psoriasis is more prevalent in children and young adults than older adults and disease onset is strongly related to streptococcal throat infection (such as rhinopharyngitis, pharyngitis or tonsillitis) (4). This type of psoriasis tends to go into spontaneous remission after several weeks and can reappear either in the same form, or as classical plaque psoriasis.
Nummular psoriasis
Nummular psoriasis is characterised by rounded plaques which are several centimetres in diameter. Their shape and size are more or less the same as a coin.
Pustular psoriasisThis type of psoriasis affects less than 10% of patients. It can appear as a complication to plaque psoriasis, as a result of taking certain medicines, or of abruptly withdrawing from them. Lesions are characterized by pustules. The palms of the hands, soles of the feet, fingers and nails are most affected.
Erythrodermic psoriasis
Erythrodermic psoriasis can affect most of the body's surface, and skin becomes erythemato-squamous (covered by red, scaling patches). Limited patches of pustules may appear.
Psoriasis arthritis
Psoriatic arthritis is characterised by inflammation affecting joints and in some cases entheses (=the point at which a tendon inserts into the bone). It is estimated that approximately 1% of the world population is affected by psoriatic arthritis (5).
Most severe forms of psoriasis
Some forms of psoriasis are more severe and particularly resistant to treatment. These are pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis. These should receive very careful medical treatment, in collaboration with dermatologists.

We talk about psoriasis universalis when lesions are present over the entire skin. This form of psoriasis is quite rare.
(1) Youn et al., J Dermatol, 1999; Henseler et al., J Am Acad Dermatol, 1985.
(2) Morris et al., Pediatr Dermatol, 2001.
(3) Sampogna, Br J Dermatol, 2004,; Wolkenstein, JEADV, 2006.
(4) Mallbris et al., J Invest Dermatol, 2005.
(5) Gladman et al., Ann Rheum Dis, 2005.

Symtpoms of psoriasis-Mild, moderate or severe?

How can my psoriasis be assessed in terms of severity?
In order to objectively assess the severity of psoriasis, doctors primarily use morphological criteria such as the Psoriasis Area and Severity Index (PASI). This tool allows the extent of lesions to be assessed as well as the degree of erythema and scale. A high score corresponds to an assessment of “severe psoriasis”. "
This scoring system has the advantage of being reproducible, but it gives no indication of the objective or subjective severity of the condition," says Professor Grob.
Many specialists believe that numerous factors contribute to the severity of psoriasis, such as its impact on quality of life and resistance to treatment, and not just morphological criteria and the extent of lesions.
Essentially, the severity of psoriasis relates to how well a patient copes with the condition. The notion of perceived stress is key as psoriasis affects patients very differently. For example, two people who have similar lesions as regards extent and location may cope with their condition differently, with the first believing she has a "serious" skin condition, and the second considering his condition "mild".
Extensive psoriasis can sometimes have a lower impact on quality of life than very localised lesions. For example, lesions on the palms and soles of the feet can lead to significant functional handicap. Profound psychological stress can result from facial or genital involvement.
This does not mean that the extent of lesions does not have a psychological impact. Certain studies have found that patients experiencing lesions on more than 30% of the surface of their skin would be ready to sacrifice a quarter of their life expectancy to live without psoriasis.
It is therefore clear that the notion of severity cannot be reduced to a single dimension, and although the extent and topography of lesions are important, the crucial factor remains how patients deal with psoriasis within their own cultural and professional environment.
It is essential to assess the impact of psoriasis on quality of life as the risks and benefits of any medication must be weighed according to its impact on patient quality of life.
As with any condition that affects quality of life, psoriasis should be treated in a holistic manner, with the patient, not the condition, as the focus.

Itching in psoriasis

Key points
1. Itching (pruritus) is a disagreeable sensation that causes a more or less irrepressible urge to scratch.
2. Itching and pain do have some features in common. They are both unpleasant sensations.
3. Stress and depression can exacerbate itching.
4. Psoriatic lesions must be treated in order to treat itching.
5. It is important to avoid anything which could encourage itchiness, such as very hot baths and showers, clothing which causes friction and stimulants such as coffee.
What about itching?
The medical term for itching is “pruritus”. The sensation can be limited to one area of the skin or extend over the whole body. There are numerous causes for itching, such as inflammatory skin conditions or general illnesses. Psoriasis was long believed to be non-pruritic (non-itchy) and not all patients with psoriasis are suffering from itchyness. However, several studies have shown that 80% of patients with psoriasis do experience it. There are varying degrees of itchiness, measured using visual analogue scales.

