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  • Diabetes - Type 1 vs Type 2

    Diabetes - Type 1 vs Type 2

    Diabetes - Type 1 vs Type 2 The 14th November 2020 marked the 29th World Diabetes Day. Since its conception in 1991, World Diabetes Day has been the principal worldwide campaign that raises awareness of the disease diabetes mellitus (DM). This year’s theme focuses on ‘The nurse and diabetes’, and how pivotal a role nurses play in supporting those living with this condition. Do you understand diabetes? Are you familiar with its effects on the human body? If the answer is no, this blog is for you. Facts Here’s a few startling facts about DM… In 2019, nearly 465 million adults had a DM diagnosis worldwide. This figure is predicted to increase to nearly 580 million by the year 2030. In the same year, the disease took the life of 4.2 million people with healthcare costs totaling more than $760 billion. This equates to approximately 10% of the total global spend on all healthcare, which is a huge figure! It also puts into perspective just how big a problem DM is across the planet. What is diabetes mellitus? Diabetes is a chronic, metabolic disease. The word ‘metabolic’ derives from ‘metabolism’, which refers to the body’s ability to breakdown food into energy. With DM, the problem lies with the body’s ability to breakdown sugar (in the form of glucose) into energy for the body to use. When we eat food, the body breaks it down into smaller pieces. Some of these smaller pieces are in the form of glucose, our body’s main energy source. Once in the blood, it travels around the body, being dispensed to all cells, so all of our bodily processes can be carried out and function correctly. The body uses a hormone called insulin to help in the process of converting glucose into energy, ready for use by our cells. Insulin is produced by the pancreas, an organ that is part of our digestive system. In DM, the pancreas either doesn’t produce insulin at all, or it does not produce enough good quality insulin, meaning there is nowhere for the glucose to go but stay in the blood. As a result, the glucose levels rise, which then leads to symptoms of DM. Types of DM There are three main types of diabetes: • Type 1 (DM1): An autoimmune form of the condition, meaning the body’s immune system attacks and destroys the cells of the pancreas that are responsible for producing insulin. People with DM1 must rely on a synthetic form of insulin, usually injected by the person several times a day, in order to control blood sugar at safe levels. Sometimes an insulin pump is fitted which negates the need to inject. • Type 2 (DM2): The most common form of the disease. With DM2, the pancreas either does not produce enough insulin, does not produce effective insulin, or the cells of the body do not react to insulin correctly. In the early stages, this form of the disease can be effectively managed by exercising regularly, eating healthily and making necessary lifestyle changes. Over time, the disease progresses, and people may require medication in the form of tablets, and eventually insulin injections, like with DM1. • Gestational: A form of DM that develops during pregnancy and usually resolves once the baby is born. Women who are overweight, 40+ years of age, and have a family history of DM2 are more at risk of developing this condition. This blog will mainly focus on the differences between DM1 and DM2. We will discuss gestational diabetes in more detail in a future blog. Effects of DM on the body The short and long-term effects of DM1 and DM2 are the same. The short-term effects of DM1 tend to come on quickly and may be fatal if not controlled promptly. Some of the shared and more immediate symptoms of DM1 and DM2 include: • Excessive thirst and hunger• Increased urination• Tiredness and fatigue• Skin infections and slowly healing skin wounds• Visual disturbance, including blurred vision• Mood swings• Headaches• Weight changes (DM1 is usually associated with unexplained weight loss, whereas DM2 is usually associated with progressive weight gain) If DM is not managed well, long-term complications of the disease relate to problems with the cardiovascular, kidney, nerve and visual systems of the body. This leaves a person susceptible to developing: • Heart attacks and/or stroke• Kidney disease• Poor nerve function• Ulcers that affect the limbs• Blindness Poorly managed diabetes is a common cause of limb amputations (due to the resultant poor blood flow and nerve function) and there is a strong association between diabetes and anxiety and/or depression. The key to managing DM in any form is an early diagnosis. The beauty of seeing a physiotherapist regularly is that we are constantly monitoring your conditions and general health. If we suspect there may be an underlying problem that needs medical attention, we will discuss this with you and help direct you to the right person to ensure you receive the correct diagnosis and treatment. Diseases like diabetes are usually diagnosed under supervision of your GP. If you have any questions relating to DM, and how this may affect your ability to exercise, please speak to your practitioner next time you are in. We hope you found this blog informative and interesting. The key to managing disease and injury is to first understand it. If you have any questions, let us know and we’ll be happy to put your mind at ease!  References International Diabetes Federation. 2020. World Diabetes Day. [Online [Accessed 07 Oct 2020]. World Health Organisation. 2020. Diabetes. [Online [Accessed 07 Oct 2020]. Diabetes Australia. 2020. What is diabetes. [Online [Accessed 07 Oct 2020]. Uploaded : 17 November 2020 Read More
  • Foam rolling: Pros and cons

    Foam rolling: Pros and cons

    Foam rolling: Pros and cons New foam roller and wondering where to start? Have a read of this, and you’ll feel more informed. And if you still aren’t convinced or have more questions, feel free to ask us next time you are in the clinic and we will discuss it with you in person. For now, let’s keep on rollin’. Head into any sports store and there is a good chance they’ll have some foam rollers for sale. Foam rollers are widely available and have been used as a therapy aid by millions of people for years since first coming on the market in the 1980s. What is a foam roller? Foam rollers are usually cylindrical in shape, very lightweight, and range in length and firmness from long to short and soft to hard. Their design and use is simple. You simply lie the roller on the ground, choose a body part, place it on top and start rolling. But what are the actual benefits of foam rolling? Are there any potential side effects? Or negative impacts? Let’s take a look… History Foam rollers were originally used by practitioners that followed the Feldenkrais method of treating the body. Early practitioners used the rollers as a way of providing support to the body and would get their patients to stand on the rollers during balance exercises. Use of rollers progressed over the years. In 1987, their use as a self-massage tool was pioneered by physical therapist, Sean Gallagher. They are now used by millions of people across the globe, including gym goers, weightlifters, gymnasts, athletes and many others, as a tool to massage and release tight muscles. Pros Some of the benefits of foam rolling include: • Reducing muscle pain (including the management of certain pain syndromes like fibromyalgia)• Increasing range of motion around a joint• Making muscles more responsive to stretching• Relaxation• It’s a relatively safe way to self-massage tight muscles Cons Due to their widespread availability, foam rollers can be purchased by anyone, even though they may not be a suitable tool to use for that particular person. There are certain conditions and circumstances where use of a foam roller could be detrimental or damaging to a person’s body. Foam rolling exercises load and stress the underlying tissues, including nerves, skin receptors, blood and lymphatic vessels, as well as bones. People with conditions including advanced diabetes mellitus, lymphedema, varicose veins and severe osteoporosis should avoid this form of exercise, unless advised otherwise by a medical professional. When recovering from a muscle strain, a foam roller may be a handy thing to have around, but rolling over a torn muscle should be avoided in the early stages of injury and until you’ve been given the all-clear by your therapist. Rolling over an acutely torn muscle could hinder the repair of the muscle and at the very least would be incredibly uncomfortable and painful. Please note that scientific evidence supporting the use of foam rolling for therapeutic reasons is sparse and caution should be taken by anyone who uses them. Our advice to you is to ask your trusted physiotherapist if it’s suitable for you. We have the expertise to guide you in the right direction and if it’s a great option for you and your body, we’ll give you the thumbs up to rock’n’ROLL! References 1. Healthline. 2019. What are the benefits of foam rolling? [Online [Accessed 06 Oct 2020 [Accessed 06 Oct 2020 Uploaded : 17 November 2020 Read More
  • Rock Climbing

    Rock Climbing

    Climbing and musculoskeletal considerations by Martin Krause Good climbers use a combination of strength, endurance and flexibility. Power is developed by the arms through an upward throwing action of the arms, which instigates efficient eccentric muscle lengthening decelerating forces (rather than concentric - muscle shortening). Additionally, they are able to facilitate kinetic energy across the chain of movement from toes through the legs and pelvis into the trunk and torso. Ideal posture Ideal climbing involves extended arms to hang from thoracic extension, lateral flexion and rotation hip external rotation knee flexion and slight heel rise to develop power through the legs "An inch is a mile" In climbing, 'an inch is a mile' refers to delicate foot and hand placement where body length through the elongation of the thorax with thoracic ring elevation. The shoulder blade needs to elevate and allow the thorax to hang from it.  Restrictions of thoracic rotation results in excessive contralateral gluteal contractions. Inadequate shoulder flexion due to limited thoracic ring extension can cause reduced contralateral gluteal activity Gorillas on the Cliff Climbers can develop a 'gorilla-like' posture due to over emphasis on grip arm flexion a '6 pack' Since the abdominal muscles cross the lower 6 ribs, sufficient trunk core stability should not compromise the mobility (especially rotation) of the thorax. Excessive development of the low thoracic - upper lumbar erector spinae can create reduced gluteal muscle strength, reduced diaphragmatic breathing, increased psoas major tightness and reduced core stability. Postural problems associated with climbing could lead to musculoskeletal injury Climbers may develop a gorilla-like appearance due to the unique nature of the sport Gorilla-like appearance alters the centre of gravity of various limb and trunk segments this may lead to shoulder injuries, headaches, neck, arm and back pain Stomach crunches or 'curls' may cause tightness of the rectus abdominis ("6 pack") and external obliques at the expense of weakness of the transverse abdominis muscle increased thoracic kyphosis (rounded back) reduced diaphragmatic lateral expansion which contributes to the gorilla posture resulting in altered thoracic biomechanics which affects active SLR and active PKB suggesting reduced lumbopelvic rhythm (gluteal : hamstring timing) reduced strength in the lumbo-pelvic-hip musculature reduced gliding of the myofascial trains extending from the superficial front line of the latissimus dorsi to the superficial back line of the thoracolumbar fascia and the gluteals  Myofascial Trains Arm elevation normally results in contralateral gluteal and transverse abdominal activity in the 'wall plank' position Power = strength, speed and flexibility Training should involve functional movement patterns, whereby some muscles are used as stabilisers whilst others are used as mobilisers. The deeper lying endurance muscles tend to be the stabilisers and are frequently found to cross only one joint or work in an area of limited movement. The mobilising, power muscles, tend to be the 'energy straps' crossing more than one joint and conferring kinetic energy to the movement system. A balance between mobility and stability needs to be attained. Overhead reaching This requires extension and rotation flexibility in the thorax, as well as front of shoulder and chest flexibility. Balanced with this flexibility should be strength in the serratus anterior so that the thoracic rings can 'hang off the arms'.     The serratus anterior inter-digitate with the abdominal muscles which cross the lower 6 ribs. So, as the upper rib cage and thoracic rings elevate upwards, an eccentric lower thoracic ring stabilisation must take place to bring the semi squat power of the legs into play. Development of the scapular stabilisers An interplay with the muscular slings, their stabilisers and mobilisers comes into play.    The shoulder joint has a shallow socket which provides a surface for the large 'ball' (same size as the hip!) to interface. To maintain stability, the rotator cuff muscles need to provide consistent support and pressure around a centre of rotation. Since these muscles are attached to the scapula (shoulder blade), the shoulder blade requires correct and consistent orientation, otherwise the rotator cuff function is rendered useless (see example below if only the rhomboids [Rh] were used).    Read more about stability elsewhere on this site Excessive and prolonged reaching results in tight serratus anterior and pectoral (chest) muscles contributing to excessive strain on the blood vessels, nerves and joints of the shoulder - neck - arm complex (TOS = thoracic outlet syndrome) creates excessive low thoracic erector spinae activity contributing to loss of costal expansion, as well as reduced diaphragmatic rhythm has been associated with impingement in the supraspinatus (superior rotator cuff and subacromial bursa) muscle leading to discomfort in the shoulder with loss of muscle power during activities above shoulder height Acromioclavicular and sternoclavicular (collar bone joints) joints may become inflamed Overhead reaching can result in excessive strain on the back and shoulder blade muscles cause the rhomboids and levator scapulae to become long and weak facilitates the latissimus dorsi to become short and strong scalene muscle tightness, rib elevation and circulations compromise, similar to Thoracic Outlet Syndrome (TOS)  Training - the trapezius muscles requires synergistic (complimentary) action by the latissimus dorsi erector spinae (back) oblique and transverse abdominal muscles (not the "6-pack"!!) - the deltoid muscle requires synergistic action by the internal oblique and transverse abdominal muscles contralateral gluteal activation lumbar erector spinae activity - the serratus anterior needs synergy with the external obliques intercostals diaphragm - should replicate the combination of muscle synergies in the most climbing functional way as possible.   - arm strength requires gluteal strength   Bridging exercises with the Swiss Gym ball and elastic tubing allows functional activity which stretches the pectoral girdle and "6 pack" strengthening of the abdominal, spinal and shoulder blade muscles dynamic stability of the pelvis and hips allowing enhanced freedom of movement on the cliff face   "Prone bridging" allows abdominal, pelvic, trunk and arm control to be trained   Supine bridging can be used to develop gluteal and lower abdominal strength, especially when done, one legged. with the thighs consistently parallel. Whilst modified planks and side planks can be used to develop arm, gluteal and abdominal strength simultaneously. The following example from a client with pelvic pain demonstrates the muscle synergies required, across the body, and in particular around the pelvis, for functional integrity.    These exercises and modified versions of these can be used to improve climbing ability and agility. Functional exercises In climbing, ideally there are three points of contact, meaning that three points are either statically or dynamically stabilising whilst a limb is moving off the rock. The following describes a series of exercises for stability whilst moving various body parts Modifications can be made into climbing patterns, such as semi squat rather than sitting To reduce a "poked chin" the deep neck muscles need activation and the thoracic rings require elevation through Alexander technique and lateral diaphragmatic breathing   Clinical observations Clinically, people fall into two broad categories - the hypermobile or the hypomobile. Hypermobile people generally work with their ballistic power generating muscles, using inertia to stabilise. These ballistic muscles can be long and strong but also long and weak if they haven't been appropriately conditioned. Hypomobile people tend to use their slow twitch endurance muscles and have short tight ballistic muscles. General rule of thumb is that 'floppies' need to work on endurance and stability, whereas 'stiffies' need to work on their flexibility and ballistic power. It is also possible to have hypermobile soft tissue (lax joints) but tight protective overlying muscles. Floppies tend to be good at 'pulling' into themselves, whereas 'stiffies' tend to be better able to push away. Ideally, individuals should work at what they aren't naturally endowed with to gain a 'musculoskeletal' protective balance. Frequently, one finds the 'floppies' in the yoga class and the stiffies in the pilates class when it really should be the other way around. Interested readers should read the Joint Hypermobility Syndrome and Ehlers Danlos Syndrome section elsewhere on this website. Too much pulling, with too little stability can lead to shoulder subluxation and even posterior dislocation. These shoulders need to have the soft tissue at the back of the shoulder 'buffed up' and be very conscious of 'scapula setting' when commencing movements. Ideally, muscle synergies are developed where the nett gain of all muscles working at their most efficient level to gain a mutually beneficial movement outcome is what is desired. In such a scenario, the distinction between agonists and antagonists, postural muscles and ballistic muscles becomes superfluous, let alone one body part being dominant over another. Interested readers should read 'game theory' and 'deterministic chaos' elsewhere on this site    Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducible; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized ligamentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumb to his forearm Fingers, elbows and wrists are also common places for climbing injuries. Taping can be particularly useful in protecting and unloading tendinous structures. Conclusion Seek guidance from your physiotherapist as the ultimate aim is to improve your power-weight ratio without inducing an injury. An optimal combination of strength, stability, and mobility needs to be acquired across the the entire body. The following videos should give you an insight of some of the things which are possible. Laterality of thought, improvisation and proper progression of exercise should allow refinement of climbing technique as well as reduce the risk of injury. Hip stabilisation and thoracic mobilisation  Several exercises exist which stabilise the hip and shoulders whilst mobilising the thorax.  Swiss Ball exercises can also be used to improve thoracic ring stability Thoracic strengthening regimes should be instigated to maintain the ring alignment Stretching regimes - 'don't let the tail wag the dog' Many people stretch their limb muscles. However, if the thorax is the 'driver' of limb muscle tension, then the thorax needs to be nullified beforehand and/or involved in the process of stretching. For example both hamstrings and quadriceps can be stretched with lateral flexion and lateral breathing of the diaphragm. Classic moves out of yoga such as the 'down dog -> high plank -> warrior pose -> triangle' can involve rib cage movements. Don't forget the calf muscles!   Summary of leg, back and shoulder exercises Front, back, inside, outside and spiral 'slings'   References Shoulder stability : Hypermobility : Joint Stability : Game Theory and Cortical Resources : Pelvic - Hip - Lumbar stability : Thorax :  Conceptualised whilst working and living in the mountains of Switzerland and the Blue Mountains, west of Sydney, NSW, Australia (!988-2001) Uploaded : 13 October 2020  Read More
  • Hip pain in the elderly

    Hip pain in the elderly

    Hip pain in the elderly Joint pain in the elderly population is a common complaint, with women being affected more often than men. There are several causes of hip pain amongst the elderly. We’ve put together this quick-fire list to inform you of what can cause hip pain in our senior citizens. Joint disease One of the most common causes of hip pain in the elderly is joint disease that leads to degeneration of the joint surfaces and results in a poorly moveable joint. The most common condition affecting the hip is osteoarthritis (OA), affecting approximately 25% of the population. The hip is a weight-bearing joint and through a lifetime has to withstand a great deal of force passing through it on a daily basis. Many factors in a person's life can lead to the onset and progression of OA in the hip joint. An injury to the hip earlier in life can kick start a process of early degeneration leading to poor movement and the development of pain as a person journeys through the second half of life. Other factors that may lead to the development of hip OA include obesity and or poor exercise regimes (or lack of exercise altogether). Other forms of joint disease that can cause hip pain include rheumatoid arthritis (RA), gout and pseudogout. Bursitis The word ‘bursitis’ means inflammation of a bursa. A bursa is a small, fluid-filled sac found throughout the body around joints and areas of high movement to reduce friction. There are several bursae found around the hip. These are usually located between a bone and tendon (or other tissues) and help to maintain smooth-moving joints. Weakness or long-standing dysfunction of the gluteal and other hip-related muscles (often seen in the elderly) can lead to compression of the bursae which increases the load on them. Over time and repetition of movement, the bursae can become inflamed and cause pain, often felt on the bony, outside part of the hip. Bursitis can be treated with hands-on therapy and exercise prescription aimed at strengthening and improving movement at the joint. Frequently, bursitis has a immune-metabolic origin. Clinically, I noticed this when working with young elite Swiss sports people back in the early 1990's, that they could suddenly develop bursitis which invariably involved some sort of predisposing immune compromise. Commonly, this involved a case of diarrhea or a cold or similar, in the 6 weeks prior to the onset of the bursitis. I've continued to notice this trend across the spectrum of ages and physical activity in the decades since. A similar trend exists for tendinopathy as well. where scientific research has demonstrated invasion of immune and fatty substances. Moreover, the bursitis and tendinopathy usually co-exist. Please see the shoulder section of this website for details on the latter and see the section on immune system and chaos for the former.  Importantly, the gut biome should be consider in either case. The use of pro-biotics may be considered, such as sauerkraut, acidophilus, etc  Tendinopathy Tendons join muscles to bones. As we age, the health of our muscle and tendon tissue declines and the efficiency of movement is affected. Similarly to bursitis, long-standing muscle dysfunction because of a failing hip joint can place excessive load on the tendon which attaches the muscle (e.g. the gluteal muscles) to the thigh-bone. If strengthening of the muscles and tendons is not achieved in the early stages of injury or disease, the fibres that make up the tendon become degenerated and deranged, resulting in a condition known as tendinopathy. This affects the tendon’s ability to withstand high loads passing through it and can lead to pain, regularly felt before and after exercise or movement. Long standing tendinopathy can lead to a tear which is common in older persons and can be the cause of much disability. Lower back dysfunction This is a very common cause of hip pain in the elderly population. As we age, our spines and the various tissues that play a pivotal role in its functioning can become degenerated. If a degenerated bone or joint in the spine presses on a nerve coming out of the spine, it can lead to a phenomena known as ‘radicular pain’. This is pain that may be felt in the hip (or other areas of the lower limb) but actually the problem lies in the lower back. Fracture Due to the increased rates of conditions including osteoporosis (loss of bone mass) and sarcopenia (loss of muscle mass), we are more prone to falling as we get older. A fall onto the outside of the hip can easily result in a fracture of the neck of the thighbone, close to where it attaches into the pelvis. As with any bone fracture, pain is a common symptom. A hip fracture may require surgical intervention and can greatly impact the health of an elderly person with increased risks of infection and death posing a real threat. If you have hip pain and are concerned, please call us today on 02 9922 6806 to book your appointment immediately. Stay safe everyone! Uploaded : 2 October 2020 Read More
  • Meniscus tears