Patients indicate the severity of their itching on a scale from one to 10 (from moderate pruritus to severe pruritus where patients scratch plaques until they bleed). Itching causes a vicious circle, as scratching leads to the hypertrophy (enlargement) of cutaneous nerve endings, which in turn become more sensitive.
In addition, excessive scratching leads to the brain reacting to any external stimulation by causing a sensation of itching. Scratching is a type of trauma, and psoriatic lesions frequently appear in traumatised areas, in a response known as the Koebner phenomenon.
Do itching and pain have anything in common?
Much less is known about the brain centres involved in itching than those involved in pain. Some researchers believe that neurotransmitters play an important role in itching. Itching and pain do have some features in common. They are both unpleasant sensations, and information is transmitted along the same neural pathways.
Information is transmitted by the first neuron to the spinal cord, then a second neuron transmits it to the thalamus (at the base of the brain) and a third relays it to the cortex (the conscious brain). The patient becomes conscious of pain and itching after a certain threshold level has been passed, which varies according to psychological factors, such as stress and depression. Stress aggravates itching.
Moreover, studies have shown that in people suffering from depression, there is a correlation between the degree of itchiness and the degree of depression. Itching therefore causes real physical and psychological suffering, just as pain does.
What drugs are available for itching?
First and foremost, the psoriatic lesions need to be treated. Topical corticosteroids, UVA and UVB rays and cyclosporin frequently decrease itching. However, in cases where these therapies have been unsuccessful, it becomes difficult to stop itching. Although antihistamines prevent itching in some conditions, they do not appear to be effective in treating the itchiness caused by psoriasis.
Patients suffering from depression or anxiety who also suffer from itching should receive therapy which specifically targets their psychological problems.
Can other treatments help?
Applying moisturising lotion once or several times a day can help to soothe the skin as it counteracts dryness. Spa treatments may also be beneficial as some thermal mineral water has anti-inflammatory properties and reduces itching. Stressed and depressed patients may also find relaxation techniques, such as sophrology and yoga, helpful to combat anxiety and so decrease itchiness.

Friction and minor skin trauma can provoke lesions, so natural fibres, such as cotton, should be worn. Very hot showers and baths should also be avoided, and only mild skin care products should be used. Gloves are useful for limiting exposure to strong detergents. It is better to cut nails short to minimise damage caused by scratching. Finally, alcohol and coffee should be avoided.

Friday, December 26, 2008

Lifting (squat & stoop) & Posture

Despite the well-recognized role of lifting in back injuries, the relative biomechanical merits of squat versus stoop lifting remain controversial. In vivo kinematics measurements and model studies are combined to estimate trunk muscle forces and internal spinal loads under dynamic squat and stoop lifts with and without load in hands. Measurements were performed on healthy subjects to collect segmental rotations during lifts needed as input data. Results tell us that passive (muscle or ligamentous) forces and internal compression/shear forces were larger in stoop lifts than in squat ones. These were due to significantly larger thorax, lumbar and pelvis rotations in stoop lifts. So it is advocated squat lifting over stoop lifting as the technique of choice in reducing net moments, muscle forces and internal spinal loads (i.e., moment, compression and shear force).
Role of posture in static lifts:
Despite the recognition of the contributory role of lifting in spinal injuries, the advantages of preservation or flattening of the lumbar lordosis while performing lifting tasks is not yet clear. Role of changes in the lumbar posture on muscle forces, internal loads, and system stability in static lifting tasks with and without load in hands was studied by a group of researcher.
The study:
Kinematics of the spine and surface EMG activity of selected muscles were measured in 15 healthy subjects under different forward trunk flexion angles and load cases. Apart from the freestyle lumbar posture, subjects were instructed to take either lordotic or kyphotic posture as well.
This study revealed:
In comparison with the kyphotic postures, the lordotic postures increased the pelvic rotation, active component of extensor muscle forces, segmental axial compression and shear forces at L5-S1, and spinal stability margin while decreasing the passive muscle forces and segmental flexion moments.
So the study concluded that alterations in the lumbar lordosis in lifting resulted in significant changes in the muscle forces and internal spinal loads. Spinal shear forces at different segmental levels were influenced by changes in both the disc inclinations and extensor muscle lines of action as the posture altered. Considering internal spinal loads and active-passive muscle forces, it is recommended that the freestyle posture or a posture with moderate flexion as the posture of choice in static lifting tasks.

Load transmission during lumbosacral SMT.

Benefits to patients with low back pain from manipulation have been reported. Little is known about how the loads that are applied affect the spine. Studies of isolated forces applied during HVLA (high-velocity and low-amplitude) procedures in controlled conditions reveal force ranges from 20 N to 550 N at rates up to 7101 N/sec. Vertebral motions arising from these forces have been estimated to be up to 0.1 cm and 1.8 degrees.
But complex loads that pass from common lumbar procedures through the spine have not been studied. A group of researchers did an in vivo biomechanical study of three separate manipulation procedures administered in random order. A biomechanical computer model estimated the loads passing through the spine at the level of interest. At last the difference in loading effects from manipulation was contrasted for all six degrees of freedom based on treatment method.
Results showed:
1. Muscular response during the procedures was negligible and did not enter into the estimates of loads transmitted through the spine.
2. There was statistically significant difference found between components load transmission in post-manipulative posture than initial posture (pre-manipulative).
3. Effects on the spine on both sexes ware estimated to be of sufficient strength to sustain them.
4. None of the volunteers who have undergone HVLA experienced any discomfort or complications as a result of the tests.

Thursday, December 25, 2008

SMT biomechanics

Modern scientific investigations into spinal manipulative therapy (SMT) began in 1975. Conditions often treated include acute and chronic low back pain, radicular pain, neck pain, and some forms of headache. The field of spinal manipulation has often been treated by the literature, incorrectly, as being homogeneous. Much of the confusion regarding this form of treatment can be traced to the ambiguity surrounding the procedures themselves.

A categorization system for SMT was sought that would be more objective than is clinically available. Such a system may serve as a means to strengthen future studies, determine operating principles, applicability, treatment effectiveness, and nature of the manipulable lesion.
Attempt to classify SMTs:
Attempt to classify SMTs on biomechanical basis has been taken form different studies are as follows:
Studies that include measurements of mechanical characteristics of treatment techniques used under the general headings of SMT or manual therapy, studies exploring the biomechanics of buckling behavior of vertebral segments as a model of the manipulable lesion & quantitative characteristics of SMT were grouped to form a basis for classification.
These studies conclude:
There currently are a number of named systems of manual procedures. No current triage system is available that predicts which patient has the greater likelihood of benefiting from manual treatment or the procedure type. The biomechanical parameters of SMT form a systematic characterization of manual procedures. Such a system may be used in future studies to test hypotheses of treatment effect from quantitatively defined procedures.

spine manipulation in sports

Spinal manipulation or manual therapy is becoming an increasingly popular method of treating athletes with spinal problems. The primary theoretic basis for the claimed beneficial results of manipulation is the restoration of motion with subsequent effect on ligamentous adhesions, muscle spasm, disk nutrition, and central nervous system endorphin systems.
The concept of joint barriers has been developed to differentiate among exercise therapy, mobilization, and manipulation. Research trials suggest that spinal manipulation is beneficial in relieving or reducing the duration of acute low back pain and acute neck pain but has much less effect on chronic low back pain and neck pain. There is evidence that manipulation increases certain parameters of motion of the spine but this evidence is not yet conclusive.
There are a wide variety of manipulative procedures that are utilized to manipulate the spine to increase range of motion, and the selection of the procedures is based on manual diagnostic skills. Manipulation, however, is not a benign procedure and has been implicated in the aggravation of disk herniation or bony fractures as well as the precipitation of vertebrobasilar artery occlusion.

Wednesday, December 24, 2008

Osteoarthritis- classification & diagnosis

Given the puzzling etiology of osteoarthritis, different classifications of the disease have been proposed, yet all coincide in making a clear distinction between primary or idiopathic osteoarthritis and secondary osteoarthritis. According to the American College of Rheumatology (ACR):
- Localized (spine, knee, hip, hands, feet, elbow, shoulder, and other joints)
- Generalized (involving 3 or more joints)
- Trauma
- Developmental and congenital diseases (dysplasia, etc.)
- Metabolic diseases (gout, etc.) - Endocrine disorders (diabetes, hypothyroidism, etc.)
- Calcium deposition diseases (pyrophosphate, hydroxyapatite, etc.)
- Other bone and joint diseases (rheumatoid arthritis, etc.)
- Neuropathic (Charcot) arthropathy
- Septic arthritis
- etc.
Osteoarthritis is diagnosed by evaluating symptoms related to the location and characteristics of pain, the conditions under which it improves (rest) and worsens (when bearing a load), crepitus, and disorders in the axes of the lower limbs and the affected areas.
The symptoms of osteoarthritis depend on the joints affected, but have some characteristics in common. Symptoms begin gradually and progression is slow. At first, the pain appears when the joint is moved and goes away after rest. As osteoarthritis becomes more severe, the pain becomes more persistent. Pain usually appears after a period of rest until the joint warms up, and then reappears after prolonged exercise. Sometimes, as a result of rest and a lack of exercise, the muscles around the joints become atrophied, while on other occasions, the pain and bone deformations cause muscle contractures. In both cases, disorders in the muscles produce more pain, affect the normal mobility of the joint and result in a greater tendency for the disease to progress.
Radiographic studies make it possible to observe the characteristic changes caused by osteoarthritis in any location, as well as the intensity of those changes. The advantage of performing laboratory tests is that other diseases can be ruled out. It is always necessary for clinical symptoms to be present for radiographic tests to be useful. About 15% of people with disorders visible as a result of radiographic tests do not present with any discomfort.

Among others, the main signs and symptoms of osteoarthritis are:
Pain; restricted, painful movement
Stiff joints
Loss of mobility
A feeling of insecurity or instability
Functional impairment
Soft spots around the joint
Inflammation around the joint

Diagnosis of osteoarthritis is usually very simple. In general, the disease can be detected because of its clinical and radiological signs. The doctor can diagnose it based on the location and kind of pain, the situations under which it improves or worsens, and through a simple exploration of the joints affected. S

Methods used to detect the clinical manifestations of osteoarthritis include:

Measuring pain: pain can be quantified by the patient with the help of a scale using words (e.g.: no pain, minimal, moderate, severe, very severe), or by asking patients to evaluate the pain using the following scales:

- The most commonly used method at the present time is Huskisson’s Visual Analogue Scale (VAS), in which patients have to rate their level of pain from 1 to 10 or from 0 to 100.

- The WOMAC ( Western Ontario and McMaster Universities ) Osteoarthritis Index is also used because is has a section with five questions to be answered by patients to evaluate their own pain.
Measuring functional status: different indices are available, based on the location of osteoarthritis:
- Lequesne Algofunctional Index: indicated for gonarthritis and coxarthrosis. Consists of a questionnaire to be filled in by the patient with questions about pain and functional capacity.
- WOMAC Index: also contains a section to be filled in by patients to evaluate their functional capacity.
- Dreiser Functional Index for arthropathies of the hand: another questionnaire to be filled in by patients that includes questions on their ability to perform everyday hand movements.
There are other measurement tools that have not been validated but which are regularly used in practice to detect the clinical manifestations of osteoarthritis: measure of joint rigidity, inflammation, joint mobility, joint deformation, esthetic repercussions, functional impairment, quality of life and use of symptomatic treatments ( analgesics , NSAIDs, etc.).