    Meniscus tears

    Injury blog: Meniscus tears Hello readers and welcome to another of our monthly health blogs. This month we take a look into the world of knee meniscus injuries. Studies from the US report approximately 61 in every 100,000 people experience a knee meniscus injury every year. You are more susceptible to injuring a meniscus in your knee if you participate in sports such as football (all forms), basketball, netball, skiing, baseball and wrestling. There is also a high rate of meniscus injury seen in those who work in the military on active duty. Essentially any job or sport that requires lots of squatting and kneeling can leave you open to an injury of this kind. But what is a meniscus? Anatomy The meniscus are found inside the knee joint, nestling nicely between the thigh and shinbones. They are crescent-shaped pieces of toughened tissue (a type of cartilage) and there are two in each knee. One sits on the outside part of the knee joint (i.e. lateral meniscus) and one sits on the inside part (i.e. medial meniscus). They act as shock absorbers to the various loads and forces that pass through the knee during movement. They also have a slightly wedge-shaped appearance being thicker around the outside compared to the inside, and this provides a deepening of the joint surface to allow for a more snug-fit joint. The top of the shinbone is quite flat compared to the very rounded ends of the thighbone… The meniscus help to stabilise this slight mismatch of joint surfaces. Causes of a tear The most common cause of a meniscus tear is an excessive or forceful twisting of the knee whilst the foot is planted on the ground. This might happen as a result of landing awkwardly from a jump, or from the force of another person or opponent’s body acting on the knee. During this type of movement, if the force is too much for the meniscus to withstand, tearing may occur. The medial (inside) meniscus tends to be injured more than the lateral (outside) meniscus. This is because the medial meniscus attaches to other structures inside the knee joint, leaving it less mobile to forces acting on it compared to its lateral counterpart. Signs and symptoms The experience of a meniscal tear will vary from person to person depending on the cause. A young footballer who has been injured during a tackle with high forces involved will likely present in a great deal of pain with a swollen and restricted knee. Injuries sustained in this way are likely to be more severe with associated ligament injuries as well. On the flip side, an older person who has been gardening for the weekend spending lots of time squatting and kneeling may present to the clinic with a very different picture. There may be no high force movement involved, but instead the tear has occurred due to degenerative changes that have occurred to the cartilage tissue. Symptoms in these types of injury are less likely to be so acute and may only appear 24-48 hours down the line. Signs and symptoms you might expect from a meniscal tear may include any or all of the following: • Pain when walking, squatting or jumping• Restriction of the knee joint with or without swelling• Knee joint locking• A popping or clicking sensation (often following an episode of locking)• A feeling that the knee may give way • Tenderness around the line of the knee joint where the tear has occurred Diagnosis and treatment The first thing to do if you have injured your knee is to see a physiotherapist as soon as possible. A painful, swollen, restricted and inflamed knee following an incident is a sign something is not right, so seek help quickly. We will ask questions about what has happened and examine your knee closely. Some people will be able to move around well, others with a severe injury may be more limited. The management of meniscal tears will vary depending on how the injury happened (i.e. are we also dealing with a ligament injury?), and the age and goals of the patient. In some instances, we might suspect a small tear and a patient is presenting with pain but has good overall movement and doesn’t have any of the more severe symptoms such as locking or giving way. In these cases,; we’d use hands-on treatment and exercise prescription in order to strengthen the knee and restore full function through massage, mobilisation and whole body movement. In instances where we suspect a large tear and a patient is presenting with high amounts of pain, restriction and locking and/or giving way in the joint, we may first need the assistance of some imaging or surgery (i.e. an arthroscope) to determine the severity and clear the knee of any large tears. Some tears require removal of the cartilage tissue whereas some can be repaired. The surgeon will always try to retain as much of the meniscus as possible to reduce the impact on knee mechanics following recovery and for the future. Regardless of the initial management, rehabilitation will aim to: • Reduce pain and increase range of motion to the knee• Improve strength of the quads, hamstrings, calves and other knee and hip related muscles• Return to sport or previous duties as soon as possible without risking further injury Seeing us as soon as possible will help to limit complications and help get you back to 110% (we always like to get you back fitter than you were before the injury!) at the earliest possible opportunity. Whether your goal is to garden or return to kicking goals, we can help get you there. Call us today on 02 9922 6806 to book your appointment. And squat! Uploaded : 27 September 2020 Read More
  • Sacroiliac Pain - imaging and stability testing exercises

    Sacroiliac Pain - imaging and stability testing exercises

    Sacroiliac Pain - imaging and stability testing exercises The sacroiliac joint (SIJ) is designed to transfer the load from along muscle energy straps of the limbs into the torso. The torso, hip and pelvis are constructed into a series of slings (front, back, side, inside and spiral) which supports those structures receiving the load. Consider a person lying in a hammock and you have an analogy, for skeletal support, by the soft tissue structures of the body. Andre Vleeming described these 'slings' in the 1990's and body work practitioners such as Ida Rolf (and Thomas Meiers) referred to myofascial trains in the 1970's. As such, a series of exercises can be used to assess and treat stability across the SIJ. People interested in the 'energy straps' across the lower limb should look at 'inverse dynamics' elsewhere on this site. Inverse Dynamics Those interested in 'hands on' treatment of pelvic dysfunction should look at : elsewhere on this site  Uploaded : 19 September 2020 Read More
  • Tips for sleeping like a baby

    Tips for sleeping like a baby

    Tips for sleeping like a baby Do you consistently struggle to get a good night’s sleep? Well lucky for you we’ve compiled a helpful little guide to getting the best Zzz’s’s possible. It’s easy to get caught up in life and develop nasty habits that can affect our body’s ability to get itself prepared for lights-out time. Read on for tips on taking control of your sleep. • Create a routine: Routine equals consistency. If it’s possible, try to stick to a routine of going to bed at the same time every day. This would ideally run throughout the whole week, including weekends. There will always be occasions where you won’t be able to stick to this… meals out, parties, etc. But when that happens, try to get straight back into your routine as soon as possible. Your body will respond well to routine and you may find falling asleep easier once you are locked into a pattern. Think about including some relaxation time each night where you snuggle up with a book or drink a soothing cup of chamomile tea. • Create the ideal environment: What is your bedroom doing for you? Is it too hot or too cold? Temperature is important for creating the ideal sleep environment. The Sleep Foundation recommend a room temperature between 15.5 – 19.5 degrees Celsius for optimal sleep. Also, think about keeping your bedroom as noise and light-free as possible. And of course, a comfortable pillow and mattress to support your body is a must! We can help find a suitable option when it comes to pillows and mattresses. Chat to us next time you’re in the clinic. • You get out what you put in: Try to avoid smoking, drinking alcohol and eating a hearty meal before bed. Aim to eat your last meal a minimum of two to three hours before you hit the sack. All of these things can lead to disturbed sleep and increase the risk of wak-ing up tired the next day. The saying sticks… you get out what you put in! • Bedroom = sleep: This is a big one. Technology is finding its way into our bedrooms more and more. For many people it’s the only time they get to switch off and check their social media accounts or catch up on emails. But we recommend avoiding screens. Keep your bedroom for sleep and sleep only. If you have to use a screen before bed, set aside time earlier in the evening to get this work done. The light given off by tablet or phone screens stimulates the brain, when in reality, you should be trying to relax, allowing it to switch off. • Avoid daytime naps: We all know how nice it is to have a little siesta during the day. But there is logic in the assumption that if you struggle to sleep through the night, removing your daytime nap could help to regulate your night-time sleep pattern. • Exercise regularly: Emerging research into the effect of exercise on sleep shows that light-to-vigorous exercise helps a person to fall asleep faster and improves the overall quality of sleep. It is thought that exercise helps to increase the amount of deep sleep you get, as well as helping to de-stress the mind to allow for a more relaxed cognitive state. We suggest not trying to implement all of these at once. Why not pick just one or two changes and work with them for a few weeks. It may take some time to find what works best for you. References1. Help Guide. 2019. How to sleep better. [Online]. Available from: [Accessed 15 Jul 2020]2. 2020. Healthy sleep tips. [Online]. Available from: [Accessed 15 Jul 2020]3. Johns Hopkins Medicine. 2020. Exercising for better sleep. [Online]. Available from: [Accessed 27 Jul 2020] Uploaded : 25 August 2020 Read More
  • Hip flexor injury: Contusion vs strain

    Hip flexor injury: Contusion vs strain

    Hip flexor injury: Contusion vs strain Hey everyone! This month we are drawing focus on injuries that affect our hip flexor muscles. Injury to the hip flexor muscles can lead to pain felt in the front of the thigh region, as well as the hip and groin. Hip flexor injuries are common in sports, including football (all forms), basketball, hockey and athletics. What are your hip flexors? Your hip flexors are a group of muscles that move the thigh forwards and outwards, in front of the body. The main muscles involved in the movement of hip flexion include: • Rectus Femoris (one of the quadriceps muscles)• Iliacus and psoas (pronounced ‘so-ass’ — collectively known as the ‘iliopsoas’ muscle)• Tensor Fascia Latae (or TFL)• Sartorius• Some of the groin muscles known as the ‘adductors’ The most commonly injured hip flexor muscle is the rectus femoris muscle (pictured above). This is the muscle that runs from the pelvis, down the centre front of the thigh, to below the knee. This muscle not only flexes the hip, but also extends (or straightens) the knee. Types of injury The most common injuries of the hip flexor muscles (i.e. rectus femoris) include contusions and strains. Contusion: A contusion is an area of skin and underlying tissue that has been damaged by a blunt force trauma. This may come in the form of an opponent’s knee during sport, or an object like a hockey puck striking the thigh. A contusion is also known as a ‘cork’’. The impact of an object causes the tiny blood vessels under the skin and in the muscles to break and bleed. The blood collects into a space around the impacted muscle fibres creating a pool of blood. A bruise appears on the skin where the impact has occurred. Strain: A strain is a tearing of muscle fibres usually caused by a force too great for the muscle to withstand. This may occur during an explosive movement including kicking, jumping or running. Strains are either partial (where some muscle fibres tear and others remain intact — known as Grade 1 or 2 strains depending on severity) or complete (where every muscle fibre tears — known as a Grade 3 strain or in the old nomenclature Grade 3 partial complete full thickness tear, grade 4 complete tear. The latter is still commonly used in calf tears). Strains most commonly occur at the location where the muscle merges into a tendon. In the case of the rectus femoris muscle which runs vertically down thigh, strains usually occur at either the hip-end or the knee-end of the muscle. It can be difficult to distinguish between a contusion and a strain as many of the signs and symptoms are similar. A thorough case history which takes down information including how the injury occurred and how it developed over time can help your physio come to an accurate diagnosis. Signs, symptoms and features The following table compares the features seen with a typical contusion versus a strain: Treatment The way we treat a contusion and a strain are very similar. The length of treatment tends to increase for more severe strain injuries, but the principles of treatment are largely the same. As with any acute injury, the first line of treatment is to control the bleeding and swelling under the skin. This includes protecting the body part from worsening injury, loading the part appropriately (i.e. being on crutches vs full weight-bearing), ice, compression and elevation of the affected body part. Gentle stretching and contraction of the affected muscle is allowed if tolerable. The next stage is to get the knee and hip joints back to full, pain-free range of motion. We can help here with some hands-on massage and joint mobilisation. We’ll kick up the stretching and increase the amount of strength training too. You should be able to use an exercise bike and go swimming at this stage, but we’ll advise when you can do it safely. When you are back to full weight-bearing exercises with full range of motion, the aim is to progress strength and flexibility exercises gradually over a period of weeks. These will include a combination of agility, jumping and balance exercises. When you reach your exercise goals, we’ll advise when return to training/full sport participation is appropriate… If that’s what your ultimate goal is. The most important thing is to ensure the return to sport/activity does not happen too soon. Strains commonly recur, usually as a result of rushed or incomplete rehabilitation before returning to the sports field. So… taken a hit or felt a tear? Give us a call on 02 9922 6806. If you need help with a hip flexor injury, please do not hesitate to get in touch immediately. Early treatment is always preferred over the waiting game. With our help, you’ll be back hopping, skipping and jumping your way to a gold medal in no time at all. References 1. Healthline. 2019. Understanding hip flexor strain. [Online]. Available from: [Accessed 15 Jul 2020].2. Brukner, P. et al. 2017. Clinical Sports Medicine. 5th ed. Australia: McGraw Hill Education3. Margo, K. et al. 2003. Evaluation and management of hip pain: An algorithmic approach. The Journal of Family Practice. 52 (8). Available from: Uploaded : 25 August 2020 Read More
  • Whole Body Vibration

    Whole Body Vibration

    Whole Body Vibration (WBV) by Martin Krause In 2009, we (Alfio Albisini and myself) published the first book (DOI: 10.1016/B978-0-7020-3173-1.X0001-4) on the therapeutic application of Whole Body Vibration (WBV). Since that time, new research has described, some new and novel mechanisms and effects of WBV. Introduction Most human movement involves low amplitude, moderate frequency vibration (<1g, 30-90Hz). Such mechanical loading results in what is termed mechano-transduction. The transition of a mechanical load to a hormonal response, involves the stimulation of hydroxyapatite crystals (interspersed amongst a collagen matrix), which in turn has an influence on osteoclastic (bone mineral resorption) versus osteoblastic (bone mineral forming) activity. As such, the use of WBV therapy, in the treatment of osteoporosis in the frail elderly, or young individuals with osteogenesis imperfecta, has become popularised in recent decades. Additionally, within the fitness industry, entire gym programs exist, which incorporate WBV machines (e.g. Galileo), to improve strength and agility. Although, superimposing exercises on WBV is very popular, the effect of 4 weeks of heavy strength training, superimposed with WBV, have shown equivocal results, when examining corticospinal neuronal drive (Weigal AT & Kidgell DJ 2012 The Scientific World Journal Article ID 876328 ). Twelve participants (6 male and 6 female aged between 18 and 27) performed four sets of six to eight repetitions at 80% of 1RM, with three minutes recovery between sets. WBV was set at 35hz and 2.5mm displacement. It may well be, that WBV has more obvious effects on people with greater functional impairment. One investigation, in poeple with strokes found, the effect on muscle strength and balance and gait function, were small. However, the effect for bone metabolism and spasticity were moderate, suggesting that WBV training may provide a safe, alternative treatment method for improving the symptoms of stroke (Park YJ 2018,BioMed Research International Article ID 5083634 ). Mechanisms It has been suggested that WBV works via at least two mechanisms. The first, traditional mechanism, was a direct influence on muscle mechanics. It was thought that the stimulation of working muscles stimulated the hydroxyapatite crystals and hence the osteocytes in the bone, thereby ameliorating osteopenia and osteoporosis. The more contemporary thought, is that WBV has a direct influence on the stimulation of the osteocalcin, residing on the bones, which in turn acts on the muscles, preventing or ameliorating sarcopenia, which then provides the functional strength needed for weight bearing activities and sporting accomplishments. It could obviously be both, where a cycle exists, of one influencing the other. If this were the case, then in functionally impaired people, the direct influence of the vibration on the bone will be more critical to muscle mass than in the athletic environment, where the exercises themselves, accompanied by the vibration, has a more profound direct effect on muscles, over the indirect effect from the bone? Frail elderly and athletes Apart, from the therapeutic effects on the bones and muscles of the frail elderly, WBV has also been used to improve sporting performance, in athletes, through the stimulation of muscle. At lower frequencies (<20Hz) WBV is thought to help with muscle relaxation and hence can be used during stretching routines. WBV has also been used to improve explosive strength and postural control thereby enhancing athletic performance (Fort A, et al 2012, J Strength Cond Res. 26, 4, 926-36). At higher frequencies (30-50Hz), it's been used as an adjunct to plyometric (box jump) strength training, as it is thought, that each oscillation, is the equivalent to a jump, at a neurophysiological (muscle spindle receptor - spinal cord) level. The addition of functional exercises, to the passive WBV stimulation, probably brings higher center motor control in to play. In fact, investigators have demonstrated enhanced descending modulation after 10 minutes of WBV, as well as reduced spinal cord reflex activity in the soleus muscle (Krause A et al 2016 J Musculoskelet Neuronal Interact., 16, 4, 327–338). In another investigation, it was shown that WBV, during squat exercise, compared to no WBV, led to a corticospinal facilitation concomitant with intracortical modulation, thus describing increased intracortical inhibition and diminished intracortical facilitation (Mileva KN et al 2009, Exp Physiol., 94, 1, 103-16). One could assume that these results represent enhanced motor control. WBV has also been used, in a variety of other settings, to improve implant adherence to bone, in people with bone softening (Zhaoug et al 2015 Bone, 71, 17-24, , used in neurological conditions, such as stroke (Tankisheva E, et al 2014, Arch Phys Med Rehabil., 95, 3, 439-46). and cerebral palsy (Ahlborg L, et al 2006, J Rehabil Med.,38, 5, 302-8), to improve balance and muscle spasticity, to improve gait after spinal cord injury (Ness LL, et al 2009, Gait Posture. 30,4, 436-40), as well as being used to improve cosmonauts musculoskeletal health, after prolonged space missions. Children with haemophilia 30 children (aged 9-13 years) with haemophilia. were divided into 2 groups, comparing standard physiotherapy to WBV (30-40Hz, 2-4mm amplitude, 15 minutes, 3 x wk for 12 weeks) in conjunction with standard physiotherapy. Researchers found that children in the vibration training group showed significant improvement in all outcomes including quadriceps strength, bone mineral density, and functional capacity, which was evaluated using a six-minute walking test. Children in the vibration training group were able to walk an average of 325 meters in six minutes compared to only 290 meters in the standard physiotherapy intervention group (El Sharmy S 2017 J Musculoskelet Neuronal Interact, 17, 2, 19-26). Osteocalcin Traditionally, bone has been considered an inert structure. Purely, providing the frame where upon muscles exert their work, through the bony levers. However, contemporary evidence suggests that bones are more than mere mechanical levers, where in fact the reverse applies, whereby bone acts on muscles. It's been suggested that bone remodelling is an energy intensive process which requires a sensor and regulator of energy needs. This hypothesis led to the demonstration a few years ago that osteocalcin, an osteoblast-derived protein, was a hormone regulating glucose and energy homeostasis (Lee NK (2007) Cell, 130, 456-469). Such an energy system, would suggest a gut-bone and a muscle gut axis. Indeed, gut-derived hormones such as glucagon-like peptides 1 and 2 and serotonin have been shown to regulate both bone remodelling and energy homeostasis (Henriksen DB et al (2009), Bone 45, 833-842; Ma, X et al (2013) Bone Miner Res, 28, 1641-1652; Sumara, G et al (2012) Cell Metab.,16, 588-600; Yadav, VK et al (2009) Cell 138, 976-989) Osteocalcin (glutamate derived decarboxylated structural protein), resides on the surface of bones, and has several interactions with organs, thus making bone an endocrine organ. Animal models, have shown that reduced osteoclacin leads to type II diabetes, obesity, and hypertension (Moser SC et al 2019, Front. Endocrinol., 10, January  Matthieu Ferron & Julie Lacombe (2014) Additionally, the review (Moser et al 2019) suggested that reduced osteocalcin affects male fertility, muscle mass (especially in the presence of sarcopenia), cognitive ability, brain development and inflammation. Even, suggestions of effects on tumours has been entertained. Apart from the effect of osteocalcin, on insulin sensitivity, described above, additionally it has been shown, in vivo mice experiments, that osteoblasts have Glut 4 receptors metabolically involved in glucose absorption, at a rate similar to that seen in muscle (Li Z et al 2016, Endocrinology, 157, 11,4094-4103). Presumably, WBV can have a direct effect on osteoblasts as well as osteocalcin, suggesting a dual mechanism of action? Moser et al 2019. Front. Endocrinol., 10 January | WBV, insulin sensitivity, inflammatory markers and DNA injury in white blood cells Investigators (Yin H et al 2015 Springerplus, 4, 578,, using an animal model, demonstrated profound effects, of WBV, on markers of inflammation and glucose metabolism/sensitivity. Improved Glucose Sensitivity Reduced Inflammation Indication of DNA injury in white blood cells markedly reduced in WBV Conclusion Since publishing our book in 2009, both human and animal research has shed more light on some of the significant beneficial effects of WBV. Furthermore, the mechanism by which it has such an effect, seems to reside within bone itself and osteocalcin in particular. Further research is still required to establish dose - responses in various population groups, from the frail to elite athletes. Never-the-less, currently, stimulation <20 Hz is considered to improve muscle relaxation. Stimulation in the range 30-50 Hz improves muscle power. Stimulation at higher frequencies (>1g and >50Hz) needs to establish a risk-benefit ratio in various population groups. Currently, when considering dose,  we suggest a familiarisation period of 2 weeks, with short duration sessions (10-20 minutes), incrementally increasing these up to an hour in healthy population groups. A similar strategy can be employed during rehabilitation, so long as functional outcomes are being monitored, whereby incremental increases in dose, are reflected through demonstration of continued improvement. Individual technique and fitness levels, as well as the morphology of the person (muscle mass, floppy vs stiffy) will considerably influence the selection of dosage and the tolerability of the WBV stimulus.   References Uploaded : 23 July 2020 Updated : 26 July 2020 Read More
  • The twists and turns of torticollis

    The twists and turns of torticollis

    The twists and turns of torticollis Hello readers and welcome to our August 2020 blog. This month’s topic is a neck condition known as ‘Torticollis’. You may have also heard this condition referred to as ‘wry neck’.  What is Torticollis? Torticollis is a painful neck condition where one of the strong muscles on the side of the neck shortens, causing the head to twist and tilt out of its normal position. The muscle we are referring to is the ‘Sternocleidomastoid’, or SCM for short. It’s easy to locate this long ‘strap’ muscle… Turn your head to the left and the SCM pops out on the right-side of the neck. Trace a line from the base of your skull just behind the ear, down to the top of your breastbone and you should be able to feel the muscle. Although the name is a bit of a mouthful, it perfectly describes the at-tachment points for the muscle on the body: • Sterno- refers to ‘sternum’ which is the name of your chest / breastbone• Cleido- refers to ‘clavicle’ which is the name of your collar bone• Mastoid- refers to the ‘mastoid process’ which is a bony lump found behind the ear at the base of the skull There is a SCM muscle on each side of the neck. This muscle helps you to:• Turn your head to the opposite site• Touch your ear to your shoulder• Bend the neck forward• Tilt the head backwards• Breathe (it is an ‘accessory' muscle for breathing - kind of like a little helper to the main breath-ing muscles) Types and causes There are two main types of torticollis—congenital and acquired.Congenital torticollis means the condition is present at birth. This problem can develop in the mother’s womb if the baby’s head is held in an awkward position, or if the blood supply to the muscle is disrupted. Sometimes the bones in the neck do not develop properly and become fused together, this can also lead to a rare type of torticollis called Klippel-Feil Syndrome. Acquired torticollis means the condition develops after birth. The condition is common in both children and adults. Acquired torticollis can be caused by injury to the muscle, or the nerve that supplies electricity to the muscle. In the majority of cases, the cause is completely unknown. As with congenital forms, there are some rarer acquired types, including ‘spasmodic’ torticollis. This type is also known as ‘cervical dystonia’ and is a form seen in adults where all the usual symp-toms are seen, but may also come with a jerking type motion of the head caused by spasms in the SCM muscle. Signs and symptoms The signs and symptoms of torticollis depend on the type, but the main features include: • Neck pain and/or stiffness• An inability to move the head in the usual way• A tilted head to one side• Swollen and tender neck muscles• Uneven shoulder height• Headaches Treatment Parents reading this who have experienced torticollis with their newborn or young child will prob-ably remember the stress that comes with seeing their helpless little human with a seemingly un-changeable head position. It really is quite unsettling. The good news is that for the majority of cases, some focused regular stretching is all that’s needed to correct the head position and re-store the muscle to its full length. Young children usually respond very quickly to hands-on treatment. Some of the rarer congenital forms of torticollis can also be treated in a similar way, but these forms may also require the opinion of a surgeon who can perform a procedure to lengthen the muscle. As with a lot of conditions, surgery is a last resort and will only be considered when all non-surgical treatment techniques have failed. Other treatment techniques used for torticollis include:• Massage of shortened and tight muscles• Heat pack therapy to increase blood flow and relax tight muscles• Joint mobilisation and manipulation For people who live with a permanent or chronic torticollis, other complications are common. These include difficulties carrying out activities of daily living, depression, social isolation and chronic pain. Treatment should be from a multidisciplinary approach. This means that as well as seeing your physio for hands-on therapy, your doctor, psychologist, friends and family will all play a part. If you or a family member are struggling with torticollis, or a neck issue of another kind, please call us here at Back in Business Physiotherapy on 02 9922 6806 to arrange a convenient time to come in for a consultation. We’d love to help unravel the twists and turns of your torticollis and get your neck feeling relaxed and happy Uploaded : 20 July 2020 Read More
  • Injury blog: Shoulder impingement