Methods are also used to determine the progression of osteoarthritis in different joints:

Method developed by Gust Verbruggen to determine the progression of osteoarthritis in the finger joints. According to this scale, this progression can be determined by its evolution through previously described anatomical phases: “N” (not affected), “S” (classic osteoarthritis), “J” (loss of joint space), “E” (erosive osteoarthritis) and “R” (remodeled joint).

Method developed by Vignon et al. to determine the progression of osteoarthritis in the knee joints. It is based on the evaluation of the reduction in the articular space of the knee using quantitative radiology. X-rays are taken of both knees with the foot in the standard position and the knee in the Schuss position (flexed at 20%) at the beginning and after a certain amount of time. The X-rays are blindly analyzed using a validated digital image analysis system to observe the progression of: mean thickness, minimum width of the joint space and surface area.
Rheumatologists occasionally perform a series of tests to confirm the initial diagnosis and to gain an idea of the severity of the disease and its progression at the structural level. These tests may include:

Joint-fluid aspiration: The synovial fluid can be analyzed when viscosity is high and cellularity is low. This analysis is particularly useful for ruling out the existence of other inflammatory or microcrystalline processes.
Blood analysis: Blood disorders are not common in osteoarthritic patients, unless there is an associated disease. The sedimentation rate is usually normal except in cases of primary osteoarthritis, when it is moderately high. The results of systematic analysis (hemogram, urine, biochemistry parameters, etc.) are normal.
Radiology: In early stages, few or no disorders are detected, but the following symptoms gradually appear as the disease progresses:
- Narrowing of the joint space as a consequence of the loss of joint cartilage.
- Subchondral sclerosis, detected as an increase in bone density below the joint cartilage, the result of the reactive response of the bone.
- Osteophytes, the most specific symptoms of osteoarthritis. They are bone spurs the body produces and deposits in the osteoarticular area as a result of the new secondary bone formation due to constant stress on the joint bone.
- Subchondral cysts or geodes, which appear in intermediate stages of osteoarthritis.
- Luxations, joint dislocations that are found in advanced stages of osteoarthritis.

Other tests include: nuclear magnetic resonance (NMR), ultrasound, bone gammagram, CT scan, arthroscopy, etc.

A system of radiographic grading of osteoarthritis is also used. It was developed by Kellgren and Lawrence and is key in current radiological assessment of osteoarthritis:
Grade Classification Description of X-ray
0- normal no symptoms of OA
1- doubtful indications of osteophytes
2- minimal definite osteophytes
3- moderate moderate narrowing of joint space
4- severe joint space very narrow, subchondral bone loss

Tuesday, December 23, 2008

Brachial plexus injuries in sports

Cervical nerve pinch syndrome, a neurapraxia of the brachial plexus, is a common occurrence in contact games. The more serious injury, brachial plexus axonotmesis, has received little attention in the literature. Acute brachial neuropathy is an uncommon etiology of shoulder pain and disability. It can, however, present in association with athletic activity and therefore must be included in the differential diagnosis of athletes with such symptomatology.
Findings that should alert the examiner to the possible presence of acute brachial neuropathy include 1) onset with non-contact as well as contact sports, 2) rather acute onset of pain without specific inciting trauma, 3) persistent, often severe pain that continues despite rest, 4) patchy brachial plexus and/or peripheral nerve involvement, and, 5) dominant arm predominance of symptoms and signs.
Electromyography and nerve conduction studies often can confirm the diagnosis. Treatment begins with rest and continues through a rehabilitation phase. Follow up of athletes with acute brachial neuropathy discloses that weakness may persist in the affected muscles. Absolute strength parity may be difficult to achieve, so permission to participate in athletics must be given on a case by case basis. These brachial plexus axonotmesis injuries may initially present as a cervical nerve pinch syndrome. All significant or repeated cervical nerve pinch injuries should be reexamined at 2 weeks. Those patients with axonotmesis should not be allowed to return to competi tion until they have achieved normal strength in the involved muscles and the electromy ogram shows no signs of active denervation.

Friday, December 19, 2008

Audible crack of manipulation

Clinicians routinely consider the success of a thrust manipulation technique based on the presence or absence of an audible pop despite the lack of evidence suggesting that this pop is associated with improved outcomes. Cleland JA et al determined the relationship between the number of audible pops with thoracic spinal manipulation and improvement in pain and function in patients with mechanical neck pain.
The study:
78 patients referred to physical therapy with mechanical neck pain underwent a standardized examination and thoracic spine manipulation treatment protocol. All patients were treated with a total of 6 thrust manipulation techniques directed to the thoracic spine followed by a basic cervical range of motion exercise. The treating clinician recorded the presence or absence of a pop during each manipulation.
The result & conclusion:
The results of this analysis provide preliminary evidence for the hypothesis that there is no relationship between the number of audible pops during thoracic spine thrust manipulation and clinically meaningful improvements in pain, disability, or CROM in patients with mechanical neck pain. Additionally, a greater number of audible pops experienced was not associated with a dramatic improvement with manipulation treatment.

Respiration- Osteopathic philosophy & Manual therapy

The osteopathic philosophy:
Osteopathic medicine as we know it begins with Andrew Taylor Still, M.D. (1828 - 1917), who introduced its concepts in 1874. "Osteopathy is based on the perfection of Nature's work. When all parts of the human body are in line we have health. When they are not the effect is disease. When the parts are readjusted, disease gives place to health.
According to Dr. Still the musculoskeletal system (bones, muscles, ligaments and connective tissues) is the largest collective system of the body, making up 60 percent or more of the body's mass. From the osteopathic point of view, the musculoskeletal system is the primary machinery of life.Viscera & internal organs with which medicine is always so concerned are the secondary machinery of life.
Through careful study and experimentation, he was able to associate abnormalities in the structural system (musculoskeletal system) of the body with signs and symptoms of various diseases. Dr. Still developed manipulative methods (now known as osteopathic manipulative treatment) to remove these musculoskeletal structural abnormalities to alleviate the patient's illness.
Dr Sutherland, Breath of Life & Craniosacral bio-dynamics:
Biodynamic view of craniosacral therapy stress an emphasis on the inherent healing potency called “the Breath of Life”. The diagnosis and treatment by this approach has a direct link to the pioneering insights of Dr Sutherland.
Cranial movement & History of discovery of CST
While examining the bevel-shaped sutures of a sphenoid and temporal bone, Sutherland had an insight which changed the course of his life. William Sutherland set out to try prove to himself that cranial bones do not move, just as he had been taught. As a true experimental scientist, he reasoned that if cranial bones did move and that if this movement could be prevented, it should be possible to experience the effect. So he designed a kind of helmet made of linen bandages and leather straps which could be tightened in various positions, thus preventing any potential cranial motion from occurring.
Experimenting on his own head, he tightened the straps, first in one direction and then in another. Within a short period of time he started to experience headaches and digestive upsets. This response was not what he was expecting, so he decided to continue his research to find out more. Some of his experiments with the "helmet" led to quite severe symptoms of cranial tightness, headaches, sickness and disorientation. Of particular interest was that when the helmet straps were tightened in certain other positions, it produced a sense of great relief and an improvement in cranial circulation.
After many months of pulling and restricting his cranial bones in different positions with these varying results, Dr Sutherland eventually stopped this research, having convinced himself that adult cranial bones do, in fact, move. Furthermore, the surprising responses that he felt in his own body had shown him that cranial movement must have some important physiological function. Sutherland spent the remaining 50 years of his life exploring the significance of this motion.
As Dr Sutherland dug deeper into the origins of these rhythms, he realized that there are no external muscular agencies which could be responsible. He concluded that this motion is produced by the body's inherent life-force itself, which he called the Breath of Life.
Dr Sutherland realized that the cerebrospinal fluid has a significant role in the expressing and distributing the potency of the Breath of Life. As potency is taken up by the cerebrospinal fluid, it generates a tide-like motion which is described as its longitudinal fluctuation. This motion has great importance in carrying the Breath of Life throughout the body and, as long as it is expressed, health will follow.
Primary respiratory motion.
Dr. Sutherland named the system of tissues and fluids at the core of the body which express a subtle rhythmic motion, the primary respiratory mechanism. As these tissues are not under voluntary muscular control, they are also sometimes referred to as the involuntary mechanism (or I.V.M.). Dr. Sutherland used the term "primary" because this motion underlies all others. It is the manifestation of the life-stream itself. Every cell expresses this primary respiratory motion throughout its life. Significantly, many different symptoms and pathologies which involve both body and mind are related to disturbances of primary respiratory motion.
There are, of course, other vital rhythmic motions in the body such as the heartbeat and lung respiratory breathing. Although necessary for the maintenance of life, these are considered "secondary" motions because they are not the root cause of the body’s expression of life. Without the Breath of Life there would be no other motion. Lung respiration or the breathing of air is therefore sometimes called secondary respiration.
Sustained by the Breath of Life.
The expression of the Breath of Life at a cellular level is a fundamental necessity for good health. If the rhythmic expressions of the Breath of Life become congested or restricted, then the body’s basic ordering principle is impeded and health is compromised. The main intention of craniosacral work is to encourage these rhythmic expressions of health. This is done by gently facilitating a restoration of primary respiratory motion in places where inertia has developed.

Tuesday, December 16, 2008

Vitanims & Minerals- alarmingly decreasing in fruits & vegitables

Following is an USDA report...................
A group of doctors introduced a document to the floor of the United States Senate back in 1936. . It was a dire warning that the mineral content of the soil was eroding. Vegetables were losing their power and people were at risk.
The effects are…
US Department of Agriculture’s (USDA) nutritional values for fruits and vegetables today compared to 1975 is as follows:

Apples, Vitamin A is down 41%
Sweet Peppers, Vitamin C is down 31%
Watercress, Iron is down 88%
Broccoli, Calcium and Vitamin A are down 50%
Cauliflower, Vitamin C is down 45%; Vitamin B1 is down 48%; and Vitmain B2 is down 47%
Collards Greens, Vitamin A is down 45%; Potassium is down 60%; and Magnesium is down 85%
According to USDA’s own numbers, the vitamin and mineral content has dramatically plummeted – in just 30 years!