    Injury blog: Shoulder impingement

    Injury blog: Shoulder impingement Do you have shoulder pain? Are you an office worker, professional athlete, hairdresser or full-time parent? These are just some of the types of people we see in the clinic who need help with shoulder pain. One of the most common complaints we treat here, at Back in Business Physiotherapy, is shoulder ‘impingement’ (aka subacromial impingement). “What is impingement?” we hear you ask. Read on to find out. Anatomy overview The shoulder is a pretty complex region of the body when it comes to anatomy and how it all works together to allow us to move. The connections between the arm bone ( humerus), collar bone ( clavicle), shoulder blade (scapula) and the rib cage, provide us with the perfect base for a limb that is able to move through an extremely wide range of motion… The most movement out of any other joint in the body. Having lots of movement is great because it means we can do lots of wonderful things like reach the back of our head to wash our hair and reach our backs too (like when tying an apron). In order to achieve this level of movement the shoulder has to be less stable, and this leaves it prone to injury. The arm bone and shoulder blade form the ‘ball and socket’ part of the shoulder, where a large amount of the movement takes place. The ligaments between these bones are quite loose and a group of muscles, known as the ‘rotator cuff’ muscles, help to keep the ‘ball’ of the arm bone po-sitioned correctly over the ‘socket’ of the shoulder blade, as well as aid with certain movements, including rotation or turning of the arm. Small spaces..... Over the top of the ball and socket joint sits the ‘acromion’, which is a bony prominence of the shoulder blade which creates a roof over the joint. Between the top of the ball and the bottom of the acromion is a small space known as the ‘subacromial space’. Some tendons of the arm muscles that create movement of the shoulder pass through this space on their way to their at-tachment site on the bones. There is also a ‘bursa’, which is a small sac of fluid which helps to keep movements around joints smooth and frictionless. There is quite a lot of tissue all crammed into one small space, and this is an important factor in the development of impingement. Common causes of shoulder impingement include:• Repetitive overarm throwing or other above-shoulder movements• Long-standing poor posture or poor movement patterns• De-conditioned or weak shoulder muscles from leading a sedentary lifestyle• Heavy lifting Immune metabolic compromise can also affect the tendon-bursa complex. These include high cholestereol, diabetes, irritable bowel syndrom, etc Anything that leads to the structures which pass through the subacromial space becoming irritated and inflamed can cause impingement-related pain. Inflammation can lead to swelling of the tissues in the small space and when we move our arm up or out to the side, these tissues get pinched between the bones, and we feel pain. Any of the above-mentioned structures can be-come inflamed, but there is rarely just one tissue solely responsible. If the tendon of a rotator cuff muscle is inflamed, there is every chance the bursa will also be inflamed. Signs and symptoms Signs and symptoms of shoulder impingement include:• Pain with arm movements (particularly movement in front and out to the side of the body)• Pain with shoulder rotation• Pain that radiates down the outside of the upper arm• Reduced shoulder range of motion Treatment At the root of most cases of shoulder impingement is poor and inefficient shoulder movement. When you come to see us for treatment, we will look beyond the shoulder to other areas of the body, like the spine. The neck and mid-back areas of the spine are regularly restricted and need some help to move well again. Once the spine moves well, shoulder function improves too. The shoulder blade also needs to sit correctly over the rib cage in order for the ball and socket joint (and other joints) to work efficiently. Weakness of the muscles which stabilise the shoulder blade on the rib cage can lead to poor positioning of the blade during movement, so we will aim to improve this by giving you focused strengthening and stability exercises. A solid base = good, smooth movement. Through a combination of us using our hand techniques (like massage and joint mobilisation), progressive exercises and lifestyle changes, you can expect to see positive changes quite quick-ly. The end goal of ensuring your pain doesn’t return is always a lengthier process and requires dedication from yourself (and us) to make sure the changes we make early on stay in place for time to come. We are here to help you every step of the way. Shoulder pain? Call us today on 02 9922 6806 Uploaded : 3 July 2020 Read More
  • Shoulder injury blog: Labral tear

    Shoulder injury blog: Labral tear

    Shoulder injury blog: Labral tear The shoulder is one of the most complex joints in the body. It is made up of a total of four joints, numerous ligaments, joint capsules, muscles and other soft tissues. Movement at the shoulder is a complicated process and it relies on the controlled function of all the involved muscles and joints for that movement to be efficient and complete. Our shoulders are the most mobile joints in the body which is great for us because it means as humans we get to partake in fun activities like throwing sports, gymnastics and dancing, as well as movements we generally take for granted like being able to do up our bra’s behind our backs. This wide range of movement is only possible because the shoulder is less stable when compared to other joints in the body, leaving the shoulder prone to injury. This blog specifically focuses on an injury that relates closely to the ball and socket part of the shoulder joint. If you are into throwing sports, you may be familiar with it… It’s called the labral tear. A bit of anatomy… There are two main ball and socket joints in the body, found at the shoulder and the hip. Both work where a rounded ‘ball’ of one bone fits into a hollowed ‘socket’ of another. At the hip (the strongest joint in the body), the socket is very deep, and the ball part fits quite snuggly into it. This is a very stable joint. The socket in the shoulder is very shallow by comparison, and the ball part is still quite large. This is what gives the shoulder its lack of stability. Both the shoulder and the hip sockets are deepened and supported by the presence of a labrum — a rounded soft-type of cartilage. In the shoulder, the labrum completely surrounds the rim of the socket creating a ring. The very top part of this ring also acts as the attachment site for one of the tendons of the biceps muscle — a powerful mover of the shoulder and elbow joints. How does a labrum tear? The main ways labral tears occur are: • Repetitive movements such as overhead throwing• Carrying heavy objects• Dropping and catching heavy objects A tear can occur over time as the tissues degenerate over time and become weaker, or it might be from one single, forceful event. In most cases there is usually a combination of both degeneration and a large force which becomes the ‘straw that breaks the camel’s back type of scenario. As the biceps tendon attaches to the socket through the labrum, any large force that pulls on the biceps tendon (like suddenly catching a heavy object) can lead to the tearing of the labrum itself. The most common type of tear occurs across the top of the labrum from front to back, and these are known as SLAP (i.e. Superior Labrum Anterior Posterior) tears. Signs and symptoms If you have sustained an injury to the labrum in the shoulder, you may notice any or all of the following signs and symptoms: • Pain during shoulder movement (especially overhead and behind back movements)• Restricted shoulder movement• Popping, catching or grinding during shoulder movements• Tenderness at the front of the shoulder Depending on how you were injured, how severe your symptoms are, and your personal circumstances regarding work and home life, you may be sent for some imaging to confirm the tear. The tests we perform in clinic when we assess you do not always give us all the information we need to determine the best plan of action. A combination of clinical tests and imaging may give us a clearer picture of what’s going on. Can it be treated by a physio? Yes, but this completely depends on the severity of the injury and what your goals are. In most cases it is recommended that conservative therapy from a physiotherapist is tried first. Many athletes who have a labral tear can return to playing to some capacity with a non-surgical approach. The treatment aims to return the shoulder to full, pain-free range of motion through hands-on massage, mobilisation and rehab exercises that focus on range, control and strength of the shoulder girdle. For severe tears, you may require the opinion of a shoulder specialist. A labrum is not great at healing itself and sometimes needs help from a surgeon to return to normal. A professional athlete wanting to return to sport may choose this pathway, but a non-athlete who has no desire to throw a ball seriously again may be able to avoid surgery altogether. If you have a diagnosed labral tear, or have recently injured your shoulder and need help, we recommend coming to us at Back in Business Physiotherapy where we can discuss the best course of action for you and your circumstances.  Upload : 2 June 2020 Read More
  • COVID mental health check-in

    COVID mental health check-in With the coronavirus outbreak still affecting millions around the world, we thought it would be a good time to check-in and see how you are all going. The news is pretty grim at the moment and you may be finding yourself asking the question, “When will there be any good news?!” This day-to-day bombardment of the effect of the virus across the world is enough to get the happiest of people down. We’re here to make sure you are keeping your mental health in check. We ask you the question… What are you doing to look after your mental health? These have been difficult and stressful times for many of us. Some of us are starting to come out of strict lockdown restrictions, some of us are still feeling the effects, and many of us will feel these ef-fects for some time to come. It’s good to talk If you are struggling on a daily basis and this pandemic has had a real effect on your mental health, you are not alone and help is out there. Being made to stay away from family members and friends is tough and some people, especially the elderly, will have found this extremely diffi-cult at times. Please talk. A phone call or face-to-face video call (technology is great these days!) is a simple way to stay in touch with loved ones. Speak to someone close to you if you are struggling with personal circumstances. Getting a load off your chest is sometimes enough to make you feel relief, even if it doesn’t solve the root cause of the problem. We understand that your problems may run deeper than this and talking to a loved one is simply not enough. The good news is there are lots of great people out there who are trained to work through such things with people. And even if you cannot get a one-to-one session in person where you live, many mental health professionals including life coaches, counsellors and psychologists are running phone or video/telehealth sessions with their clients. Alternatively, chat to your GP or give Beyond Blue a call on 1300 22 4636. Please do not suffer in silence. Simple tips for keeping your mental health in check  Want some other ideas to help keep your mental health in check? Check out our list below for some go to’s: • Exercise: It’s simple and well researched. Exercise helps to maintain good mental health. Even in lockdown, find a space in the house or outside in the garden and just move. Squat, lunge, hop, skip, jump, dance… We don’t care what it is, just move regularly (and safely please!).• Eat well: Keep your diet clean and hydrate every day and you’ll be doing your bit to keep the body and mind functioning well. Vegetables and fruit of the green leafy and berry va-rieties are packed with nutrients that can help keep the brain healthy.• Go to time-out: No, we don’t mean the naughty step, more so a quiet place where you can be with your own thoughts without the distraction of TV, tablets and other types of media. Read a book, take a bath, give the eyes and ears a rest from it all. It may be hard to break your screen habit, but trust us... It’s refreshing!• Get out the colouring pencils: Yes adults, we are talking to you. Colouring is becoming a very popular ‘escape’ for millions of adults around the world. It has been shown to help reduce the effects of anxiety and stress. Get to your local book store or newsagent to-day, support local shops, and start getting creative (or if you’re unable to do so safely, order online).....or do an amazing puzzle. They are addictive!!! Our message today is simple. Life is sometimes hard, but there is always action you can take to reduce the impact this has on your mental health. Talk. Move. Engage. Relax. Enjoy and stay safe. The Team from Back in Business Physiotherapy Uploaded : 2 June 2020 Read More
  • Injury blog: Abdominal hernias

    Injury blog: Abdominal hernias

    Injury blog: Abdominal hernias Mention the word ‘hernia’ and most people will think of something painful sticking out of the belly region. You’ll be pleased to know this is not always the case. Many cases are completely pain-free and are only noticeable on a person when they are in a particular position. At other times there may be no other visual sign that a hernia even exists! Read on for more information... What is a hernia? A hernia is a protrusion of the abdominal contents (i.e. intestines) through a weakened or damaged part of the muscle or tissue that holds it in place. Hernias are commonly found in the abdominal region of the body; that area between the bottom of the rib cage and the hip / pelvic area. Abdominal hernias can be broken down into two locations: • Abdominal wall location: Hernias that occur through the wall of the abdomen on the front of the belly region• Groin location: Hernias that occur lower down in the abdomen around the groin region  Abdominal wall location There are a few different types of abdominal wall hernias with the most common being: • Incisional: These hernias occur in and around a scar or ‘incision’ left over from a previous abdominal surgery. During surgery, the muscles of the abdominal wall are cut to allow the surgeon to access the inside of the abdomen. This leaves a weakened area of the wall which is a potential site for herniation to occur. This type of hernia accounts for approximately 10-15% of all abdominal hernias. • Umbilical: This is a protrusion at the belly button which is regularly seen from birth. Over time these usually dry up and disappear altogether. It is possible to get these hernias as an adult too, usually as a result of being overweight or pregnant. • Epigastric: There is a tough, fibrous piece of tissue that spans from the tip of the rib cage to the pelvis in the mid-line of the body known as the ‘Linea Alba’. This forms an area of muscular attachment of the abdominal muscles. Due to a weakness in the abdominal wall above the belly button, a hernia can occur. This is common in infants, but again may happen later in life. Groin location • Inguinal: This is the most common type of abdominal hernia accounting for approximately 75% of all cases. The opening for this hernia is a region known as the ‘inguinal canal’ which allows for the testicles and spermatic cord to descend into the scrotum during male development. After this event, the canal should tighten, but in some males the muscles responsible for this do not respond as well as expected, leaving an area of weakness. As females do not forego this part of development, it rarely affects women. • Femoral: There is a space in the floor of the abdomen for a vein and artery to pass through and down into the leg, known as the femoral canal. In females this canal is wider which results in this type of hernia being more common in women than men. It accounts for approximately 10-15% of all abdominal hernias. Treatment Treatment of abdominal hernias depends on the severity and symptoms associated with them. Sometimes with a hernia, the abdominal contents inside them can become trapped and ‘strangled’, ’which can lead to loss of blood supply and ultimately death of tissue. These complications can possibly be fatal if left untreated. In these cases, and with most uncomplicated cases, surgery is the best course of action to ensure a full recovery. There is also a place for physical therapies like physiotherapy. Physio is particularly helpful following a surgical procedure to aid with strengthening of the abdominal muscles and surrounding area, supporting the area and reducing the risk of re-herniation. Scar tissue following surgery can affect our ability to move efficiently, however exercise as well as hands-on therapy can help to reduce the effect of this. If you have an abdominal hernia and would like advice on how to manage it, please get in touch today by going to our online booking website or by calling us on 02 9922 6806 to book a face-to-face or Tele Health appointment. If you require the opinion of a doctor or specialist, we'll ensure you are placed in the best possible hands. References 1. MSD Manual. 2020. Hernias of the Abdominal Wall. [Online]. Available from: [Accessed 08 April 2020]2. Melbourne Hernia Clinic. 2018. What is a Hernia? [Online]. Available from: [Accessed 08 April 2020]3. MedicineNet. 2020. Hernia (Abdominal Hernia) 9 Types, Symptoms, Causes and Surgery. [Online]. Available from: [Accessed 08 April 2020]4. Healthline. 2019. Everything You Want to Know About a Hernia. [Online]. Available from: [Accessed 08 April 2020] Uploaded : 28 April 2020 Read More
  • Connective Tissue Disease

    Connective Tissue Disease

    Connective tissue disease Hello readers and welcome to our next blog instalment. This month it’s Connective Tissue (CT) Disease. There are many different CT disorders, with too many to cover in one blog, so we’ve written a bit of an overview so you can learn the basics. The big question we hear you ask is “What is connective tissue?”. Connective tissue is the stuff in our bodies that holds all of our cells together. It's a bit like glue. It has a special role, allowing our skin and other tissues to stretch and then return back to their original state. You can kind of think of it like an elastic band that stretches and recoils over and over. Connective tissue is made of protein, and the main examples in the body include collagen and elastin. Connective tissue disease can pretty much affect any part of our body. Our bodies are made up of trillions of cells (approximately 37.2 trillion!) which all require some form of glue to ensure we are held together in our human form. There are diseases that affect our skin, muscles and tendons, ligaments, bones and cartilage, blood and blood vessels, eyes and more! Types of disease To make things a little easier to get your head around, we can break CT diseases into two categories: • Inherited diseases: These are diseases passed down to us in our genetic make-up. Most of these diseases occur due to a mutation of a single gene.• Autoimmune diseases: These are diseases where our bodies create antibodies that fight against our own tissues. In this case, it’s the connective tissues that our body is fighting against. Inherited diseases Here’s a brief overview of a few inherited CT diseases: • Ehlers-Danlos Syndrome (EDS): A group of 13 differing conditions that affect collagen in the body. Common symptoms include very mobile joints and excessively stretchy and fragile skin. People may also experience heart and lung problems as well as weakened blood vessels. • Marfan Syndrome: A condition that affects the production of the protein Fibrillin-1 in the body. Symptoms are widespread, affecting the blood vessels, heart, bones, joints and eyes. Marfan Syndrome affects approximately 1 in every 5000 people. • Osteogenesis Imperfecta: Also known as 'Brittle Bone' disease. This is a condition that affects collagen (specifically Type I) and leaves bone more fragile and prone to fracture. Other signs and symptoms include a blue tinge to the whites of the eyes, hearing loss and weak joints and teeth. Autoimmune diseases Here’s a brief overview of some autoimmune CT diseases: • Rheumatoid Arthritis (RA): This is not to be confused with the more common Osteoarthritis (OA). RA is a condition typically associated with inflammation of the small joints of the body, like those found in the hands, feet and wrists. Joints become hot, red, swollen, painful and stiff as the body fights against the tissues that line and surround the joints. Over time, the joints go through degenerative change and may appear deformed. This condition may also cause inflammation around the lungs and heart, as well as affecting many other systems of the body. • Systemic Lupus Erythematosus (SLE): A condition that causes inflammation of the skin, joints and various organs of the body. Symptoms are widespread and include a butterfly shaped rash on the face and nose, light sensitivity, mouth ulcers, kidney disease and mental illness including memory loss. • Scleroderma: A group of conditions that lead to the thickening and scarring of the skin, organs and blood vessels. People may also experience Raynaud’s Phenomenon; a condition where the blood vessels in the fingers and toes go into spasm resulting in a lack of blood flow to the area. This will look like areas of white and blue over the skin with numbness being another symptom. It is not uncommon for people with one autoimmune CT disease to show signs and symptoms of other autoimmune diseases too. In these instances, a person is referred to as having Mixed Connective Tissue Disease (MCTD). Many people with these overlapping conditions go on to receive a firm diagnosis of SLE or Scleroderma later in life. We hope you found this blog a helpful tool for learning about CT diseases. If you have a CT disease or want to know more information on a particular condition, feel free to ask us next time you are in the clinic or through Tele Health. Have a great month and stay safe everyone. References: 1. Healthline. 2018. Diseases of Connective Tissue, from Genetic to Autoimmune. [Online]. Available from: [Accessed 08 April 2020]2. National Geographic. 2013. How Many Cells are in Your Body? [Online]. Available from: [Accessed 08 April 2020]3. Arthritis Foundation. 2020. Mixed Connective Tissue Disease. [Online]. Available from: [Accessed 08 April 2020] Uploaded : 28 April 2020 Read More
  • Exercise, Chaos and the Immune System during COVID-19