Notice minerals like iron and magnesium have dropped by more than 80 percent. That’s from commercial farming technology and powerful fertilizers that practically sterilize the soil – leaving it with little to no mineral content.
If the soil doesn’t have minerals, there’s no way for vegetables to absorb them. And that’s bad news for your health… Magnesium regulates over 300 body functions – every day and is critical to heart health and healthy glucose metabolism. find out a proper source to replace thsese things from vitamin tabs & capsules most prfarably from natural sources. HERBALIFE company has a excelent suppliment try it.

Monday, December 15, 2008

Osteoporosis & Physical Activity

Atricle of Siegrist M.
In recent years, osteoporosis has become a leading cause of morbidity and mortality in elderly women. Research has demonstrated that the prevention of osteoporosis and osteoporosis-related fractures may best be achieved by initiating sound health behaviors early in life and continuing them throughout life. Evidence suggests that osteoporosis is easier to prevent than to treat. In fact, healthy early life practices, including the adequate consumption of most nutrients, calcium in particular, and regular physical activity, contribute to greater bone mineral mass and optimal peak bone mass. Bone is living tissue that responds to exercise by becoming stronger. Two types of exercises are important for building and maintaining bone mass and density: Weight-bearing exercises, in which bones and muscles work against gravity and resistance training that use muscular strength to improve muscle mass and strengthen bone. Exercise can also improve gait, balance, coordination, proprioception, reaction time, and muscle strength, even in very old and frail elderly people. Overall, the evidence strongly suggests that regular physical activity, especially started in childhood and adolescence, is a cheap and safe way of both improving bone strength and reducing the risk to fall.

Facets Of sports Injury Prevention

Definition of Injury

“Unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy, or the absence of such essentials as heat or oxygen.”

Causative factors for sports injuries:

Intrinsic factors
Body size
Injury history
Fitness level
Muscle strength/Flexibility
Skill level
Psychological state
Extrinsic factors
Type of activity
Conditioning errors

What is Injury Prevention?

Injuries are preventable by changing the environment, individual behavior, products, social norms, legislation, and governmental and institutional policies to reduce or eliminate risks and increase protective factors.

Primary & secondary prevention:

Primary prevention is prevention of occurrence of injury
Secondary prevention is prevention of reoccurrence of injury

There are a number of factors responsible for injury prevention. They are:

1. Warm up, 2. Stretching, 3. Taping & bracing, 4. Protective equipment, 5. Correct biomechanics, 6. Suitable equipment, 7. Appropriate surfaces, 8. Appropriate training, 9. Adequate recovery, 10. Psychology
11. Nutrition

1. Warm up:
The literary meaning of warm up is to raise the core body temperature. Warm up is further classified in to general & sports specific warm ups.

Benefits of warm up include:

1. Increased blood flow to muscles
2. Reduced muscle viscosity leading smooth muscle contractions
3. Enhanced muscle’s mechanical efficiency
4. Favorable neuro- myo conductance
5. Favorable muscle receptor changes which decreases the sensitivity of muscles to stretch.
6. Enhanced cardiovascular compatibility
7. Enhanced mental concentration to sporting activities

How warm up helps in injury prevention:

1. Increase the pre-warm up ROM
2. Decrease the stiffness of the connective tissue- this further leads to greater forces and length of stretch required for a tear to occur.

2. Stretching:
The ability to move joints smoothly throughout a full ROM is an important component of good health.

Basic principles of stretching are:

1. Warm up prior to stretching
2. Stretch before & after exercise/sports
3. Stretch gently & slowly
4. Stretch to the point of tension but not up to the point of pain

How stretching helps in injury prevention:

There is considerable research evidence to claim;

Increased flexibility attended through stretching appears to result in decreased incidence of musculo-skeletal injuries, minimize & alleviate muscle soreness. Further stretching may enhance athletic performance.

3. Taping & bracing:

Taping and bracing are used to restrict unrestricted, potentially harmful motion & allow desired motion. There are two main indicators for use of tapes & braces:

1. prevention- from the above said two procedures taping is used used as a preventive measure for high risk activities. For example ankle taping of basketballers.
2. rehabilitation- taping is used as a protective mechanism during the healing & rehabilitation phase.

4. Protective equipments:

Protective equipment shields various vital body parts against injuries. The most important is that protective equipment must not interfere with sporting activities.

5. Correct biomechanics:

Correct biomechanics is an important factor in achieving maximum efficiency of movement and in prevention of injuries. Faulty biomechanics may result from static (anatomical) abnormalities or dynamic (functional) abnormalities.


Static abnormalities: LLD, Genu valgum, pronated calcanium

Dynamic abnormalities: running with excessive anterior pelvic tilt.

What happens when there is altered biomechanics?

Poor techniques are the result of improper biomechanics. This poor technique results not only in injuries but also in reduced performance.

6. Suitable equipments:

Equipment may range from simple to complex.

Example of simple equipment is the sports shoes.
Examples of complex equipments are; racquets, sticks, bicycles, motor vehicles etc

According to Khan & Brukner 3 major injury producers are- foot wares, racquets & bicycles.

Parts of a sports shoe: heel counter, toe box, mid sole.

Parts of racquet: handle grip, shaft & racquet head

Important parts of a bicycle from sporting angle: seat height, saddle position, handle bear position. Pedaling technique is one of the most important aspect where injuries can be prevented.

7. Appropriate surface:

During walking & running, the body is subjected to high-repetitive, short duration forces, increasing the susceptibility to injury. Maximal impact forces during walking, running, jumping has been shown to approach 2 times, 3-4 times, 5-12 times respectively.