    Exercise, Chaos and the Immune System during COVID-19

    Chaos Theory, Exercise, Physiotherapy and the Immune System (during COVID-19) by Martin Krause Known Kowns, Known Unknowns, Unknown Unknowns - the latter is what we need to recognise Since the onset of COVID-19 many of us have asked why are there so few antivirals? The answer boils down to biology, and specifically the fact viruses use our own cells to multiply. This makes it hard to kill viruses without killing our own cells in the process. So how do we ensure cell survival, whilst priming the immune system to make antigens for its defence system. What does this even mean? Can exercise be an answer to reduce the extent of our immune response if exposed to COVID-19? Will knowing why exercise is good for our immune system motivate people to exercise more? During this time of crisis, we've been told to exercise. Exercise for physical and mental well-being. Whether in partial 'lock down' or 'full lock down' or 'opening up', exercise is still important. But Why? How do chaos theory and non-linear dynamics explain movement and the immune system? The following represents a synopsis of my past research in the field of biomechanics, pathomechanics, neurophysiology, cognition, immunology, sarcopenia and my current interest in chaos. The slides are from a Keynote presentation I made in Rome in 2005. We were born from the chaotic fire of genesis. Laws of thermodynamics dictate our existence. Evolution of heat shock proteins (HSP) means that we are our immune system. Today, human multi-cellular life is still totally dependent on our unicellular ancestors and their componentry. Trillions of species and bacteria in the gut (flora) and skin alone, associated with immune substances, attest to the importance of unicellular life in the immune system. The abundance of energy species in the gut suggests a nexus with one of the organs most in need of energy, the skeletal muscle. Importantly, muscle cells have more mitochondria than most other cells, so they can readily produce work for movement. Consequently, muscles are an energy system and an immune endocrine organ. Notably, the development from unicellular to multi-cellular life needed movement. A commonality of cellular movement and macro-muscular movements exist. Physiotherapeutic and training interventions must consider the health of the immune system and its ability to deploy and be re-deployed. Training should avoid becoming 'stale' by having enough variety (chaos) to create perturbations in the immune system which induce up and down regulation of immune componentry. Physiotherapy should be innovative and creative, whereby the physiotherapist additionally considers immune-cognitive aspects of pain and inflammation, when people seek physiotherapeutic intervention after/during a change in their training regime and/or commencement of unaccustomed exercise, or in the presence of immune compromise. Index 1. What is a stressor? 2. COVID-19 3. General Adaptation Theory 4. Nasal Heat Shock Proteins 5. Heat Shock Proteins (HSP) pictures 6. Damping Ratios 7. Sympathetic N.S. & Chaos 8. Butterfly Effect & Chaos 9. Chaos theory and Physiology 10.COVID-19 Clinical Presentation 11.Infection & HSP 12.HSP70 viral response (1) 13.Muscle-Immune response 14.Matzinger's Danger Hypothesis 15.Classes of HSP 16.HSP72 and HSP27 and muscle 17.Extracellular HSP 18.Aging, HSP and CK 19.Age, COVID-19 & thrombocytes 20.COVID-19 and Platelets 21.Pulmonary emboli 22.Exercise & Respiratory Tract 23.Exercise and Resp Tract Infections 24.HSP viral response (2) 25.HSP-90 26.Mechano-transduction & heat 27.Actin-Myosin Cross Bridge 28.Entropy 29.Bicycle Cadence and Entropy 30.Eccentric Contractions 31.Eccentric Exercise & Immune Markers 32.Sarcopenia 33.Muscle Glutamine 34.Muscle Immune Conversion 35.Over-training 36.Chaos Theory 37.Deterministic Chaos & Immune System 38.Maths & Deterministic Chaos  39.Uncontrolled Manifold Hypothesis 40.Game Theory 41.Cortical Resources 42.Exercise induced disease 43.Anti-Carcinogenic Effect of Exercise 44.Allostasis 45.Neural Componentry & Chaos 46.COVID-19 and Allostasis 47.Recovery & Sleep 48.Psychology & Immunity 49.Diet 50.Gut-Muscle Immune axis 51.COVID-19, gut and lungs  52.Dosage of Exercise 53.Motivators to Exercise and to eat  54.Leptin, Diabetes and X's  55.Leptin and Diet 56.Exposure 57.Musculoskeletal Physiotherapy  58.Conclusion 59.Justification 60.Links What is a 'stressor' and why is muscle considered an endocrine immune organ? The sympathetic nervous system has traditionally been assigned the responsibility for the 'freeze, fight or flight' stress response. Regardless of mechanism, the call to action goes to muscles. Culturally, we generally consider a muscular person as the 'picture of health'. Yet, what resides and moves within muscle is as important as the work those muscles produce.  When we exercise, the body adapts to a stressor, which is calorific, metabolic, physiological, immune and psychological. Phylogenetically, heat shock proteins (HSP) evolved from uni-cellular to multi-cellular life, and 'exercise' (physical activity) was associated with survival skills, such as food acquisition and defence (self-preservation). Interestingly, those same mechanisms can be 'fine tuned' to improve the age of your immune system. If we can get or maintain muscle bulk, we can maintain a reservoir of protein for immune function. If we can maintain adaptive processes to mechanical trauma and inflammation, we have a fighting chance of using similar processes to launch an appropriate immune response, fight infection, prevent cell death (apoptosis) and muscle-organ failure (cachexia).  What is the mechanism behind an 'appropriate' immune response? What sets the system in motion (perturbation) and what 'dampens' it? How do the laws of thermodynamics and conservation of energy apply? What is the predicted 'chaos' in the system and how do the immune and sympathetic nervous system act as oscillating 'manifold' for chaos to 'unfold' and 'refold'? COVID-19 In March 2020, of those patients who test positive for COVID-19, approximately 14% develop severe disease requiring hospitalisation and oxygen support and 5% require admission to an intensive care unit. 10% to 20% of severe patients develop acute respiratory distress syndrome (ARDS) during 8–14 days of the illness with complications including sepsis and septic shock, multiorgan failure, including acute kidney injury and cardiac injury (Yang et al, 2020). Older age and co-morbid disease (cardiovascular disease, diabetes, chronic respiratory disease, hypertension, cancer) are associated with higher mortality rates during COVID-19 infection. There is low quality evidence to suggest exercise has no impact on the rate and duration of acute respiratory infection but may provide a small reduction in severity of symptoms. Increasingly evident, COVID-19 appears to be a disease of the vasculature, especially in the young, where thrombus formation, multi-organ inflammation and cytokine storms are evident. By October 2020, therapeutics directed at multiple organs and using anti-viral, symptom moderation medication, as well as anti-body experimental treatments have been used to improve survival rates, by reducing the severity of the disease. At this point in time, a vaccine for the spike protein is non-existent. Research in exercise immunology suggests moderate exertion may decrease the risk of acute respiratory infection in healthy adults but lacks assessment of its reliability (  However, we do know that regular exercise attenuates the afore-mentioned co-morbidity. Additionally, low evidence means we should pursue the (construct validity) evidence if 'face validity' is evident. The following describes muscle as an immune organ, exercise as an 'adaptor' of that organ, based on immunological principles (from non-linear and linear mechanics) such as heat shock proteins (HSP), cytokines and platelets, importance of 'outliers' based on 'deterministic chaos' as associated with exercise, the sympathetic nervous system, as well as the gut-muscle axis associated with 'energy species'. Stress and the General Adaptation Syndrome The general adaptation syndrome (GAS) model of stress posits three stages to stress: alarm, resistance and exhaustion. In the alarm stage, the nervous system releases stress hormones to facilitate a freeze-fight-flight response. When a stressor is ongoing, like the COVID-19 pandemic, returning to homeostasis is more difficult. In the second stage — resistance — the individual’s allostatic load ideally returns to baseline. But many people will not, especially in the prolonged stress of a pandemic. Physicians should consider that patients reporting symptom exacerbations (of pre-existing issues), during this time, may benefit from stress mitigation techniques, including: Diaphragmatic breathing Guided imagery Mindfulness Limiting media exposure Progressive muscle relaxation Physical activity These techniques may include holistic approaches such as Yoga, Progressive Resistance Exercise (PRE), and endurance training. In the third stage, called exhaustion, people become overwhelmed from the ongoing stressor. This is where prolonged dysfunction can occur, and in which identifying a coping strategy becomes more difficult for the person. One would hope that intervention occurs during the second stage, when acceptance of behavioural modification is more likely. Furthermore, it is hoped that the general population remains active for life, even in the post COVID-19 era. The following is an overview of why exercise is so important, for the immune system, by using a 'deterministic chaos' theoretical approach to protect against chaos. Nasal Heat Shock Proteins Heat Shock Proteins (HSP) are found in virtually all living organisms, from bacteria to humans. They are a class of proteins which react both to heat, cold and oxidative stress. Since unicellular life, these small protein chains, have developed with evolution, and despite the complexity of multi-cellular life, they still have an important fundamental role to play in human survival. Incredibly, this, evolution, means that complex multi-cellular life, can still recognise their unicellular ancestor counterparts! Frequent confrontation of the host (human) immune system, with conserved regions of HSP, which are also shared by various microbial pathogens, can potentiate antimicrobial immunity. However, long-term confrontation of the immune system with HSP antigens, which are similar in the host and invaders, may convert the immune response against these host antigens and promote autoimmune disease. Since COVID-19 is thought to have an 'auto-immune' mechanism and has a profound impact on the airways, in symptomatic individuals, the following is an example of nasal mucosa HSP responding to heat stress. Nasal HSP's 1 hour after heat shock stimuli (Min et al 2020 International journal of medical sciences 17(5):640-646)  Heat Shock Protein - what they look like Small HSP (mycobacterium) by Kim, K.K., Kim, R., Kim, S.H.(1998) Nature 394: 595-599 PubMed: 9707123 DOI: 10.1038/29106  HSP 27 by Michael H. Chiu, Chunhua Shi, Matthew Rosin, Zarah Batulan, Edward R. O’Brien (2019) HSP 72 by Osipiuk, J., Gu, M., Mihelic, M., Orton, K., Morimoto, R.I., Joachimiak, A., Midwest Center for Structural Genomics (MCSG) 2010 Damping ratio To understand energy systems we must also understand 'oscillation control' by examining 'simple harmonic motion' (SHM) in terms of linear dynamics (kinetic and potential energy ) of a mass spring and it's 'damping ratio'. Simply stated, if you hang a mass off a spring and pull down on it and let it go, in the absence of plastic deformation, the mass will 'overshoot' back and forth several times before resuming its original position. That is, it experiences a restoring force proportional to its displacement. Depending on the weight of the mass and the thickness of the spring, the non-optimised system may experience overdamping or underdamping (Wikipedia).    A lower damping ratio implies a lower decay rate, and so very underdamped systems oscillate for long times. Importantly, this model applies to energy systems and hence obeys the law of thermodynamics. Traditionally, health was considered in terms of predictability. Consistent heart rate was considered good, irregular heart rate as bad. Unfortunately, it isn't quite so simple. In fact in terms of training concepts, low resting heart rate and how quickly the heart rate can oscillate with demand is used to diagnose if an athlete has become 'stale' or said in another way is in a state of 'over-training' or enhance physiological and/or psychological stress. Hence, in the light of these confounding 'beliefs', a more complex system (model) needs to be employed, involving random perturbations of an oscillatory system, if random 'outliers' are to be incorporated into our understanding of health. Simplistic versions of sympathetic vs parasympathetic tone balancing the autonomic nervous system do not explain complexity. It is difficult to reconcile that the parasympathetic vagus nerve controls all thoracic and abdominal organ function and alone counters all 'chaos' of sympathetic nervous system activity, where the latter activity has a multitude of redundancy and interacts in multiple dimensions with an interlaced muscle-gut immune system complex. The sympathetic nervous system is the tight rope, the trapeze artist, the dancer, the orchestra, forged from the fire of genesis and the evolution of heat shock proteins. To understand the development of the muscle-gut immune system complex we must understand its uni-cellular componentry. Using Alexandr Lyapunov theory of stability, in non-linear dynamic systems, the oscillations near the point of origin (equilibrium) are determined by exponential decay.  That is, if the solutions that start out near an equilibrium point Xe, stay near Xe forever, then Xe is Lyapunov stable. More strongly, if Xe is Lyapunov stable and all solutions that start out near Xe converge to Xe, then Xe is asymptotically stable (As an illustration, suppose that we are interested in the properties of a function f(n) as n becomes very large. If f(n) = n2 + 3n, then as n increases, the term 3n becomes insignificant compared to n2. The function f(n) is said to be "asymptotically equivalent to n2, as n → ∞". This is often written symbolically as f(n) ~ n2, which is read as "f(n) is asymptotic to n2 "). The notion of exponential stability guarantees a minimal rate of decay, i.e., an estimate of how quickly the solutions converge. The idea of Lyapunov stability can be extended to infinite-dimensional manifolds (chaos theory), where it is known as structural stability (in mathematics, this is a fundamental property of a dynamical system which means that the qualitative behaviour of the trajectories is unaffected by small perturbations), which, in this case concerns the behaviour of different but "nearby" solutions to differential equations. Later, this will be applied, not only to EMG analysis of muscle activity, but also to cytokine interactions, from nearby solutions Sympathetic Nervous System and Deterministic Chaos The sympathetic nervous system (SNS) has, as previously stated, traditionally been associated with the freeze-fight-flight response - you fight the lion or run from the lion. A reaction to a 'danger signal' (Matzinger). However, there is a lot more to it. Never-the-less, this example describes a bi-directional nervous system, one which is driven by 'motor curiosity' and wanting to arouse sensory stimuli, whilst the other is reacting to 'sensory stimuli'. Frequently, these moments are described as an 'adrenalin rush' associated with fear, excitement and tremor. The greater the chaos and tremor in the system, the greater the perturbations and the greater the damping needed in the system. Ideally, what drives the system also dampens it. Otherwise, at 'extremely high frequencies' we would only 'freeze'. Clinically, some people believe, that right hemisphere dominant tremor tend to have a higher component of irrationality and hypervigilance, whereas left hemisphere dominant tremor may have a more rational generator of tremor. However, this simplification ignores cross-hemispheric communication systems. It is important to note that in health systems, it's the odd asynchronicity in the system which attests to it's health. That is the chaos, 'outlier', in the system. This control by chaos is relative, it's a ratio, it's a magnification, it defines itself and it 'dampens' itself. Furthermore, the outliers define what it isn't! Hence, 'deterministic chaos'. When looking at 'fractals', you can have an infinite length in a finite space. Bifurcation upon bifurcations, getting smaller and smaller ad-infinitum but within a finite space! For example, the length of the coastline of the United Kingdom is known to an error margin of + 10-20% depending on how closely one looks at it (ie at what magnification ratio or scale). As we examine the movement system, we frequently see tremor at each end of the spectrum. With fine delicate movements and with movements which require a lot of force we see a tremor.  In scenarios of many repetitions and fatigued muscles, they gradually cramp up and lose their oscillatory fidelity. This can be considered as an energy or metabolic constraint. In novel tasks, we see more rigidity in movements, due to increased muscular activity, resulting in reduced freedom of movement. In the latter scenario, cognitive constraints arise at a conscious and sub-conscious level, where learning becomes important to improve the degrees of freedom, reduce the amount of muscle tension and hence lower the rigidity in the system. Are degrees of freedom, and hence variability, important for the immune system? A system dependent upon ratios of heat shock proteins, pro and anti inflammatory cytokines, immuno-globulins, lymphocytes, neuropeptides, short fatty acid chains, metabolism, descending noradrenergic and serotonergic pathways and even a balance between 'innate' and learned 'adaptive' immune responses, occurring within and acting upon, the largest endocrine organ of the immune system, skeletal muscle. Is it a coincidence that the spinal cord looks like a butterfly?  Butterfly effect and chaos theory - from Wikipedia In chaos theory, the butterfly effect is the sensitive dependence on initial conditions in which a small change in one state of a deterministic nonlinear system can result in large differences in a later state. The term, closely associated with the work of Edward Lorenz, is derived from the metaphorical example of the details of a tornado (the exact time of formation, the exact path taken) being influenced by minor perturbations such as the flapping of the wings of a distant butterfly several weeks earlier. Lorenz discovered the effect when he observed that runs of his weather model with initial condition data that was rounded in a seemingly inconsequential manner would fail to reproduce the results of runs with the unrounded initial condition data. A very small change in initial conditions had created a significantly different outcome. The idea that small causes may have large effects in general, and in weather specifically, was earlier recognized by French mathematician and engineer Henri Poincaré and American mathematician and philosopher Norbert Wiener. Edward Lorenz's work placed the concept of instability of the Earth's atmosphere onto a quantitative base and linked the concept of instability to the properties of large classes of dynamic systems which are undergoing nonlinear dynamics and deterministic chaos.   Chaos theory and physiology What happens if the 'flapping wings of the butterfly' dampen or calm 'the tornado on the other side of the planet'? In terms of the human organism, chaos theory refers to 'deterministic chaos'. This means that if one knows the initial conditions (state) of the system exactly, then the dynamical trajectory will be the same every time it is initiated in that condition (state). If, however, two states are 'infinitesimally' apart, then the trajectories are such that it makes it impossible to predict the future dynamics (chaos).   Oscillatory dynamics is the prerequisite for many complex phenomena and the onset of chaotic dynamics. Chaos refers to complex, apparently unpredictable, dynamics that even simple deterministic dynamical systems can produce. A universal way to achieve chaos is by driving a nonlinear oscillator by an external periodic signal. When the external driving signal has low amplitude oscillations, it can entrain or synchronise the nonlinear oscillator. As the amplitude of oscillations is increased, the range of frequencies for which it can entrain becomes larger—these expanding synchronisation regions of the external amplitude–frequency parameter space are called Arnold tongues. Such entrainment/synchronisation has been observed in many different physical systems, from fluids to quantum mechanical devices, and now also in biological processes, such as cell cycles, and gene (transcription) regulatory dynamics in synthetic populations. The dynamics gets even more complex as the amplitude of the external driving signal increases further. First, Arnold tongues start overlapping, which means the nonlinear oscillator can exist in more than one entrained state with different frequencies (termed modes), and even small amounts of intrinsic or extrinsic noise can cause it to hop between these modes. Such mode-hopping has been observed in immune system (p53 tumour suppressor) and in gene transcription of the oscillatory NF-κB system, when driven by a periodically varying Tumour Necrosis Factor (TNF) signal of sufficiently high amplitude. When the external amplitude is increased even further, then chaotic dynamics is predicted (Heltberg et al 2019 Nat Commun 10, 71 Shareable link Nat Commun 10, 71 (2019). The significance of this is, that NF-κB is a major transcription factor which regulates genes responsible for both the innate and adaptive immune response. Upon activation of either the T- or B-cell receptor, NF-κB becomes activated through distinct signalling components. TNF is a major inflammatory cytokine player, found in skeletal muscle (MSK), produced by macrophages/monocytes during acute inflammation and is responsible for a diverse range of signalling events within cells, leading to necrosis or apoptosis. The protein is also important for resistance to infection and cancers. Furthermore, other immune ratios or interactions, based on maths and physics, are predicted, which will hopefully lead to a better understanding of why physiotherapists should encourage people to exercise muscle as a vaccine for the immune system. This discussion will include interactions between Interleukin IL-6 (pro inflammatory) driving IL-10 (anti-inflammatory) t-cell CD4+ : CD8+ ratio, HSP 27 and HSP72 HSP 10 and HSP 60 HSP 60 and HSP 70 HSP 90 as well as examining the gut biome and muscle - brain axis in terms of energy, resources and game theory.  COVID-19 Clinical Discussion: 1 May 2020 The following is an abstract from an online clinical forum. It serves here to illustrate the terms used in the discussion, including 'cytokine storm' (inflammatory substances), 'viral burden', 'anticoagulants' (clot busters) and 'immunosenescence' (immune dysfunction/compromise) which have been pervading posts to this forum, about COVID-19. Bear these terms in mind for later discussion. Hence, as stated, the following dissertation will consider cytokines (inflammatory substances), platelets and HSP in relation to muscle as an endocrine organ of the immune system and examine the link with the gut biome, and in particular, the energy species within the gut, as it relates to the immune system, but also as those energy species relate to movement adaptation, within the musculoskeletal system. "We are what we eat" and "healthy mind healthy body" are common sayings which will become abundantly clearer when examining the gut-brain-muscle axis. Chaos theory as it relates to ratios, synchronous to asynchronous periodicities, and magnification of movement and inflammatory markers in response to variable 'healthy' physical demands are postulated to act as a 'muscle - immune shock absorber' when confronted by pathogens. Infection - a bimodal HSP reaction of host and pathogen When entering the host from the environment, a microbial pathogen is confronted by several changes, some of which are highly stressful. These include alterations in temperature, pH, and pO2. Moreover, the pathogen is exposed to natural host resistance mechanisms such as phagocytosis by professional phagocytes. Once engulfed by phagocytes, the pathogen is confronted with reactive oxygen and nitrogen intermediates, attack by lysosomal enzymes, and depletion of Fe2+. To protect itself against the host, the pathogen activates various evasion mechanisms including its own HSP synthesis. Infection is therefore a bimodal process determined by the host and pathogen. During infection, the pathogen as well as the host increase their HSP production. Induction of host HSP synthesis in response to an encounter with a pathogen has at least two major causes. First, infected macrophages are confronted with antimicrobial mechanisms which they have activated themselves during infection. Efficient protection against their own effector molecules (e.g., reactive radicals) becomes vital for macrophage survival. Second, once inside a phagocyte, many microbes, especially those which persist in the host, interfere with intracellular host cell metabolism. Not surprisingly, many of these pathogens are potent inducers of HSP synthesis in mammalian cells (see Ulrich Zügel, Stefan H. E. Kaufmann (2019) DOI: 10.1128/CMR.12.1.19). They say, 'in life we never should forget where we came from'. This appears true for HSP, where the HSP of a multicellular host recognises and react to the HSP of unicellular pathogens. A reflection on the evolution of life on earth. Heat Shock Protein (HSP) 70 and the viral response Virus infections induce heat shock proteins (described in detail below) that in turn enhance virus gene expression. An intriguing concept is that HSP within pathogens activate HSP within the host. This phenomenon is particularly well characterized for 70 kDa heat shock protein (HSP70). However, HSP70 is also readily induced by fever, a phylogenetically conserved response to microbial infections. When released from cells, HSP70 can stimulate innate immune responses through toll like receptors 2 and 4 (TLR2 and 4). In their review, researchers (Mi Young Kim and Michael Oglesbee 2012 Cells. 2012, 1, 3,: 646–666. doi: 10.3390/cells1030646) examined how the virus-HSP70 relationship can lead to host protective innate antiviral immunity, and the importance of HSP70 dependent stimulation of virus gene expression in this host response. Beginning with the well-characterized measles virus-HSP70 relationship and the mouse model of neuronal infection in brain, they examine data indicating that the innate immune response is not driven by intracellular sensors of pathogen associated molecular patterns, but rather by extracellular ligands signalling through TLR2 and 4. Specifically, Kim & Oglesbee (2012) addressed the relationship between virus gene expression, extracellular release of HSP70 (as a damage associated molecular pattern), and HSP70-mediated induction of antigen presentation and type 1 interferons in uninfected macrophages as a novel axis of antiviral immunity. The reported antigen presentation and cross-presentation and in vitro HSP cytokine functions are a result of molecules bound to, or chaperoned by, HSPs but not a result of HSPs themselves (Tsan MF1, Gao B.2009 J Leukoc Biol.85, 6 :905-10. doi: 10.1189/jlb.0109005). Notably, intra- (IC) and extracellular (EC) HSP 72 are thought to have different functions. IC HSP 72 confers cellular protection from subsequent stressors, while EC HSP 72 has a whole-body systemic role in antigen presentation and immunity. An acute exercise bout stimulates an increase in both IC and EC HSP 72. Long-term training and improved fitness increase the rate of availability of IC HSP 72 in response to stress. Other factors that affect HSP 72 production include environmental factors, exercise mode, duration and intensity, age, Estrogen, and anti-oxidant and glycogen availability. Additionally, other HSP such as HSP27 play a role in conserving HSP72 function. Importantly, the functions and roles of HSP 72 depend on the tissue of origin (brain, muscle, etc). Ratios of HSP's will be discussed later in the context of muscle-exercise-immune responses and is represented in the following schematic (bear in mind HSP70 are a class of HSP's which include HSP72) and ubiquitin is from another class of HSP which are very small (8.5kDa) and have been highly conserved throughout the evolution of life. Similarly, the gut biome will be discussed in terms of 'energy species' and a HSP 10 and HSP 60 synergistic function. Ratios of CD4+:CD8+ appear to be critical when discussing health and disease; as will the consideration of how an acute, but not chronic, pro-inflammatory cytokines (IL-6) stimulate anti-inflammatory cytokine (IL-10) response. Muscle-immune response So, what is the role of Heat Shock Protein (HSP) in the immune system? Simply stated, early in life, we have an innate immune system, the one we are born with. It acts to protect us. It's first exposure and reaction to exposure is in the birth canal, where the cervix lining acts to induce a protective mechanism to exposure of the world. Our first 'adaptive immune response'. Antibodies are formed from exposure to antigens. These antibodies are formed from RNA into DNA, by cleaving off small protein chains from long protein chains (telomeres). It's a bit like cutting a small piece of tail off the long protein chain. We do this throughout life, with the  aid of HSP's. However, as you can imagine, those long protein chains eventually become shorter and are finite. Hence, it's important to maintain our protein reservoir in our bodies by finely tuning how much and when proteins are cleaved, unfolded and refolded or deemed as useless by HSP. Since muscle consists of 90% protein, it becomes abundantly clear that we should protect it's bulk and function by training it, when healthy, and using it's reservoir of protein immune components during or after a disease. The above schematic (Krause 2004) illustrates immune reactions occurring within muscles. Immune responses are a complex interaction of cytokine signalling. Cyto = cell, Kine = movement. These signalling reactions occur in the brain, gut, liver, kidneys, thymus and muscle, in response to a perceived-safety danger signal (Matzinger 1994, review by Martin Krause 2004). Fine tuning of the cytokine reaction is important through a direct muscle cytokine 'micro-trauma' mechanical mechanism and indirectly through 'energy cycling' including metabolic mechanisms, including oxidative stress (REDOX) induced HSP. Furthermore, a multitude of cognitive stimuli can also influence (positively and negatively) the immune system. Notable, HSP must respond to the laws of thermodynamics. In the context of COVID-19, it has become apparent that those critically ill patients, have cytokine flooding in their lungs. That is, they have an uncontrolled (auto) immune response which has been referred to as a 'cytokine storm'. Additionally, there also appears to be a delayed immune response in younger individuals relating to inflammation of blood vessels and clot formation. Further, extremely low oxygenation (<50%) has been reported suggesting hypoxic metabolic stress, potentially not to dissimilar to when we exercise, only in the later we can in most cases cease the exercise without undue effects. A notable exception is Rhabdomyolysis (which is a condition in which skeletal muscle tissue dies, from over-exertion or pathogens, releasing substances into the blood stream that cause kidney failure) discussed elsewhere on this site. It will be argued that previous 'fine tuning' of the cytokine response, through exercise induced neuro-immune perturbations, leaves the host, not necessarily less susceptible to infection, but more prepared to deal with heat stress, platelet reactions as well as the infection itself. Matzinger's Danger Hypothesis - from Wikipedia  In 1994 a new immunologic model was suggested by Polly Matzinger. She suggested that the immune system does not distinguish between self and non-self, rather, it discriminates between dangerous and safe by recognition of pathogens or alarm signals from injured or stressed cells and tissues. According to this theory, the most important stimulation of immune response are normal tissues. When tissue cells are distressed because of injury, infection and so on, they start to secrete or express on their surface so called "Danger signals". "Danger signals" are also introduced into extracellular space when stressed cells die by immunologic not-silent cell death such as necrosis or pyroptosis (highly inflammatory form of cell death, as opposed to apoptosis, controlled cell death). This model also suggests that, despite their potential immunogenicity, neoplastic tumours do not induce significant immune responses to induce the destruction of the malignant cells. According to the danger model, the immune surveillance system fails to detect tumour antigens because transformed cells do not send any danger signals which could activate dendritic cells and initiate an immune response. "Danger signals" are normal intracellular molecules that are not found in the extracellular space under physiological conditions. The danger model has evolved over the years. "Danger signals" include DNA, RNA, heat shock proteins (HSPs), hyaluronic acid, serum amyloid A protein, ATP, uric acid and also cytokines like interferon-α, interleukin-1β, CD40L and so on.  The "danger model" suggests that, upon cellular necrosis, cryptic molecules in normal cells might be liberated from the cytoplasm into the tissue microenvironment, new molecules might be expressed on the surface of killed cells, or new molecules might be synthesized by cells undergoing necrosis. In comparison, the damage associated molecular pattern "DAMP model" suggests that any non-functional molecules (regardless of their cellular location; extracellular or intracellular) that were denatured, oxidized, or had disintegrated quaternary structures might have unique biophysical patterns such as low water-solubility or stretches of polyanions on their surface. "Danger signals" and DAMPs are together with pathogen-associated molecular patterns (PAMPs) called alarmins and they are recognized by pattern recognition receptors (PRRs) of antigen presenting cells (APC). PRRs include Toll-like receptors (TLR), nucleotide oligomerization domain (NOD)-like receptors, retinoic acid inducible gene-I (RIG-I)-like receptors and C-type lectin-like receptors.[12] They are not only at the surface of these cells, but we can find them in cytoplasm and incorporated in the membrane of endolysosomes. Stimulation of PRRs leads to activation of APC cell to process antigen, upregulate expression of costimulatory molecules and present antigens to T helper cells. The danger model is a new perspective on adaptive and innate immunity. In the past innate immunity was suggested to be a minor part of the immune system — in contrast, adaptive immunity was thought to be the most important and effective part of the immune system. According to the danger model there is no adaptive immunity without the innate part. This is because APCs like dendritic cells are essential for activation of T lymphocytes and B lymphocytes, which after activation produce specific antibodies. In the case of dendritic cells deficiency, like in common variable immunodeficiency (CVID), patients suffer from hypogammaglobulinemia and from primary or secondary defects in T-cell functions. Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain. or By Mikael Häggström, used with permission. - Image:Lymphocyte_activation.png, Public Domain, Link (Matzinger, P . "Tolerance, Danger, and the Extended Family". Annual Review of Immunology. 12 (1): 991–1045. doi:10.1146/annurev.iy.12.040194.005015. PMID 8011301. Classes of Heat Shock Proteins (HSP) Heat shock proteins (HSP) play an important role during exercise and subsequently induced immune responses (Krause 2002). Phylogenetically, HSPs are the basic building blocks of life. Small protein chains of around 8–43 kDa for HSP 27 class and 72kDa for HSP 72 ranging up to 110kDa. HSP72 is abundant in muscle. HSP 27 has been shown to be released in response to muscle damage during novel or acute eccentric (muscle lengthening) exercise, whereas HSP 72 is released in response to metabolic and thermal stress, during endurance exercise, in both untrained and well trained individuals. Additionally, HSP 27 is thought to aid in the repair process of HSP 72 as well as in the repair of contractile protein myofilaments themselves (Folkerson M 2018  The relevance of the latter will become apparent when examining eccentric muscle contractions later in this treatise. HSP 60 is found abundantly in the gut and in the mitochondria of skeletal muscle, in rodents. It has been demonstrated, in rodents that HSP 60 is greater in slow twitch endurance muscle, as well as in the vastus lateralis of endurance trained men (reviewed by Mattias Folkesson 2018). HSP 60 and HSP 10 will be discussed later when considering the immune system, energy species and the gut biome.   Hence, HSP's have an important cellular function, commonly referred to as a 'chaperone'. The fate of proteins with non‐functional conformations after stress exposure may be either to re‐obtain the functional conformation, form aggregations with other misfolded proteins or become degraded. HSP's play a helper role in shifting the equilibrium in the direction of more functional proteins or degradation of damaged proteins. This can occur in an ATP-dependent or independent manner, meaning the latter doesn't require the normal oxidative metabolism to function, as muscle contraction does.  HSP had an important, stress induced, evolutionary and ecological role. As stated, it continues to play a vital role, as it's chaperone function acts to stabilise/modify exercise induced muscle damage, including micro-trauma. Additionally, HSP's play a role in apoptosis or cell death in sedentary individuals. Essentially they react to 'stressors' which can be temperature (hot and cold) and oxidative. Importantly, these ubiquitous molecular chaperones can prevent the irreversible aggregation of denaturing proteins. Specifically, to maintain protein homeostasis, HSP complex form a first line of defence against protein aggregation, with a variety of non-native proteins in an ATP-independent manner and in the context of the stress response. In vertebrates they act to maintain the clarity of the eye lens, and in humans HSP mutations are linked to myopathies and neuropathies (Haslbeck & Vierling 2015 J Mol Biol Apr 10; 427, 7: 1537–1548). Indirectly, HSP's act on the immune system by maintaining muscle bulk, which provides the environment in which cytokines can act and where proteins can be used to build antigens for an immune response. That is, reported antigen presentation and cross-presentation, activation of macrophages and lymphocytes, and activation and maturation of dendritic cells as well as in vitro HSP cytokine functions, are a result of molecules bound to or chaperoned by HSPs but not a result of HSPs themselves (Tsan MF & Gao B.J Leukoc Biol. 2009 Jun;85(6):905-10). Another, more intriguing speculation, is that the HSP of the pathogens themselves activate the innate human immune response in the presence of fever greater then 2-3 C (reviewed by Hasday JD & Signh IS 2000 Cell Stress Chaperones, 5, 5, 471–480). Regardless, an increase in core body temperature, during fever, activates and utilises elements of the heat shock response pathway, to modify cytokine and chemokine gene expression, cellular signalling and immune cell mobilisation, to sites of inflammation, infection and injury (Hasday JD & Signh IS 2013 Intl J Hyperthermia, 29, 5, 423-435). Hence, increases in temperature during exercise may be a mechanism which uses HSP's to preserve and improve muscle fibre protein, protecting it's bulk whilst adaptively fine tuning mechanistic pathways for potential innate HSP-cytokine immune responses.  Muscle and Heat Shock Proteins   (Krause 2005 Rome Presentation) Muscle is an incredible and potent reservoir of protein and immune substances. It is, in effect, one of the most important organs of the immune system. HSP are a multidimensional protein which act as a protein chaperone, an antioxidant and play a role in the inhibition of cell death (apoptosis). They act on muscle protein (actin cytoskeletal) remodelling. In particular, HSP27 has been characterized with the ability to regulate actin cytoskeletal dynamics during heat shock and other stress conditions, functioning both to promote actin polymerization and as an actin capping protein. During, intense exhaustive exercise, in hot conditions, both HSP72 and HSP27 are released into the blood stream (Periard et al, 2012, Cell Stress Chaperones, 17, 3, 375-378). HSP 27 is speculated to also have a HSP 72 preserving function. Presumably, these HSP, together, have HSP and cytokine protective roles, at certain stages in the immune-inflammatory cycle. Extracellular HSP 27 and HSP 72 during exercise Extracellular HSP expression has been demonstrated during exercise. The first investigation was in humans and treadmill running (60%VO2max) under hot conditions, where increases of eHSP 72 were found (Walsh RC, et al 2001. Cell Stress Chaperones, 6, 4,386-93). Further investigations (Periard JD et al 2012. Cell Stress Chaperones, 17, 3, 375–383), using cycling and heat at 60% and 75% intensity (HR 97% of max at termination) demonstrated core temperature reaching 39.7°C in the 60% trial (58.9 min) and 39.0°C in the 75% trial (27.2 min) (P < 0.001). The rate of rise in core temperature was 2.1°C at the 27.2 min mark and was greater in the 75% trial than in the 60% trial (P < 0.001). A significant increase and correlation were observed between eHsp72 and eHsp27 concentrations at exhaustion (P < 0.005). eHsp72 was highly correlated with the core temperature (heat storage) attained (60% trial) and the rate of increase in core temperature (75% trial; P < 0.05). Therefore, in response to an acute physiological challenge under heat stress, intensity and duration can result in similar changes to core temperature. Interestingly, if these high core temperatures presented clinically, the person would be considered febrile. Fever is used as a diagnostic criterion in clinical settings, with temperature elevations as low as 39 °C being a potent inducer of HSP 70 in the human brain (Morrison-Bogorad al, 1995 J. Neurochem. 64, 235–246. doi: 10.1046/j.1471-4159.1995.64010235.x). For example. a fever is a consistent sequel to measles virus (MeV) infection (Hutchins SS et al, 2004. J. Infect. Dis.189:S153–S159. doi: 10.1086/379652) where heat and/or virus-induced inflammatory cytokines may represent a means of indirect HSP70 induction. The latter is supported by findings in canine distemper virus infected dog brains, where HSP70 induction was observed in viral antigen negative as well as viral antigen positive astrocytes, these being restricted to areas of active viral replication and inflammation (Oglesbee M & Krakowka S 1993 Lab. Invest.68, 109–117).  . These are strange lines of best fit (correlation HSP 72 vs HSP 27), especially from baseline (60% vs 75% VO2 max), through to recovery 24 hours, after exhaustive exercise. Let's keep this in mind when discussing 'outliers' in chaos later in this dissertation. It should be noted that these extracellular HSP's are thought not to be from contracting muscle (Febbraio et al. 2002a), but rather as a result of the brain and hepatosplanchnic tissues which are capable of releasing HSP 72 in the systemic circulation (Febbraio et al. 2002b; Lancaster et al. 2004). Importantly. its extracellular expression (eHSP 72), measured in plasma and serum, has been suggested as a potential signal, triggering innate immunity and stimulating the release of proinflammatory cytokines (Pockley et al. 1998; Asea et al. 2000; Njemini et al. 2003; Pockley et al. 2003; Njemini et al. 2004; Asea 2005; Noble et al. 2008). In humans, they believe that the contracting muscles are not the source of eHSP 72. In  : . However, contrary to this belief on extracellular HSP, it will later be argued, that contracting muscles release localised HSP, during concentric (cycling) and eccentric (running and plyometrics) exercise, where the laws of thermodynamics and concepts of myofilament micro-trauma (respectively) are applied......and that although these intracellular HSP have a different function to eHSP, their relationship is 'continuous' In the 75% trial, the rate of increase in rectal temperature was a significant predictor variable of eHSP 72 expression. For the expression of eHSP 27, blood glucose was a significant predictor variable in the 60% trial. No predictor variables were found for eHSP 27 concentration in the 75% trial. Malondialdehyde (MDA) concentrations showed a significant reduction 24 hours after the completion of exhaustive exercise. MDA is one of the final products of polyunsaturated fatty acids peroxidation in the cells. An increase in free radicals (REDOX) is thought to cause overproduction of MDA, which wasn't seen in this investigation. MDA level is commonly known as a marker of oxidative stress and the antioxidant status in cancerous patients. Importantly, the correlation of glucose and FFA to eHSP 27 and MDA, may be an important aspect to bear in mind, when we later discuss the energy consuming species of the gut biome, REDOX and the immune system. Aging, HSP and cytokines (IL's and TNF-alpha) As we age, we lose our tolerance to heat and cold, suggesting a gradual loss of HSP over time. In community-dwelling elderly, serum HSP 70 and IL-10 concentrations were significantly lower and IL-6 was significantly higher when compared to healthy young control subjects. Elderly patients presenting inflammation (CRP serum levels ≥5 mg/L) showed significantly higher Hsp70 values; and Hsp70 correlated positively with IL-6 and CRP, but not with TNF-alpha or IL-10. A significant association was also noted between Hsp70 levels and the degree of dependency and cognitive decline in geriatric patients. This data provides evidence that serum concentration of Hsp70 decreases with age in a normal population. This study also showed that higher levels of Hsp70 are associated with inflammation and frailty in elderly patients (Rose et al (2011), BMC Immunology, 12, 24, 28 March) Therefore, too much IL-6 appears to be a bad thing, however, later we will discuss how increases in IL-6 in response to an acute stress induces the release of anti-inflammatory cytokine such as Il-10. Moreover, chronically elevated anti-inflammatory substances can lead to desensitisation. Therefore, it will be argued that it's the 'randomised regular intermittent impulse', whilst exercising, which tunes the system, through the laws of thermodynamics and entropy (chaos)!  Age, Heat Shock Proteins, COVID-19 and thrombocytes (clots) COVID-19 seems to disproportionately affect older people. Young people, who have a more robust 'innate' and 'younger' immune system seem to be, with some exceptions (Kawasaki Disease), immune to the disease. Some people with COVID-19, aged 20-40 years old, are presenting with neurological complications from prolific clot formation. Clots are formed from thrombocytes. Thrombocytes are formed from platelets. Investigations suggest that HSP70 and HSP90 can serve as signalling scaffolds, helping regulate function, including platelet adhesion and spreading via modulation of protein phosphatase activity. HSP27, on the other hand, may be more involved in controlling actin polymerization during the platelet shape change and subsequent aggregation (Polanowska-Grabowska R & Gear AR 2000 Platelets. Feb 11, 1, 6-22). Several roles may exist for HSPs in the immune system including intracellular roles (e.g., antigen presentation and expression of innate receptors) as well as extracellular roles (e.g., tumour immunosurveillance and auto-immunity). It has been observed that exogenously administered HSP induced various immune responses in immunotherapy of cancer, infectious diseases, and auto-immunity. Moreover, virus interaction with HSP as molecular chaperones showed important roles in regulating viral infections including cell entry and nuclear import, viral replication and gene expression, folding/assembly of viral protein, apoptosis (cell death) regulation, and host immunity (Azam B & Elnaz A Clinica Chimica Acta 2019, 498, 90-100). As already stated, viruses could regulate host HSPs at different levels such as transcription, translation, post-translational modification and cellular localization. Notably, COVID-19 seems to have unprecedented auto-immune response in those critically ill patients. Platelets Platelets are anucleate cell fragments known for their central role in coagulation and vascular integrity. However, it is becoming increasingly clear that platelets contribute to diverse immunological processes extending beyond the traditional view of platelets as fragmentary mediators of haemostasis and thrombosis (clot formation). There is recent evidence that platelets participate in: enhancement of adaptive immune responses recruitment and promotion of innate effector cell functions intervention against microbial threats modulating antigen presentation. In this way, platelets should be viewed as the under-appreciated orchestrator of the immune system (Ramadan et al 2015, Curr Trends Immunol. 16: 65–78). Pulmonary embolus and venous pulmonary clots Growing clinical evidence is finding severe clotting in some individuals with COVID-19. Moreover, pulmonary clots and even strokes have been reported in young individuals (aged 20-40) by an Australian physician in New York (Washington Post 26 April 2020), In fact, the clotting was so profound that re-clotting was occurring during clot busting surgery. Pulmonary venous clotting has also been described by French physicians. A research letter (9 April 2020) from Hôpitaux Universitaires de Strasbourg published in Radiology reported that of 106 pulmonary CT angiograms performed for COVID-19 patients over a one-month period in a tertiary care centre in France, 32 patients (30%) had acute pulmonary embolus (PE). This rate of PE is much higher than usually encountered in critically ill patients without COVID-19 infection (1.3%,) or in emergency department patients (3 to 10%). In the study, a D-dimer threshold of 2660 μg/L detected all patients with PE on chest CT. A second research letter published, described a study from Centre Hospitalier Universitaire de Besancon in France pointed to high proportion (23%) of COVID-19 patients with contrast CT had PE. PE was diagnosed at mean of 12 days from symptom onset. Patients with PE were more likely require care in the critical care unit and to require mechanical ventilation. ( Therefore, there is strong evidence of a combined airway-vascular response leading to organ failure. Such a combination of a 'cytokine storm' and thrombocytic events incorporating auto-immune responses leading to respiratory failure and the need for intubation and ventilation, and even clot busting surgery, in young people. Heat Shock Proteins, Exercise and Upper Respiratory Tract Bacterial Count (Int. J. Med. Sci. 2020, Vol. 17) Exercise modifies airway immune responses and susceptibility to infection in healthy individuals. Investigators (Min et al 2020 Int J Med Sc, 17, 5, 640-646) examined the effects of exercise on HSP 27 and HSP 72 expression levels in nasal mucosa of both professional competitive athletes (volleyball) and non-athletes. Nasal lavage (NAL) fluids were collected from 12 male professional volleyball players and 6 healthy males pre-submaximal exercise (running for 30 min at 70-80% of maximal heart rate) and post-submaximal exercise. Expression levels of HSP27, HSP70, Interleukin (IL)-8, and Tumour necrosis factor (TNF)-α in NAL fluids were quantified and antibacterial assay using Staphylococcus aureus was performed to assess the immunological role of HSPs in NAL fluids. In non-athlete controls, HSP27, HSP70, and IL-8 were unchanged after exercise. In the professional athletes, HSP70 expression declined significantly (p<0.05), but HSP27 was not significantly changed. nor were IL-8 and TNF-α. Further, it was found that the number of active bacterial populations were influenced by the presence or absence of HSP27 and HSP70 in NAL fluids. Upon removal of HSP27 and HSP70, the initially observed augmentation of anti-bacterial activity in post-exercise NAL fluids was abolished. This is a super-interesting result, where reduced HSP concentrations were correlated with improved bacterial counts, suggesting that HSP can reduce 'good' or functional bacteria in the mucosa. Moreover, there seemed to be difference in the innate immune response, to exercise, in trained vs untrained. The influence of bacteria and the gut biome will be discussed later in relation to the immune system. Additionally, of even more interest is the effect of training on pre exercise HSP levels. Needless to say, a balance of HSP is required for a balanced mucosal bacteria and that the resting HSP levels in athletes is lower than in non-athletes. However, it needs to be said that the non-athlete group was only 6 compared to 12 athletes. Regardless, the trained athletes appear to have lower basal levels of HSP. Importantly, this could be the result of 'over-training' and/or it makes sense that training creates the optimised system which conserves these vital proteins for essential use. Notably, as we age, the number of HSP reduce, so ideally, our immune biological age is younger than it's chronological age.  