Surfaces alter the peak force that the body is subjected to during activity. Maximal impact forces are much higher on the hard than on the soft surfaces. Hence softer surfaces reduce the chances of sports injuries.

8. Appropriate training:

Training errors are the most common predisposing factors in the development of sporting injuries.

Training is a constant balance between performing sufficient quality & quantity of work to maximize performance, but not so much that injury occurs.

Full explanation of training is beyond the scope of this discussion.

In nutshell:

Principle of training are:

1. periodization
2. specificity
3. overload
4. individuality

Different training methods involves:

1. aerobic training or endurance training
2. anaerobic training or lactate training
3. strength & power training
4. flexibility training
5. speed & agility training
7. specific skill training
8. cross training

9. Adequate recovery:

Adequate recovery is essential if the full training effect is to be gained & injuries are to be prevented.

“Over-reaching”: inadequate recovery leads to impaired performance and associated symptoms such as tiredness & lethargy called “Over-reaching”. If from this point onwards if training is continued injury may occur. How ever, frequently athletes respond to above said symptoms by an increase in training as they perceive it as “lack of fitness”. This leads to what is called “over training syndrome”. Hence it is important for the coach to monitor the training program keenly.

Adequate recovery includes:

1. warm downs
2. whirl pools & spa
3. massage
4. rest & sleep
5. psychological & nutritional advices

10. Psychology & injury prevention:

Excessive arousal:
The detrimental effect of excessive psychological arousal is a well recognized entity. Excessive psychological arousal predisposes the athlete to injuries.

Excessive arousal leads to altered muscle tension. This further leads to alteration of fine balance between agonist & antagonist which is the hall mark of a quality performance. Once this synergy is lost between agonist & antagonist; a changed technique rather than the natural technique is used. There is also “Loss of rhythm”. This factor predisposes to injury.
Excessive arousal also leads to loss of mental concentration. Consequently the feet & body are placed do not get into proper position on the sports field. Hence the participant gets in to a biomechanically poor position to play return shots. This predisposes to injury.

Excessive arousal leads to “narrow attentional focus”; hence he fails to read the play. This may result in them being easily tackled or bumped from the “blind side”.

“The white line fever”: this is another example of excessive arousal. Here the athlete loses all perception of danger on taking the field. Consequently he places his body in positions vulnerable to injury.

Over aroused players enter a competition without proper nutrition. This further lead the individual to sports injuries.

Under arousal: less common variety. It occur trial matches or lower level of competition.

The under aroused athlete shows following:

1. Impaired reading of visual cues.
2. Slow decision making.
3. Do not take appropriate evasive action.
4. Makes technical errors.

These above said points are responsible for sporting injuries in under-aroused athletes.

11. Nutrition & injury prevention:

1. Adequate nutrition may indirectly lead to injury through it’s effect on the recovery process.
2. Due to continuous intense training; labile muscle proteins are channeled in gluco-neo-genesis to produce energy. Hence deficient dietary protein may lead to muscle soft tissue damage.
3. Inadequate hydration has immediate & acute impact on athletic performance especially exercising under thermal challenge.
4. Minerals such as calcium has very important role to play in muscle contraction physiology. Increased exercise draws upon the body stores of the calcium. Inadequate calcium intake weakens the bone and may lead to fractures. Electrolyte balance; further the internal milieu is maintained by Sodium & Potassium. Deficiency of these minerals leads to severe metabolic impairments. They may even cause death.
5. Low calorie diet may lead to dropping of the fat proportion to such an extent that females loose monthly period. This further leads to osteoporosis and fractures.

Friday, December 12, 2008

Respiration & Nutrition

“How much we need oxygen to live” is only felt at the lack of it. Process of respiration is the fundamental biological process that sustains life. In the exchange of harmful CO2 ; O2 is exchanged. Further without O2 no energy liberating combustion can take.
Combustion (process of energy release) in living being was first described by Lavoisier (1743-1794). He discovered the true nature of oxygen & how it’s combustion with carbon & hydrogen result in the formation of CO2, H2O and heat.
In 1842, Liebig discovered that the substances burned in the body for energy liberation are carbohydrate, fat & protein.
Importance of respiratory exchange ratio in knowing the nutrient fuel of body:
In one breath, you normally breathe in more molecules of oxygen than you breathe out molecules of carbon dioxide. The ratio between these CO2 / %O2 is the respiratory exchange ratio (RER).
Measuring this ratio can be used for estimating the respiratory quotient (RQ), an indicator of which fuel (carbohydrate or fat) is being metabolized to supply the body with energy.
RER is about 0.8 at rest with a modern diet. This value however, can exceed 1 during intense exercise, as CO2 production by the working muscles becomes greater and more of the inhaled O2 gets used rather than being expelled. It is important to note that during exercise, using RER for estimating RQ loses accuracy because of factors including bicarbonate buffering of lactic acid, which affects the CO2 levels being expelled by the respiratory system.
Calculation of RER is commonly done in conjunction with exercise tests such as the VO2 Max Test and can be used as an indicator that the participant is nearing exhaustion and the limits of their cardio-respiratory system. An RER of approximately 1.2 is reached at this point.
An RER of 0.70 indicates that fat is the predominant fuel source, RER of 0.85 indicates a mix of 50/50 between fat and carbohydrates, and any value above 1.00 is indicative of carbohydrate being the predominant fuel source.