A systematic literature review (Moreira A et al (2009) British Med Bul, 90, 1, 111–131, (of 30 studies, comprising 4 descriptive, 18 observational and 8 randomized or controlled reports, that included a total of 8595 athletes, including 5471 runners and 2803 swimmers and 1798 non-athletes) found athletes were more susceptible to upper respiratory tract infections (URT) than non-athletes after prolonged and intense exercise. They postulated that the significant immune suppression (down regulation) was a protective response to limit inflammation. Furthermore, they hypothesised that as the fitness of the athlete increased, the incidence of URT should decrease, contrary to their findings. However, they also described data in marathon runners taking Vitamin C (anti-oxidant), where it was found to reduce the incidence in URT. In one study which they reviewed, the gut biome was considered to be important, where Lactobacillus fermentum appeared to have a slight anti-inflammatory effect, reflected by a decrease in IL-6 production, which is the main inducer of C-reactive protein and a decrease in the number of monocytes, which are one of the major producers of IL-6. Consumption of carbohydrate-rich beverages during exercise appears to attenuate some of the immunosuppressive effects of prolonged exercise, but confirmation of any clinical significance in this awaits further research. Exercise and Respiratory Tract Infections A narrative review (Pederson & Toft, 2000, highlights evidence that exercise across a lifespan seems to increase resistance to upper respiratory tract infections, whereas repeated strenuous exercise suppresses immune function. There was no assessment of the reliability of data in the included studies. In an overview, researchers  (Rocco et al., 2018) analysed data from four systematic reviews (including an older version of the Cochrane review; 14 primary studies) to examine clinical effectiveness of exercise to prevent upper respiratory tract infections. The authors were able to meta-analyse five randomized trials involving only 311 participants. They observed a reduction in incidence of infection (RR 0.84, 95% CI 0.65 to 1.10; 72 infections less [157 less to 45 more] per 1000 people) in people randomised for moderate intensity exercise for 8 weeks to 12 months. The evidence was judged “very low” quality based on GRADE, meaning the findings are highly uncertain. Martin et al (2009, Ex Sp Sc Rev, 37, 4, 157-164 doi: 10.1097/JES.0b013e3181b7b57b) suggest outcomes following respiratory viral infections are improved after moderate exercise based on epidemiological evidence and animal models. They propose stress hormones stimulated during exercise reduce excessive local inflammation and skew the immune response away from a TH1 and toward a TH2 phenotype. Human studies and experimental modelling of mechanisms are lacking. Heat Shock Proteins and the 'viral' diseased state Heat shock proteins (HSPs) are recognized for their support of protein metabolism. Interaction with viral proteins also functions to enhance the development of innate and adaptive immune responses against the infecting agent. At the level of the infected cell, HSP are uniquely expressed on the cell surface, where they represent targets of lymphokine activated killer cells. Necrosis of the infected cell releases complexes of HSP and viral protein, which, in turn, binds antigen-presenting cells (APCs). One effect of binding is to stimulate APC maturation and the release of proinflammatory cytokines, an adjuvant effect, that prepares the way for adaptive immune responses. A second effect of binding is to direct the antigenic cargo of the HSP into endogenous MHC presentation pathways for priming of naive cytotoxic T cells (CTL) or activation of antigen-specific CTLs. For example, this alternate pathway of antigen presentation is essential to CTL priming following primary brain infection such as in measles (Oglesbee et al 2002, Viral Immunology, 15, 3, 399-416) Both HSP72 and HSP27 has been implicated in different disease states playing both protective and counter-protective roles. In multiple disease contexts, HSP-27, plays a role in renal injury and fibrosis, cancer, neuro-degenerative and cardiovascular disease (Vidyasgar et el 2012, Fibrogenesis and Tissue Repair, 5, 7, ( Interestingly, HSP27 has been characterized with the ability to regulate actin cytoskeletal dynamics during heat shock and other stress conditions, functioning both to promote actin polymerization and as an actin capping protein (Guay J et al (1997) J Cell Sci, 110: 357-368; Huot et al (1996) Cancer Res., 56: 273-279). This capping function is important in respect to DNA splitting where telomeres are the caps at the end of each strand of DNA that protect our chromosomes, like the plastic tips at the end of shoelaces. Without the coating, shoelaces become frayed until they can no longer do their job, just as without telomeres, DNA strands become damaged and our cells can't do their job. HSP 70 has been associated with CNS responses to viral load from measles. Importantly, this model suggests a self-perpetuating (positive feedback) HSP expression with virus gene expression, which in turn stimulates innate immune responses in macrophages of the brain microglia (Kim & Oglesbee 2012). The extracellular HSP70 is a ligand for TLR2 and TLR4, activating signal transduction pathways that drive type 1 IFN expression (IFN-β in brain) and expression of antigen presenting complexes (MHC). IFN-β expression by brain macrophages is key to immunity against virus infected neurons (in a mice measle model). However, studies that directly examine the contribution of HSP70 to antiviral immunity and the impact upon viral virulence are lacking.   When looking at the HSP70 family as a whole, their fundamental role in protein metabolism and the abundance within cells reinforces their potential support of viral replication at multiple levels. For every step,  in viral replication (i.e., attachment/penetration, uncoating, transcription and genome replication, and virion morphogenesis), one can cite an example of a viral system that draws upon an HSP70 family member for support. Heat Shock Protein 90 (HSP-90), Geldanamycin and COVID-19 : 19 May 2020 An interesting article on drug repositioning (defined as the use of approved drugs for new indications), offering an unmatched opportunity to offer novel therapeutics to treat SARS family of coronaviruses (SARS-FCoVs); Researchers analysed, a dataset of patients who presented with SARS during the 2003 outbreak whereby they established a gene signature that defines differential gene expression in patients who were sick with SARS vs. healthy controls and convalescent patients. They used a robust platform to conduct drug repositioning based on clustered gene expression and pathway enrichment to identify best matching drugs. They identified 55 agents of potential benefit. In most of these drugs they were able to establish a link to previous related research, use as antiviral, or at least a hypothetical role in treating SARS-FCoVs. Most notably, the heat shock protein 90 (HSP 90) emerged as a major component that enables viruses to hijack infected cells through the process of autophagy (self devouring). Almost half of the drugs identified could be linked to HSP 90. As such, they propose using HSP 90 inhibitors, mainly geldanamycin and its derivatives, to treat COVID-19. ( Based on their findings, they suggest adding more drugs to the experimental arsenal deployed against SARS-FCoVs. These included the use of nontoxic drugs that are readily available for wide scale prophylaxis or for the treatment of mild cases of COVID–19. These drugs would include omeprazole, nonsteroidal anti-inflammatory drugs, colchicine, sulfoanamide antibiotics, antimalarial drugs and clozapine/chlorpromazine. For patients with serious COVID–19 illnesses, the above drugs can be combined with immune modulators like sirolimus, and direct HSP 90 inhibitors under well-designed clinical trials. Given the high pathogenicity of the current ongoing epidemic, they suggested that it seems prudent to attempt to use multiple drugs in combination if low risk toxicity and drug-drug interaction is established. Choosing a combination of drugs identified in this study or other drug-repositioning studies and careful reporting of the efficacy of these experiences can result in rapid accumulation of knowledge.(Iyad Sultan, Scott Howard, Abdelghani Tbakhi (2020, DOI : 10.21203/ Therefore, albeit evidence from another class of HSP, it is plausible that fine tuning (down regulation from regular exercise) of HSP function is equally important to it's subsequent role as a fine tuner of cytokine - immune responses. This is an interesting finding, as one of the functions of another class of HSP (HSP 70) is the inhibition of apoptosis (cell death) which could be considered to enhance viral replication by preserving the viral factory. Inhibition of HSP 70 expression in human breast tumour cells result in massive cell death. Conversely, adenovirus infection causes a dramatic suppression of HSP 70 mRNA levels during the late phases of the viral replication cycle when the viral particles are already assembled, enhancing apoptosis in order to promote viral particle release (in Mi Young Kim and Michael Oglesbee 2012 Cells 1, 3, 646–666.doi: 10.3390/cells1030646). This suggests that HSP importance and function varies depending on the stage of the disease. A cycling dynamic of HSP outliers from the pathogen and host itself. Mechano-transduction: how does a mechanical force transduce to a thermodynamic energy system? We all know the feeling after unaccustomed exercise. Delayed Onset Muscle Soreness (DOMS); that feeling of heaviness and stiffness which worsens over a 2 day period. After the first run, on soft sand, in many years, resulting in the inability to walk down any stairs except backwards! Scientists describe it as 'broadening and streaming of the z-bands'. These are the micro-filaments between actin-myosin sliding filaments (introduced by Huxley 1957) which allow our muscles to lengthen and shorten. Additionally, an elastic element has been incorporated which is considered to be made up of passive collagen tissue (such as myofascia and tendon - which isn't quite true, as these tissues fibroblasts have motility and can change the structural integrity/density ), as well as myofilaments such as Titin. Furthermore, the cycling of ATP-ADP energy reserves give muscle another (sinusoidal) elastic element when doing exercise such as running or plyometric jumping-counter jumping. Did you know muscles require energy, in the form of ATP, to relax? Hence, the contracted rigid muscle (e.g. rigor mortice or cramp) can be considered a lower energy state than a relaxed one! Paradox? However, the eccentric (lengthened) contracted muscle, which requires less EMG activity (than concentric contractions) enhances the potential recoil for concentric (muscle shortening) contractions. In biomechanics, the Hill model of muscle thermodynamics was developed in the 1930's and redefined in 1974. Still today, it's considered as fundamental in any conservation on muscle dynamics, where an inverse relationship exists between muscle velocity and force production. This has direct bearing on the development of power (P=Fv or P=F. δ s/t). Considering energy, where Work = Power x time, it becomes apparent that the displacement of sliding filaments resulting in muscle lengthening and shortening defines the use of derivations from the laws of thermodynamics. The following is taken directly out of the seminal paper of 1974. Homsher E, Mommerts WFHM, Richhiuti NV (January 1974) The Journal of General Physiology Apart from calorific energy values, this model has practical implications, where an optimal velocity (change in displacement over time) and muscle length dependent force, develops optimal power i.e. the rate at which work is done (which, like your energy bill, is measured in Watts)  Plyometrics such as the one depicted above, can induce severe muscle soreness (DOMS) in the uninitiated. However, in the trained, this form of training has been known to improve the ability to run and jump. Actin-myosin cross bridge model (Huxley 1957) Force-velocity temperature dependent model (Ranatunga KW 1984 J Physiol. 351, 517-29) Cross filament model and four kinetic phases of half-sarcomere (hs) shortening following steps to the loads indicated (Ranatunga KW 1984 J Physiol. 351, 517-29) Later, Piazzesi G et al (2007 Cell 16, 131, 4, 784-95) demonstrated that it was the number of myosin motors rather than motor force or stroke size which determined force production at varying velocities, thereby providing a molecular basis for the parabolic relationship described earlier. However, later we will describe a large micro-filament called 'Titin' which has been considered the 'spring' in the system Discrepancies exist at low and high loading when using variations and additions to Hills equation. These have been attributed to the internal kinematics of actin-myosin, as well ADP-ATP energy cycling through the sarcoplasmic reticulum. However, non-linear mechanics (deterministic chaos theory) would expect such rules to break down at the extremes...and new predictive rules should take their place. That is, the 'outliers' define what 'norm' it isn't. This sliding filament system ( has been modelled into a modification of Hooke's Law, Young's modulus of elasticity (using microfilament Titin as the spring) and the oscillating mass-spring. This was extrapolated, at a later date, into Bernstein's perspective of 'degrees of freedom' and motor control (adding a cognitive perspective). As the muscle shortens and lengthen it generates heat, based on tension and displacement and the load applied. The concepts of concentric (muscle shortening) vs eccentric (muscle lengthening) muscle contractions, as related to energy and the immune system will be discussed later. Subsequently, inverse dynamics was extrapolated to describe the transfer of energy across accelerating body parts (inertia) through 'muscle energy straps'. Put simply, muscles which cross just one joint, tend to be deeper muscles and act as stabilisers across the joint, whereas the bulkier, more superficial, two joint muscles, are the energy straps. This is linear dynamics which we generally learn of at school. The following will describe this in more detail. Later I will examine non-linear dynamics and deterministic chaos elsewhere in the treatise. Therefore, the development of Τorque through the movement of body parts (inertia), conservation of momentum (energy), the production of potential/elastic energy describes a 'perfectly stable' sinusoidal system. However, it is becoming more apparent, that the imperfections in the system, are what drives a healthy and optimised process of power (P = Force x velocity) production and work (W=Power x time) output. Obtaining, transforming, and using energy to do work may seem simple. However, the second law of thermodynamics explains why these tasks are harder than they appear. None of the energy transfers we’ve discussed, along with all energy transfers and transformations in the universe, are completely efficient. In every energy transfer, some amount of energy is lost in a form that is unusable (as work). In most cases, this form is heat energy. Thermodynamically, heat energy is defined as the energy transferred from one system to another that is not doing work. However, what if that heat is activating HSP or other immune-metabolic procesess? Entropy Some energy is lost as heat energy during mechanical and cellular metabolic reactions. This is good for warm-blooded creatures like us, because heat energy helps to maintain our body temperature as well as regulate HSP. As stated, strictly speaking, no energy transfer is completely efficient, because some energy is lost in a 'so called' 'unusable form'. This is called entropy but ignores concepts from deterministic chaos. The traditional definition of entropy is1. a thermodynamic quantity representing the unavailability of a system's thermal energy for conversion into mechanical work. Often interpreted as the degree of disorder or randomness in the system."the second law of thermodynamics says that entropy always increases with time"2. "lack of order or predictability"; "gradual decline into disorder".  However, the latter definition 'of the gradual decline into disorder' is not what is seen when examining high performance cycling demands or when looking at muscle paralysis. In fact, it will be shown that the supposed 'decline' into disorder of the EMG readings result in predicting a more optimised function.  Cycling, concentric contractions and optimisation of cadence frequency using entropy considerations One of the key determinants of muscle co-ordination and movement efficiency during cycling is pedalling cadence consistency. Such cadence needs to occur across multiple joints and limb segments. Whereas, inverse dynamics requires changes in velocity to achieve accelerating body parts. So, in the absence of changes in cadence, how can changes in acceleration be incorporated into the model of cycling efficiency? In-order-to achieve minimal neuromuscular fatigue, optimal pedal cadence for long distance cyclists tends to be between 85 and 95 revolutions. In contrast, maximum power (as in track cyclists) is achieved with pedal cadences between 110-135 rpm. Higher pedal rates lead to shorter duration pedal cycles, coupled with longer duty cycles, recruitment of fast twitch muscle fibres and de-recruitment of slow twitch muscle fibres leading to significant inefficiencies and loss of power at higher cadence. Furthermore, people with long limbs aren't able to develop the same moments of inertia compared to shorter limbed people. To conceptualise the latter, think of the case of the ice figure skater spinning with arms close to midline vs stretched out from midline. Chaos theory would suggest that the randomization of movement pattern, requiring perturbations of periodicity, may make the scaling of muscle action/inaction important, when considering minor fluctuations in cadence and moments of inertia. Similar to the mass-spring model described previously, a system with three orthogonal axis and a fixed point of perturbation, which has a moving point of seemingly random perturbations and everything else, can be envisage. These random perturbations are the 'outliers' which traditionally have been statistically removed from linear dynamic models. However, they should be included, as only in this way can a cadence of constant velocity be used to describe efficiency. Perturbations from the manifold, new temporary fixed points of oscillation, magnify and fine tune the system As such the intrinsic firing pattern (motor unit potential shape, firing rate variability , coherence between motor units) of muscles need to be established. Additionally, their co-ordinated firing pattern across the same muscle, other muscle synergies on the same body segment and muscles of different body segments executing the same motor task, should ascertain 'extrinsic' firing patterns. That is, one wishes to determine the influence of oscillations within muscles and the influence of oscillations from not only nearby motor units but also from nearby muscles as well. The deterministic chaos of nearby oscillations influencing the prime parameter.  (Krause M and Preston R 2002) A term entrotropic half life (EnHL) using EMG was coined and developed to examine what limits mechanical power output at higher cadences above 120rpm. Hodson-Tole et al (2020, Med Sc Sp Ex, 52, 1, 214-224) found that, in trained male cyclists (~ 10000km/yr, average 33yrs), changes in the individual muscle excitations can occur even when changes in co-ordination were more limited. Importantly, they demonstrated that features of the EMG change in a non-linear fashion with increasing cadence and that both 80 and 120 rpm represent inflection points, hinge points or potential manifolds critical in EnHL relations. In other words, cadences less than 80rpm and higher than 120rpm may have fewer fluctuations in muscle recruitment or firing characteristics leading to reduced application of force at the pedal. This variability is particular true for the bi-articular muscles, such as the gastrocs (medial and lateral), biceps femoris, rectus femoris, whereas the vastus medialis and vastus lateralis (one joint muscles) reached a minimum at 80rpm and did not change across the faster cadences studied. In this day and age of gears and the optimisation of mechanical ratios for optimal cadence, we lose light of the fact that cyclists once rode without gears and until only a few decades ago (1980's) elite cyclists used very high gears (12-20 teeth rear cluster) on dirt roads and mountain passes. My personal experience, of this time, is that I felt I had a number of gears within my muscle synergy, which I could call upon to change (in this case increase) my overall velocity. This internal gearing system was at the random mercy of the variable terrain which we encountered. Deterministic chaotic input generating an internalised randomised gearing ratio, preventing fatigue? In orienteering, people talk of internal calm, whilst running and thinking at maximum endurance power. Later in this dissertation we'll take a look at an 'uncontrolled manifold hypothesis' in orienteering which is employed as an experiential learning strategy to teach predictive reasoning (through map reading), i.e. the random from the non-random, in novel terrain. This is done through a process of filtering, contrasting the 'value' of the information and subsequent minimisation of certain information and magnification of predictive 'outliers'. That data used is that which doesn't 'cloud' the 'fidelity' within the cognitive domain. Later, we will also examine the effects of 30Hz electrical input into exercising muscles for the magnification of that muscles representation in the brain. Similarly, the lack of gears in track cycling has been exploited to produce endurance road world champion cyclists, potentially by forcing an internalisation of 'fidelity' to draw out the maximum (myosin motor unit) efficiency in the system. Arguably, this recruitment of motor units, is similar to a team sport, where individual players are strategically 'engaged', so as to maximise 'players', and minimise 'passengers' in the game. Game theory will be discussed later. Eccentric muscle contractions, loading, damage and adaptation : how a mechanical force transduces to a cytokine reaction We've examined potential and kinetic energy and thermodynamics in the muscle models of power production. Using concentric (muscle shortening) contractions it could be shown that the energy state change, and heat is dissipated. This heat might be what drives the heat shock proteins (HSP's) which we discussed earlier. What those models don't take into consideration are eccentric (muscle lengthening) contractions and their influence on muscle elasticity (stiffer -> less elastic = more damping) as well as the potential myofilament damaging aspects of this sort of exercise.  What is also of particular interest is how eccentric contractions can exert more force for less EMG input (compared with concentric contraction) and how the concentric contraction is better if immediately preceded by an eccentric one. The latter being the principle behind plyometrics training such as jump downs and counter-jumps. Touron et al (2019) examined the impact of eccentric vs concentric training on body composition and energy expenditure. Typical eccentric exercises are plyometrics and downhill running.  Eccentric training is well known for inducing greater micro tears and severe post exercise muscle soreness (DOMS). It is associated with distinctive inflammation patterns and repair processes that are particularly effective in promoting adaptations, such as skeletal muscle hypertrophy (Roig et al 2009, Br J Sports Med, 42, 8, 556-568) and mitochondrial H2O2 production ((Isner et al 2014, Muscle Nerve, 50, 5, 803-811). Eccentric exercises are, considered to be, particularly useful in cardio-respiratory compromised people, as localised muscle contractions can be made without large cardiac demands. Moreover, Touron et al (2019) found beneficial effects of exercise on body composition (lean body mass), particularly with eccentric exercise (vs concentric) at high muscular, but low cardiorespiratory, loads. The mechanical 'spring' of the muscle may be considered as that of one of muscles largest proteins 'Titin', which spans an entire half-sarcomere from Z-disc to M-line. Titin functions as serially linked springs that develop tension when stretched. There are multiple titin isoforms that vary in size and stiffness, which explains the elastic-stiffness diversity across vertebrate muscle (mouse ->elephant). Because of titin’s structural properties, its most significant role may be as the muscle spring ( Evidence suggests that small heat shock proteins that protect the cytoskeleton structures (e.g. titin) increase dramatically after repeated eccentric bouts (Koh TJ. 2002 Ex Sport Sci Rev. 30, 117-121). If titin is functioning as a locomotor spring, then it should be tuned to the frequency of muscle use and adapt in response to changes in physiological demand due to exercise or disease. This notion has been reinforced as titin isoform expression has been reported as an adaptable property of striated muscle (Bell SP et al 2000 Circ Res. 87, 235-240). see video : Apart from mechanical considerations, metabolic aspects of loading, energy transduction and fatigue should also be examined. We found specific fatigue characteristics with eccentric/concentric contraction regimes (Krause M & Preston R 2002).  What is known, is that this muscle damaging and fatiguing process, has a very powerful and potent training effect, if repeated in a dose specific manner, using temporal and intensity considerations. What is unknown is whether randomisation (chaos) in this form of training attains better results once a person has become accustomed to it. Logic would suggest yes.  It can be argued that it's this microtrauma and subsequent dyskinesia, which induces an inflammatory-immune response. However, the other hypothesis are - heat production and subsequent entropy (already discussed) - that it's the asynchronicity or 'outliers' of control (chaos) which generates an immune response as well as arguing - that it's a metabolic-immune compromise which generates the cytokine response.  Furthermore, - one should consider the effect of muscle tremor whilst doing such exercise and whether this is what is needed to readjust the system to a new stable state or even reverse a gradual decay from a previously stable state? Muscle damage during eccentric exercise and immune markers Bruunsgaard H, Galbo H, Pedersen BK, et al. (J Physiol (Lond) 1997, 499, 833–41) compared concentric and eccentric ergometer bicycle exercise and found an association between increased IL-6 level and muscle damage (seen by the increase in creatine kinase). Importantly, the level of IL-6 increased more during the eccentric exercise, and a significant association was found between peak IL-6 and peak creatine kinase on the subsequent days (r = 0.722; p = 0.028). The eccentric bicycle model results in delayed muscle damage, with peak creatine kinase levels on day four or five after exercise. Researchers (Ostrowski K, Rohde T, Pedersen BK, et al. 1998 J Physiol (Lond) 508,949–53) were able to detect IL-6 mRNA in skeletal muscle biopsy specimens obtained from runners after a marathon. These data indicate that IL-6 is locally produced in response to strenuous exercise or exercise induced muscle damage. IL-1ra mRNA was not present in the skeletal muscle, but was expressed by blood mononuclear cells obtained after, but not before, the marathon, suggesting that locally produced IL-6 induces a systemic anti-inflammatory response. Sarcopenia - loss of muscle cells and hence bulk If we don't exercise regularly, our muscles atrophy, i.e. they become smaller. However, with exercise, we can reverse this process of atrophy. After a certain age, in addition to disuse atrophy, the muscles cells can be destroyed forever (apoptosis), with inactivity. This process is called sarcopenia and commences in the fourth decade of life, in sedentary individuals. As examined previously, a deterministic chaos was suggested as the TNF alpha oscillatory mediator of nuclear factor-κB (NF-κB) activation and subsequent transcription, is that which influences mitochondrial dysfunction. Investigators have found that MuRF-1, a muscle specific E3 ubiquitin ligase is an important regulator of ubiquitin-mediated protein degradation in skeletal muscle (Bodine et al., 2001 Science. 294, 5547, 1704-8). Transcriptional factors, NF-κB and FoxO3a translocate into nucleus and subsequently upregulate transcriptional activities of MuRF-1 under certain pathological conditions (Cai et al., 2004, 119, 2, 285-98.; Gumucio and Mendias, 2013 Endocrine, 43, 1, 12-21. Perry et al., 2016, Ex Immunol Rev, 22, 94-109) such as sub-clinical inflammation associated with obesity and diabetes. This suggests that inhibition of NF-κB and/or FoxO3a pathways is a promising target for preventing muscle atrophy. An exercising mouse diabetic model (Liu & Chang 2018, Front Physiol. 9, 636) has demonstrated significant muscle changes in, an eight weeks moderate-intensity exercise (5.2 m/min, 1 h/day, and 5 days/week for a total of 8 weeks) program, where mice ran on a motorized treadmill (30 min with 0° slope) and exercise duration was gradually increased from 30 min to the target of 1h (0° slope). These included improved tibialis anterior muscle mass, suppression of NF-κB signalling, as well reduced pro-inflammatory markers IL-6 and TNF-alpha.    mm = control mice, db/dh = diabetic mice, Ex = exercise So, ideally, we are exercisers for life. However, don't despair if you haven't been into fitness, it's never too late. You still have the ability, to slow down sarcopenia, as well as hypertrophy the remaining muscle. Remember, it's not just about the amount of protein, but also the thermodynamics of metabolism and repair which dictate our inflammatory-immune responses. This dynamic allows for the deployment of the immune system during a time of crisis. Muscle Glutamine It has been established that glutamine is an important fuel for lymphocytes and macrophages. Several lines of evidence suggest that glutamine is used, at a very high rate by these cells, even when they are quiescent. It has been proposed that the glutamine pathway in lymphocytes may be under external regulation, partly because of the supply of glutamine itself. Glutamine stimulates in vitro lymphocyte proliferation, lymphokine activated killer cell activity, and cytokine production.(Ardawi MS & Newsholme EA 1984, Biochem J, 217, 289–96; Rohde T, Ullum H, Pedersen BK, et al. 1995 J Appl Physiol, 79, 146–50; Rohde T, MacLean DA, Pedersen BK. 1996 Scand J Immunol, 44, 648–5036) Skeletal muscle is the major tissue involved in glutamine production and it is known to release glutamine into the bloodstream at a high rate. It has been suggested that the skeletal muscle plays a vital role in maintenance of the key process of glutamine utilisation in the immune cells. Consequently, the activity of the skeletal muscle may directly influence the immune system. The glutamine hypothesis suggests, that during intense physical exercise, or in association with surgery, trauma, burn, and sepsis, the demands on muscle and other organs for glutamine is such that the lymphoid system may be forced into a glutamine debt, which temporarily affects its function. Muscle-immune conversion "The human immune system is a highly intricate network of cells and molecules designed to keep the host free from infection and disease. Exercise is known to have a profound impact on the normal functioning of the immune system. Having higher age and sex-adjusted scores for cardiorespiratory fitness and performing regular exercise of moderate- to vigorous-intensity exercise that fall within ACSM guidelines has been shown to improve immune responses to vaccination, lower chronic low-grade inflammation, and improve various immune markers in several disease states including cancer, HIV, cardiovascular disease, diabetes, cognitive impairment and obesity. The ongoing COVID-19 pandemic has raised a lot of questions regarding how exercise can protect us from infection by boosting immunity. This is becoming more pertinent as many of us have restricted access to the gyms and parks where we would normally undertake exercise and physical activity regimens. Compounding this problem are the known negative effects of social isolation and confinement on immunity. Glucocorticoids such as cortisol are elevated during periods of isolation and confinement and can inhibit many critical functions of our immune system. When we are stressed, the ability of our T-cells to multiply in response to infectious agents is markedly reduced, as is the ability of certain effector lymphocytes (e.g., NK-cells and CD8+ T-cells) to recognize and kill cells in our body that have become cancerous or have been infected with viruses. It is also vitally important that our immune cells maintain their ability to redeploy so that they may ‘patrol’ vulnerable areas in or body (e.g., the upper respiratory tract and the lungs) to prevent viruses and other pathogens from gaining a foothold. This process is also important to minimize the impact of the virus and to expedite viral resolution should we become infected." (Richard J. Simpson, Ph.D., FACSM Mar 30, 2020) Note, a relationship exists during exercise with adrenaline, noradrenaline, neutrophils and natural killer cells with cortisol levels post exercise. Cortisol having an inhibiting/controlling influence on the immune pro-inflammatory response. Interesting to note that cytokine levels continue to rise during and after exercise. Hence, the duration of the period of the perturbations, of the immune regulating mechanism, could be assumed to have variable damping mechanisms, with higher or lower frequency, depending on the frequency, intensity and duration of exercise, as well as the period of recovery between sessions of exercise.  Pedersen & Toft (2000) "Each bout of exercise, particularly whole-body dynamic cardiorespiratory exercise, instantaneously mobilizes literally billions of immune cells, especially those cell types that are capable of carrying out effector functions such as the recognition and killing of virus-infected cells. The mobilized cells firstly enter the blood compartment from marginated vascular pools, the spleen and the bone marrow before trafficking to secondary lymphoid organs and tissues, particular to the lungs and the gut where increased immune defence may be required. The immune cells that are mobilized with exercise are primed and ‘looking for a fight.’ Their frequent recirculation between the blood and tissues functions to increase host immune surveillance, which, in theory, makes us more resistant to infection and better equipped to deal with any infectious agent that has gained a foothold. Exercise also releases various proteins that can help maintain immunity, particularly muscle-derived cytokines such as IL-6, IL-7 and IL-15. The cytokine IL-6 has been shown to ‘direct’ immune cell trafficking toward areas of infection, while IL-7 can promote the production of new T-cells from the thymus and IL-15 helps to maintain the peripheral T-cell and NK-cell compartments, all of which work in concert to increase our resistance to infection. Exercise is especially beneficial for older adults who are more susceptible to infection in general and have also been identified as a particularly vulnerable population during this COVID-19 outbreak" (Richard J. Simpson, Ph.D., FACSM  Mar 30, 2020) Over-training - variation between sympathetic and para-sympathetic tone Chaos Theory - non linear dynamics The key to exercise is not to over-train. But, to induce a response, you need to stress the system i.e create a perturbation. This fact is important in the whole spectrum of people, from the severely de-conditioned to the highly trained. Classic signs of over-training are waking tired in the morning, 'non-restorative sleep', and irritability, 'three bastards in a day or ask your partner or significant other'. The three bastards pertained to a time prior to lock-down, where it was said if you met a person who you really didn't like, then that was unfortunate, if you met a second one, in the same day, that was doubly unfortunate and if met a third, then it wasn't them, but you. Exercise requires an 'allostatic' (restorative) response by the body to mental or physical stress (see below). It's almost akin to chaos theory. Simple perturbations of the system oscillate back to the midline (linear dynamics), with the occasional outlier (non-linear dynamics). The more extreme the perturbations, the more extreme the damping mechanisms need to be, for the non-random predictive oscillations, such as mechanically intense and/or repetitive (ie metabolic, irrespective of intensity) unaccustomed exercise. But even in accustomed exercise, in a healthy body, there will be a random 'outlier'. The random outlier, in chaos theory, is not so random, but subject to three orthogonal variables, one of which is a 'locus of control'; or a 'damping manifold'. One system has influences on nearby systems. Simply stated, it is proposed that progressive exercise, building up of endurance and resistance improves our 'damping manifold' on a ratio by ratio basis. The more finely tuned, the more amplified the ratio. Such damping, or control systems, are potentially also employed in non-accustomed exercise, metabolically compromised situations, cognitively confronting and/or during immune challenges such as COVID-19. Deterministic chaos and cytokine modulation of cytokines In a seminal paper,  ' A Systems Model for Immune Cell Interactions Unravels the Mechanism of Inflammation in Human Skin' the authors (Valeyev NV, Hundhausen C, Umezawa Y, Kotov NV, Williams G, Clop A, et al. 2010), used of deterministic chaos to explain cytokine oscillations for the modulation of one other (PLoS Comput Biol 6, 12, e1001024. Their model provides a quantitative description of multiple immune reactions based on cytokine profiles, including a model of 'immune system switching', similar to 'modal switching' between various immune states described earlier for the tuning of the NF-κB system by TNF. Specifically, the inter-dependency of the immune system is highlighted using two cytokine oscillations which can maintain a 'stable' homeostatic state as well as 'switched' to an activated stable homeostatic state, of higher cytokine concentration levels, in a dose dependent manner. The model used is the autoimmune inflammatory skin condition, Psoriasis. Skin inflammation associated with Psoriasis : whilst healthy skin contains inflammatory cytokines and macrophages, the inflamed skin contains a multiple higher concentration of those substances. This is a super interesting schematic, especially when examining IL-10 (anti inflammatory) and IL-22 (involved with cell survival and synthesis of anti-microbials for wound healing).  These could be, speculated as, potential controlling 'outliers'. It also suggests that examining one cytokine response against it's baseline is relatively simplistic and potentially erroneous if it isn't examined with baseline changes of other coexisting cytokines.  Dose Dependent Cytokine Production: Homeostasis occurs when the concentrations of cytokine production of two inter-dependent cell populations meet. Importantly this is circular, cytokine A stimulates cytokine B and vice versa. Immune - Subsystem Response : Green lines are trajectories and convergence of cytokine A and B. Purple spot and dotted line are the stable 'homeostatic' point. Arrow heads indicate the direction of non-equilibrium cytokine concentration towards the stable point and equilibrium. Situation B, where a small perturbation of one cytokine leads to a 'divergence' of the trajectories and in this case a three fold perturbation of the other (numbered 3). In C and D we can see a response two fold larger than the applied spike, meaning that a small impulse can lead to a large reaction both in healthy (and inflammatory) states. Presumably, the perturbating stimulus can arise during exercise, as cytokine release from muscle damage, such as eccentric exercises, and/or metabolic factors from oxidative processes (REDOX). Additionally, as the second law of thermodynamics still applies, the influence of heat shock proteins should also be considered. Cytokine Trigger Dynamics: Two points of homeostasis (H1 and H3 'stable') after one cytokine concentration moves out of phase (H2 'unstable') with the other. Trajectories 1 and 2 are from a lower to a higher and a higher to lower stable state (resp) with the latter occurring due to the application of cytokine B (depicted in E and F). The initial onset of signalling of cytokine A is depicted in trajectory 1, C and D. Presumably, multiple points of homeostasis could exist when confronted with varying degrees (concentrations) of inflammation and repair. Oscillatory Cytokine Concentration Dynamics : one of the 'unstable' solutions forms a limit cycle of cytokine oscillations, either around a stable point of convergence or a point of homeostasis; or any other point of 'unstable' cytokine concentrations. What is amazing, is how these nullcline diagrams look like synoptic charts. (remember Edward Lorenz and the Butterfly effect eluded to much earlier)  Small amplitude perturbation results in oscillations whereas a larger amplitude results in a single spike. Noteworthy is that small perturbations result in a many fold greater response. Small perturbation results in a return to homeostasis. Resolution : one stable point at a lower cytokine concentration. Mathematics of 'deterministic chaos' and cytokine immune inter-dependence (Valeyev et al 2010) The rate of cytokine uptake Mol/sm2 by a cell population is proportional to the numberof receptors bound to the cytokine, multiplied by the total number of receptors on the cumulative cell surface: Full immune model equation is thus given by the formula  The complete dynamic mathematical equations of interactivity between inter-dependent cytokine populations (A Systems Model for Immune Cell Interactions Unravels the Mechanism of Inflammation in Human Skin' (Valeyev NV, Hundhausen C, Umezawa Y, Kotov NV, Williams G, Clop A, et al. 2010), and their use of a 'deterministic chaos' mathematical model to explain cytokine concentration inter-dependency (PLoS Comput Biol 6, 12, e1001024.  Orienteering and the 'uncontrolled manifold hypothesis' of motor control and learning (cortical resource optimisation) Orienteering is a sport requiring the efficient movement through the forest, at high speed, along an optimal route, using a calm cognitive state during a high physiological state. Another paradox? Importantly, expertise in orienteering requires decades of experiential a potentially chaotic environment. This chaos being physical, as in uneven terrain, varying vegetation and varying geological formations. Additionally, it's potentially cognitively overloading, in the sense of navigating in potentially unique and new terrain, requiring totally different central nervous system (CNS) strategies to what they are used to. To learn, is to delve into the unknown........and the cognitively superior strategy may win over the physically stronger individual (game theory).   These cognitive - mechanical concepts are entertaining when considering chaos theory and infinitesimal controlling mechanisms. Furthermore, simultaneously induced mental and physical stress, as well as exposure to environmental pathogens, adds another variable of considerable inadvertent influences on immune responses, which vary depending on the 'selective qualitative experiences' of the individual from their years of competition, conditioning, mental health and training.  Game theory and variability of the 'outlier' for adaptability It is interesting to speculate that both the novice and elite orienteer are more susceptible to infection because they both have more rigid motor patterns, are less inclined to take risk and therefore are less likely to be confronted with error generating patterns of correctability? The assumption underlying game theory is that there is a resource over which there is a conflict.  A factor which the orienteering paradigm partially defines, and identifies, is the freedom of thought and movement. That fact that many investigations are looking at exercise and the immune system, using captive animals, might be problematic in itself. These animals are in a predictable environment, which for this purpose is ethical, reductionist and conforms with rigorous scientific research protocols, which is practical, as it reduces the number of 'dependent' and 'independent' variables. However, from an evolutionary point of view, and from the perspective of the example used here, where in orienteering, more may be learnt and fine-tuned, in an unpredictable variable environment, whereby the use of caged animals may be limiting the validity of the paradigm (deterministic chaos) which is under investigation. Moreover, in terms of cognition, confinement is a stressor. Moreover, the calmness and clarity of thought needed in the freedom of orienteering (running and navigating) through the landscape can be considered the antithesis of the caged animal.  Our ancestors were striving for energy security through appeasement, subjugation or dominance over other life forms, both internally and externally. In this sense, the 'freedom to navigate and move' paradigm, suggests that our evolutionary forefathers, used their muscles, to propel themselves out of Africa, for 'greener gut biome pastures'. Therefore, maintaining good health in new and potentially 'dangerous environments', involved an unpredictable deterministic variable. As it pertains to cognition, it is an intriguing idea that a motor-sensory curiosity, drove a mechanism, which simultaneously caused muscle hypertrophy, and endowed the muscles with enhanced glutamine and cytokine concentrations, which were needed, if an immune response to pathogens was encountered. Additionally, it is conceivable, that the gut biome was driven by the laws of thermodynamics, in the search for energy. Subsequently, the gut-environment interface provided the interaction needed, to both provide energy for movement, allowed the immune system the encounters needed to flourish, and achieved the abundance of gut species required, in a variety of situations, from feast to famine. Therefore, the gut - muscle - brain cognitive pathway, was driven at a conscious and subconscious level to meet the demands of thermogenesis and immune competency, resulting in collective gain amongst all cells which required energy. Akin to Zen Buddhist philosophy, suggestions are, that the constant sensation of mild hunger, drives the clarity of thought needed, to strive for all encompassing meaning and ultimate enlightenment. Yoga, using animal poses, to stretch muscles and enhance breathing, whilst calming the cognitive state, may be based on the same primeval paradigm, of what is good for muscles is also good for the gut and brain.  The 'dove and hawk' paradigm in game theory is interesting. If a hawk and dove compete over the same resource, direct open conflict of the dove with the hawk would be suicidal. Hence, one would think it's better to be a hawk. However, what if two hawks meet, there will be only one winner and potentially both could be injured for the same net gain. Whereas, if two doves meet, they may postulate and gesticulate and eventually one may retreat or they may even share the resource, with the less risk of injury. Hence, the stakes for the Hawk are much higher. Humans have always been in conflict for resources. Does this mean that the immune system is tuned by adaptation to 'individual' resource dominance? Or, as people developed and evolved as tribes, into communities did our immune systems come to share pathogens, which may have entailed 'herd immunity' but at the same time, gave humans a lack of species variability, making them more vulnerable to 'novel' pathogens? Even more intriguing, is the notion that within a group of similar, the weakest may be driven out, seeking new resources, which in this case means new environments and new pathogens, invoking an 'immune enriching' response?   Continuing with the 'hawk dove' analogy, if we have too many hawks in a population, the consequences are constant conflict. If too many doves, constant compromise. In fact, a single dove in a hawk environment might be totally ignored, as might a single hawk in a dove environment. Thus, the apparent weaker species could be at an advantage when it's the outlier? To carry this further, we could postulate that the hawk is more prone to injury. Does this mean that in humans, the more dominant 'aggressive' individuals have an immune system which is more in demand for potential or actual injury? Whereas, the postulating dove, activates it's immune system minimally when it's performing some form of escape or deception? Interestingly, most animal conflict encounters, go out of their way to avoid injuries to themselves. Regardless, it's likely, that in both 'stressful' situations, the immune and musculoskeletal systems are activated, in a proportionately preparatory manner. Thus, the stronger the variability in the individual, the more proportional, and therefore robust their immune response. Needless-to-say, a balance between hawks and doves needs to be established for mutual gain to take effect. In terms of the human genome, it's very underwhelming, yet it has evolved to a complex multi-cellular life form, still totally dependent upon trillions of unicellular life forms within the individual gut biome. This flies in the face of Darwinian evolution and the survival of the fittest, in that simple life forms keep complex life forms alive. Even, within the gut biome, there appears to be a symbiotic relationship with parasites and a healthy immune system (i.e. parasitic exposure appears to reduce auto-immune disease such as allergies). A 'simple' multitude (gut biome) balanced with a 'complex' minority (human DNA). Humans eat to feed their gut, their gut breaks down energy from food, which in turns propels the human, with the energy gained, to find more food. A net win win situation using the gut-brain-muscle axis.  In terms of muscles, a simplistic view, (using this analogy) would be that the glycolytic (fast twitch) muscles are the 'hawks', whereas the oxidative (slow twitch) muscles are the 'doves'. The glycolytic muscle fibres tend to be ballistic two joint (mechanical) energy straps which propel the body, whereas the oxidative endurance (metabolic energy) muscles are one joint deep muscles tending to stabilise joints and prevent injury. Therefore, the 'hawks' make the large perturbations whereas the 'doves' dampen them. Luckily, there is a muscle glycolytic fibre type which can become more oxidative (endurance power). Hence, 'hawks' which can be tempered towards a 'dove' like mentality....a balance between metabolic and mechanical energy systems, where the mechanical perturbations stimulate the metabolic-immune response. In terms of neurophysiology, this analogy could potentially be taken further, where the sympathetic nervous system is the 'hawk' and the para sympathetic nervous system are the 'doves'. Fortunately, within the sympathetic nervous system there are self modulating ('dove' like) perturbating mechanisms. But it could be envisaged that putting a 'hawk' amongst the 'doves' wakes them up from a state of complacency. Similarly, 'staleness' is an 'existential threat' to any training regime and to any 'immune system'.  Cortical 'resource' representation, mapping, in knee muscles, after injury In the context of physiotherapy, a simple model of game theory might be applied to the problem of anterior knee pain. Commonly, this problem is associated with pain at the front of the knee when it is in flexion (a bent position), such as stair climbing, cycling, squats, etc. The conventional wisdom is that the patella (knee cap) is mal-aligned due to a lack of medial (VMO) muscle activity pulling the patella inwards and too much activity of the lateral thigh muscle (VL) pulling it outwards. Game theory could be applied here as the muscles compete for finite cognitive territory to represent their individual (rather than mutual) function, where ultimately neither muscle gains, both loose out to pain generating cortical representations, reducing fidelity and increasing noise in the system. However, if the muscles were to readjust for a functional outcome, they would do so through gaining a synergy of proportionally shared resources (power sharing), hereby a dominance over pain and dysfunction is gained. Physiotherapists, use functional electrical muscle stimulation (FEMS) to give added 'resources' to the VMO, which then can be used during functional exercise training. As the system adjusts, the pain improves and the gain experienced by all the muscles convinces the VL to fire with the VMO, hamstrings and gluteals in a functional synergy for stairs, cycling (see previous), squats, etc. Hereby, game theory would suggest all have won and injury has been avoided. Investigations in Australia, by the Brazilian, Abrahao Baptista (2014), looking at 40-50 year old women with chronic knee pain, demonstrated the significant reduction in the volume of muscle representation in the cerebral cortices, as well as changes in the location of these muscle representations (see below). Moreover, in the context of neurons who 'fire together, wire together' it would be of utmost importance to find exercises that act as functional synergies and relate in a real or a 'virtual' manner to the environmental context in which they need to fire. This also becomes particularly important in psychological behavioural issues of 'fear avoidance' and disuse atrophy. Ideally rehabilitation stimulates 'wiring and firing together' of goal-oriented regions of the brain rather than those which are directed at fearing and avoiding movement. Therapist must instil confidence through their choices of treatment whereby they outline and hence monitor the expectations of outcome. In this picture, it is clear that, the volume of the quadriceps muscle representation in the cortex of people with anterior knee pain (PFP = patello femoral pain) is dramatically reduced. Not seen here, but demonstrated in other research, is the phenomenon of pain processing altering cortical activity in various brain areas (see below).  