Tuesday, December 9, 2008


Seasonal variation in adult leisure-time physical activity:
Pivanik JM et al determined the effect of season on self-reported leisure-time physical activity (LTPA) behaviors of Michigan adults.
They found, weekly leisure-time energy expenditure averaged approximately 15-20% higher during spring and summer. Much of this difference was due to active respondents participating in a second activity during these seasons.

Using Energy Expenditure.

following is an abstract of MUDD LM et al(2008) on physical activity recommendation for energy expenditure:
Most adults do not meet the American College of Sports Medicine and Centers for Disease Control and Prevention (ACSM/CDC) physical activity recommendations. Even fewer meet the more extreme Institute of Medicine (IOM) physical activity recommendations. Compliance with either recommendation has been conventionally assessed by combining frequencies and durations of self-reported activities. Leisure-time energy expenditure is a cumulative measure of activity that offers an alternative method of defining compliance. PURPOSES:: To calculate the leisure-time energy expenditure of adults complying with the ACSM/CDC or the IOM physical activity recommendations determined by conventional measures and to reexamine compliance with the IOM recommendation using energy expenditure criteria. METHODS:: National, cross-sectional data from the 2000 Behavioral Risk Factor Surveillance System determined the mode, frequency, and duration of up to two leisure-time activities performed by adults. Four mutually exclusive activity groups (Non-, Low-, ACSM/CDC-, and IOM-Active) were defined on the basis of frequencies and durations of reported activities. Leisure-time energy expenditure ( was calculated per respondent. The energy expenditure threshold for meeting the IOM recommendation was calculated as 21 RESULTS:: Of the 162,669 respondents included in the analyses, 29.9% were Nonactive, whereas 42.3%, 23.3%, and 4.5% were Low-, ACSM/CDC-, and IOM-Active, respectively. Median leisure-time energy expenditure values were 9.0, 27.4, and 63.0 for Low-, ACSM/CDC-, and IOM-Active groups, respectively. When using energy expenditure criteria, compliance with the IOM recommendation rose to 27.7% of respondents. CONCLUSIONS:: Compliance with the IOM physical activity recommendation dramatically increased when assessed by energy expenditure compared with conventional criteria, thereby highlighting the potential bias of conventional methods. A significant proportion of adults meet the intent but not the letter of the IOM activity recommendation.

Sunday, December 7, 2008

A - Z of alternative medicine

Acupuncture point
Korean hand acupuncture
Medical acupuncture
Meridian therapy
Trigger point
Alexander Technique
Alternative Medical Systems
Naturopathic medicine
Traditional Chinese medicine
Applied kinesiology

Bach Flower Therapy
Bates method
Biologically Based Therapies
Bates method
Chinese food therapy
Herbal therapy
Macrobiotic lifestyle
Natural health
Natural therapy
Diet and Food
Dietary supplements
Orthomolecular medicine
Urine therapy
Bowen Technique
Body-Based Manipulative Therapies
Body work or Massage therapy
Bowen Technique
Chiropractic medicine
Craniosacral Therapy
Medical acupuncture
Body work or Massage therapy

Chelation therapy
Chinese food therapy
Chinese medicine
Chinese pulse diagnosis
Chinese martial arts
Chiropractic medicine
Cognitive behavior therapy
Coin rubbing
Colloidal silver therapy
Color Therapy
Colon Hydrotherapy (Colonics)
Concentration meditation
Craniosacral Therapy
Crystal healing


Ear Candling
Electrodermal screening
Energy diagnosis
Energy therapies
Magnet therapy
Therapeutic Touch
Eye exercises

Facial diagnosis
Faith healing
Flower essence therapy
Feldenkrais Method
Chinese food therapy
Functional medicine

Gua Sha

Hair analysis
Hatha yoga
Healing touch
Health psychology
Herbal crystallization analysis
Herbal therapy
Holistic medicine
Bach flower remedies
Flower essence therapy

Integrative medicine


Korean hand acupuncture


Mega-vitamin therapy
Magnetic healing
Manipulative therapy
Massage therapy
Medical acupuncture
Medical intuition
Medical Qigong
Concentration meditation
Mindfulness meditation
Transcendental meditation
Meridian therapy
Mind-Body Interventions
Alexander Technique
Bach Flower Therapy
Feldenkrais Method
Hatha yoga
Music therapy
Support groups
Tai Chi
Mindfulness meditation
Music therapy

Natural Health
Natural therapies
Diet and Food
Dietary supplements
Home remedies
Natural hygiene
Naturopathic medicine
Botanical medicine
Physical manipulation
Minor surgery

Orthomolecular medicine

Plum blossom
Pranic healing
Psychosocial interventions
Power yoga
Psychic surgery

Quantum touch


Support groups

T'ai Chi Ch'uan
Therapeutic Touch
Tibetan eye chart
Tongue diagnosis
Traditional Chinese medicine
Acupuncture point
Chinese pulse diagnosis
Chinese food therapy
Coin rubbing
Five Elements
Gua Sha
History of traditional Chinese medicine
Korean hand acupuncture
Plum blossom
Seven star
Trigger point
Tui Na
Zang Fu theory
Traditional Japanese medicine
Meridian therapy
Traditional Tibetan medicine
Transcendental meditation
Trigger point
Tui Na

Urine therapy




Hatha yoga
Power yoga