Individuals with patellofemoral pain (PFP) had reduced map volumes and an anterior shift in the M1 representations, greater overlap of the M1 representation and a reduction in cortical peaks across all three quadriceps (RF, VL, VMO) muscles compared with controls.(Te et al 2017 Pain Medicine, pnx036, Physiotherapists use FEMS (30HZ functional electromuscular stimulation) to enhance muscle cortical representation in the brain, which improves function and in turn improves pain. FEMS stimulation readjusted cortical mapping to that seen in asymptomatic individuals.  Alternatively, therapists use trans-cortical stimulation of the pre-frontal cortex to improve 'executive function' and pain.  Brain activation related to spatial discrimination of noxious stimuli is distinct from that related to perceived pain. These images are located at x = 0 mm, x = 30 mm, z = 5 mm, and y = –30 mm in standard stereotaxic space. IPL/SPL, Inferior parietal lobule/superior parietal lobule; GP/PT, globus pallidus/putamen; M1, primary motor cortex; DISCRIM., discrimination. (Oshiro et al 2007 J Neuroscience, 27, 13, 3388-3394) Abrahao Baptista (2020) and his colleagues are conducting research into trans-cortical stimulation and vagal (para-sympathetic) nerve stimulation in the treatment of patients with COVID-19. They are basing their assumptions and working hypothesis on some positive results a rheumatologist has had with this methodology for the treatment of auto-immune inflammatory disease. COVID-19 has many of the hallmarks of an auto-immune disease, including the cytokine storm. This treatise has argued that sympathetic, rather than para-sympathetic, stimulation is necessary to add a deterministic chaotic input which perturbs the immune system into action. It would be intriguing to speculate a large perturbation between sympathetic and para-sympathetic can also activate the immune response. In this case, the illness has already set the sympathetic nervous into a heightened chaotic state, which needs additional buffering (redundancy) from the vagal nerve stimulation. Exercise induced disease "The road to hell is paved in good intentions" (Henry G. Bohn's A Hand-book of Proverbs in 1855) The chaos of infections and the assault on the immune system has been seen amongst endurance athletes, such as cyclists, endurance road runners and orienteers. Saturation of inflammatory immune markers by uncontrolled mechanical irritation or infectious diseases from ticks found in the forests of Scandinavia, have been espoused as a theory behind extremely fit people having catastrophic immune consequences. After intense long duration exercise, the functions of (CD 16 natural killer) NK and (CD 19) B cells are suppressed. Thus, the NK cell activity (the ability of NK cells to lyse a certain number of tumour target cells) is inhibited. Furthermore, antibody production in the circulation is inhibited, and local production of secretory IgA in the mucosa is inhibited (Pedersen BK & Nieman DC. 1998 Immunol Today, 19, 204–6) Too much of a good thing can become a bad thing. Where does the balance lie? In the chaotic state? Anti - carcinogenic effects of exercise Alternatively, it has been shown, albeit in mice, that aerobic training activates Interleukin 10, which is considered to have colon anti-carcinogenic effects (Frajacomo et al 2016, Med Sc Sp Ex, 47, 9, 1806-1813). This supports reports on the association of aerobic exercise and marked reduction of colon cancer risk in humans (Boyle et al 2011, Cancer Causes Control, 22, 12, 1647-1658; Cerin et al 2005, Cancer Epidemiology Biomarkers Rev, 14, 4, 1000-1002). A mechanism for the effect of exercise is the production of Interleukin 6 (IL-6) as a result of muscle damage during exercise, which has been demonstrated to stimulate anti-inflammatory cytokines such as IL-10 (Benatti et al 2015, Nat Rev Rheumatol, 11, 86-97). Importantly, as discussed previously, chronic increases in IL-6 are related to frailty in the aged population. However, in the acute scenario, significantly, the release of pro-inflammatory substances, stimulate the release of anti-inflammatory substances elsewhere, as well as the stimulation of the controlling mechanisms, in the location, where the pro-inflammatory substances are released.  So, what are the controllers? When is too little recovery, too much exercise? Where and what are the balancing mechanisms of the cytokines? What behavioural methods can we use to improve our immune response? Allostasis Neural componentry and chaos Several investigations, examining surface EMG (electromyographic activity of muscles) using chaos and entropy theory, exist. Investigators, examining facial paralysis (Xiong et al 2014, Robot Intelligence Technology and Applications 2 pp 805-819), used chaotic analysis to extract new features of EMG, including correlation dimension, Lyapunov exponent, approximate entropy and so on. They discovered that the maximum Lyapunov exponents are all greater than 0, indicating that sEMG is a chaotic signal. Interestingly, correlation dimensions of sEMG on healthy sides are all smaller than that of diseased sides; and inversely, the approximate entropies of healthy sides are all greater than that of diseased sides. Consequently, they concluded that chaotic analysis can provide a new insight into the complexity of the EMG and may be a vital indicator of diagnosis and recovery in the assessment of facial paralysis  Application of chaos theory to a model biological system was used to examine evidence of self-organization in the intrinsic cardiac (heart) nervous system (Skinner et al 1996, Integr Physiol Behav Sci. 31,2,122-46). Using a rabbit model and ischaemic events, on electrical activity in and around the heart, they found that it's the neutral organization that determines the specific beat-to-beat pattern of cardiac behaviour. This was demonstrated in the independent regulation of the RR intervals (chronotropy) and the corresponding QT subintervals (inotropy), as the former defines the rate of contraction and the latter has a linear negative correlation with the peak pressure inside the contracting ventricular muscles. During accumulating ischemia/anoxia, dimensional fluctuations of the two sub-interval series as correlates of adaptation-dependent self-organization and reorganization in the underlying intrinsic cardiac nervous system, was seen. COVID-19 and Allostasis As we know, organs exposed to the outside world, such as the digestive and respiratory tracts and skin have a high functional immune component, which acts as an interface and barrier to external pathogens. At the outset of this pandemic, COVID-19 was considered a lung condition. However, as time went on, hypoxia and diffusion issues began to be noted, including oxygen blood saturation levels of 50%, skin changes in the periphery (esp toes) resembling lesions seen in chilblains and chicken pox, notably in young people (20-40 years of age). Additionally, vascular clotting began to be seen in this younger population leading in some cases to stroke. Furthermore, longer gastric emptying was seen which may or may not be an immune response. It has also been noted that it's highly contagious, human to human, animal to human and human to animal, as well as being highly unpredictable, in who survives and who does not. Since it is a 'novel corona virus' we do know that we need our 'innate immune response' to fight it. That's potentially why it generally doesn't affect children (however there have been exceptions) and it's mortality rate is much higher amongst the elderly and those who are already metabolically or immune compromised.  Furthermore, psychological stress from confinement has also been seen. Further mental health issues, from potentially the extreme viral exposure amongst essential services, and/or extreme exhaustion amongst health care workers has also been acknowledged. Psychology and mental stress, such as that from Post Traumatic Stress Disorder (PTSD) is thought to reduce the number of naive T cells, meaning a reduced ability to launch an immune response to a novel pathogen and is also thought to contribute to increased susceptibility to auto-immune disorders (Dr. Annette Sommershof).  Therefore, the essential question, is it purely metabolic and cognitive exhaustion, and/or exhaustion of the immune system from exposure to COVID-19? Would people (orienteers) used to mental stress, whilst exercising, better be able to launch a balanced immune defence? Adaptation has a damping mechanism whereas lack of adaptation does not. Additionally, it is important to launch a stimulus or perturbation strong enough to activate an appropriate balanced response. Recovery and sleep routine It is critical to maintain a healthy sleep pattern if we wish to maintain a healthy immune system. Routines of the day can become good anchor points for the body. These include eating regularly and sleep. Psychology of the immune state Psychologically, we also need to be prepared for what lies ahead. Currently, we're fighting an unknown assailant. A virus which our adaptive immune system has never seen before. This means that we must rely on our innate immune system, the one we're born with, to adapt it's RNA to a DNA antigen which can fight the disease. However, remember psychological stress of 'perceived dangers' such as job and income insecurity, fear of the disease, isolation and loneliness can affect where and when we deploy our cytokines. Importantly, when or if we are exposed to COVID-19, ideally your immune system is able to react and isn't already exhausted. Part of your exercise regime may need to include meditation and Yoga. Diet Another, important way of avoiding an 'exhausted immune system' is diet. Generally, a well balanced diet is important. Moreover, during exercise our immune system is enhance, whereas post exercise it can be depressed. One of the best ways to ameliorate this, is through amelioration of metabolic demands with pre-exercise, during long exercise and/or immediate, post exercise calorific intake, thereby avoiding metabolic imbalance and potential catabolic (break down) reactions, whilst promoting anabolic (building) ones. Besides nitrogen balance, contracting skeletal muscles, in sports such as running, are a major source of increases in the circulating concentration of the cytokine, Interleukin-6 (IL-6), seen during exercise. It's appearance decreases with the ingestion of glucose and with endurance training. Low pre-exercise glucose levels, results in greater transcriptional activity of IL-6 gene in muscle and higher IL-6 concentrations during subsequent exercise, which in turn stimulates hepatic glucose production and fatty acid mobilisation and oxidation. Thus, IL-6 may be a carbohydrate sensor, mobilizing substrates and/or augmenting substrate delivery to working muscles. Interestingly, IL-6 concentrations increased with increasing intensity of exercise, whereas tumour necrosing factor alpha (TNFα) did not (Scott et al 2011, Med & Sc Sp & Ex, 43,12, 2297-2306), suggesting a specific and therefore potentially finely tuned immune response. The gut-muscle-immune axis: a ratio of innate and adaptive immune substances? It could be simply argued that all systems are oscillatory, finely tuned through damping mechanisms and that the reference points of the tuning are not only defined by extent of the oscillation (linear dynamics) but also by the randomness of non-cycling oscillations. Mechanically, this may be analogous to a mass-spring system defined by Hooke's Law, but immunologically it's potentially defined by the balance between up-regulatory and down-regulatory immune pathways of the adaptive and innate systems? Using a yeast and bacteria (E.coli Hsp60 homologue known as GroEL) model, a tenuous relationship has been proposed between HSP60 and HSP70 chaperone proteins, as they are both vital for mitochondrial proteostasis, being involved in the import and/or the folding of almost 50% of the mitochondrial proteins. Moreover, both proteins were found to carry out various functions via interaction with a large number of extra-mitochondrial complexes. In the case of HSP 70, its mitochondrial functions are performed by the classical mechanism known for all HSP 70, utilising a protein and a nucleotide exchange factor. With regard to mitochondrial HSP 60 and HSP 10, it is notable that this pair developed a unique reaction cycle in the gut (Jebara F et al 2017 DOI: 10.1002/9780470015902.a0027152), a bit like the relationship of HSP27 with HSP72. The amount of human DNA is totally under-whelming compared to that of the intestinal mircobiome. The intestine is composed of a complex ecosystem of more than trillions of bacteria, viruses, fungi, Protozoa and Archea that live in a symbiosis with the host in the gut lumen. The healthy microbiome include a limited number of highly represented taxa, such as Bacteroides and Prevotella  and a large number (>2000 to date)  of minor players with low representation but high metabolic activity. These latter 'players' with high metabolic activity are likely to be the ones which interact with the musculoskeletal system. In older age, species richness and diversity of the microbiome decline, inter-individual variability increases, and resilience to perturbations are reduced. Apart from aging, the presence of acute and chronic diseases affects the microbiome. In the aging and/or unhealthy microbiome a 'dysbiosis' can occur, where a disruption of the gut balance 'symbiosis' results in intestinal permeability, allowing bacteria, or bacterial toxins and metabolites to enter the host circulation thereby promoting sub-clinical inflammation. Clinically, sub-clinical inflammation has been referred to as 'inflammaging' and 'immunosenescence'.  All components of the innate immune system exhibit profound changes during aging. Monocytes are classified into three subtypes: classical, non-classical, and intermediate. During aging the number of nonclassical CD14+CD16+ monocytes increases, indicating a shift to senescence, proinflammatory phenotype with short telomeres. Similarly, a shift in macrophages from immunoregulatory M2 macrophages to proinflammatory M1 macrophages. Furthermore, Natural Killer (NK) cells are innate lymphoid cells, where 2 subtypes are present. CD56bright cells are immature cells providing an immune regulatory function, and CD56dimCD16+NK cells which produce high levels of IFN-gamma, associated with a potential dysregulated cytokine production, as CD56bright cells decrease with aging. Moreover, exercise appears to have the opposite effect to aging, where a reduction the number of nonclassical CD14+/CD16+ monocytes, was found, in a 12 week combined strength and endurance training program. The adaptive immune system changes with aging. Although the total number of T-cells remains constant throughout life, the two main cellular subtypes CD8+ cells increase, whereas CD4+ decrease. This phenomenon is part of the immune risk profile (IRP) and indicates immunosuppression in certain diseases. Reduction of naive CD4+ cells is driven by thymic involution from chronic antigenic stimulation and inflammation. Inflammaging chronically increases IL-6 and TNF-alpha. Improved T cell function has been reported in elderly runners who trained for an average of 17 years, and thus improvements in the adaptive immune response.  In 102 male participants between 18 and 61 years of age, with above-average VO2 had fewer senescent CD28-CD57+, CD4+, and CD8+ cells and increased number of naive CD8+ T cells. Acute bouts of exercise induces cell death in apoptosis-resistant senescent T-cells. Additionally, regular endurance training in the elderly, improves CD4+/CD8+ ratio. Although exercise seems to improve the immune system, endurance exercise seems better than strength training alone. Exercise also influences inflammation induced from visceral adipose tissue (fat). Toll-like receptors (TLRs), mainly in the innate immune system, are upregulated with physical inactivity, systemic inflammation and the development of age-related diseases. They are particularly reactive to heat shock proteins (HSP). HSP's are found in muscle and released with exercise. Conversely, a reduced expression of TLR2 and TLR4 has been found in both acute and regular exercise. Importantly, skeletal muscle itself acts as an endocrine organ, whereby muscle contractions and energy metabolism induce the production of various cytokines-termed myokines-or peptides with anti-inflammatory potential. As highlighted earlier IL-6 is one of the most effective myokine. IL-6 increases during and after exercise, proportional to intensity and duration, stimulating immune-regulatory mediators such as IL-10 and the IL-1 receptor antagonists and downregulation of TNF-alpha by monocytes and macrophages. Results form middle-aged master athletes demonstrated that IL-1ra, IL-1beta, IL-4 and IL-8 levels were elevated compared to inactive, younger-middle-aged controls. Exercise-induced IL-6 has been shown to inhibit endotoxic-induced TNF-alpha. Besides IL-6, myokines such as meteorin-like has been shown to induce brown fat metabolism, increase IL-4 levels and promote polarization of M2 macrophages. IL-7 and IL-15 are myokines that might stimulate lymphocyte proliferation and it has been suggested that IL-7 exerts protective effects on the thymus.. IL-15 seems to have further effects on immune homeostasis which induces a better survival rate of naive T-cells. At a metabolic level, IL-15 reduces the accumulation of visceral and white adipose tissue by reducing the accumulation of fat. Exercise is generally considered a positive modulator of the gut biome. Regardless of age, exercise has a positive effect on taxa involved in energy, carbohydrate and protein metabolism and short chain fatty acid (SCFA) production. Maintenance of exercise is needed to induce long-lasting modifications of intestinal microbial ecosystem. Such changes have been shown to improve the inflammatory mediators of the gut. Importantly, dosage of exercise is important, as over-exercise can induce ischaemic events in the gut mucosa, associated with acute gastrointestinal symptoms including abdominal pain, nausea, and diarrhoea. Supplementations, of probiotics and prebiotics can attenuate some of these unfavourable changes of the gut.  Probiotics have been shown to modify the gut microflora population, increase natural killer (NK) cell cytotoxicity, increase secretary immunoglobulin A (IgA) levels, and enhance resistance to infections, potentially through the kynurenine/tryptophan ratio, activated T-suppressor (CD8+CD25+) and natural killer cells (CD56+CD16+)  in high doses, whilst low doses increased activated T-helper lymphocytes (CD4+CD25+), B-lymphocytes (CD19+) and antigen-presenting cells (HLA-DR+). There is a gut-muscle axis hypothesis in age-related sarcopenia. A dysbiotic intestinal microbiota can effectively result in reduced bio-availability of dietary proteins, in particular tryptophan, which is a powerful mediator of inflammation, as well as a promotor of muscle protein synthesis. Additionally, the gut bacteria are also involved in the synthesis of many vitamins, including folate, vitamin B12 and riboflavin, which exert pro-anabolic effects on muscles.  Tryptophan is a pre-curser of serotonin and plays a pivotal role in immune system regulation. Enhanced breakdown of the tryptophan kynurenine pathway occurs in aging and in conditions with an increased pro-inflammatory response. Tryptophan and particular serotonin have been known to be associated with mood and cognition. The kynurenine pathway not only plays a role in the innate immune system via IDO (an enzyme which degrades tryptophane) and it's influence on IFN-gamma, but also in the adaptive T-cells immune response, through selective apoptosis of Th1, and not Th2, cells. Accumulating evidence implicates gut microbiota in the regulation of kynurenine pathway metabolism, and thus the gut-brain axis. Chronic exercise interventions may lead to reductions in IDO activity as a result of anti-inflammation.  Assuming that chronic inflammation induces sarcopenia and vice versa, good muscle mass reduces chronic inflammation, a vicious cycle needs to be broken by any means possible, through a combination of dose specific exercise and diet. As already stated anti-oxidants and sufficient carbohydrates and protein are important in our diets. Additionally, n-3 polyunsaturated fatty acids (PUFAs), has been shown to have anti-inflammatory properties through their effect on leukocyte action, eicosanoid production, and T-cell proliferation. PUFAs in combination with strength and endurance training have been shown to have favourable muscle building effects, where 6 months of Progressive Resistance Training (PRE) (2 x week, 3 sets per x's. 50-85% 1RM) combined with n-3-PUFA-rich diet, improved gene expression, whereby pro-inflammatory IL-1beta was down-regulated and regulator of cellular growth mechanistic Target of Rapamycin (mTOR) was up-regulated in skeletal muscle in older women. Exercise training has been shown to reduce intestinal inflammation and modulate gut microbiota profiles in insulin-resistant people (Motiani et al 2020, Med Sc Sp Ex, 52, 1, 94-104), using both moderate-intensity continuous training (MICT) and sprint interval training (SIT). High fat diets reduces the Bifidobacterium, Eubactterium rectale-Blautina coccoides, and Bacteroides genus  which leads to an increase in the Gram-negative : Gram positive ratio, meaning a subsequent increase in LBP was found by Cani et al (2008 Diabetes, 57, 6, 1470-1481). Moliani et al (2020), on the other hand, found the opposite with both forms of exercise training. There was a reduction in Firmicutes/Bactroidetes ratio, mainly due to an increase in the relative abundance of Bacteroidetes and a decrease in abundance of  Blautia spp.  and Clostridium spp at genus level. This may induce regulatory T-cells to produce IL-10 (anit-inflammatory cytokine) inside the gut (Mazmaniian et al 2008 Nature, 453, 7195, 620-625). Furthermore, it was found that Bacteroidetes  at the species level correlated negatively with plasma inflammation (LBP, TNF alpha, and CRP levels) (Moliani et al (2020). Exercise training also reduced the relative abundance of Clostridium  and tended to reduce the Blautia genus. The former thought to play a role in whole body inflammatory response and the latter found in abundance in pre-diabetic people. Moliani et al (2020) also found a reduction in TNF alpha after 2 weeks of training, which also plays a critical role in inflammation. The Firmicutes/Bacteroidetes ratio is elevated in obese people, whereas it is reduced in this study as well as in some investigations examining dietary intervention.(Ley ey al 2006 Nature, 444, 7122, 1022-3)..It is thought this ratio is important in that Firmicutes may contribute to obesity because they can harvest more energy from food (Turnbaugh et al 2008, Cell Host Microbe, 3, 4 213-223). Increases in faecal Bacteroidetes were also found, which is significant as it plays an essential role in the metabolic conversions of complex sugar polymers and degradation of proteins (Rajilic-Stojanovic & Voss 2014, FEMS Micorbiol Rev, 38, 5, 996-1047). Although, these are very positive findings for exercise intervention, chaos theory would suggest that the SIT group should have shown more changes than the MICT group. Interestingly, by choosing a cycling program, any effect of muscle micro-tears and an immune response is mitigated, as would be seen with eccentric exercises, such as a running regime. Hence, this is a purely metabolic (vs mechanical load) load, where the SIT is high intensity but of a much shorter duration (30secs x 4-6 bouts)  vs MICT of 40 - 60 minute duration. One would surely elicit an anaerobic, lactic acid, response whilst the latter would elicit a Glut-4 muscle energy metabolising response. It's difficult to reconcile this on a purely metabolic basis and perhaps it's the neural activation of exercise which is the prime signalling pathway? The Paper of the Year for Exercise and Sports Science (2020) was recognised for several findings, including exercise alters the microbiome of the gut independently of diet exercise exerts strain level selection for microbes within the host more robustly than genotype reduced exercise tolerance in situations of reduced microbiome (eg anti-biotic use and gene knock out mice)  mechanism is likely via butyrate-producing microbes gut-immune interactions via gut-associated-lymphoid tissue bile acid circulation metabolic flux Specifically, Fecalibacterium prausnitzii, has been shown, not only to be enhanced with exercise training, it is thought to improve type II diabetes outcomes, as well as improve symptoms of depression and anxiety. (Mailing et al 2019, Ex Sp Sc Rev, 47, 75-85. Weyh C et al (2020), Nutrients, 12, 622: doi:10.3390/nu12030622 Ticinesi A et al (2019) EIR 25, 84-95 Ticinesi A et al (2019) Nutrients, 11, 1633; doi:10.3390/nu11071633 Codella et al (2017), Digestive and Liver Disease, doi:10.1016/j.dld.2017.11.016 Dietert R & Dietert J (2012), Entropy, 14, 2036-2065: doi:10.3390/e14112036 COVID-19 is not just in the lungs - it's also in the gut. Bursitis, tendinopathy and the immune system Clinically, I began to notice a relationship between bursitis, tendinopathy and gut immune compromise back in the early 1990's when I was working with Swiss elite national teams in various sporting endeavours. It seemed like a common occurrence for young healthy athletes to suddenly develop bursa and tendon symptoms after a gut infection, severe cold, etc. Since that time, many investigations have demonstrated a relationship between metabolic-immune compromise and fatty-immune substance infiltration into bursa and tendon resulting in pain. Interested readers should see shoulder tendinopathy elsewhere on this website for further details. Dosage of exercise to fine tune the immune system Hence, dosage and type of exercise becomes important as well as the way you progress your loading. The benefit of resistance training, is that you can do this indoors, using weights around the house, as well as body weight. Additionally, it is easy and important to establish a base line. That is, how many repetitions for a certain number of sets. Each set of repetitions should feel the same in each set. The last repetition is the 'point of failure' ie you cannot do another repetition. You will also need to establish the time of recovery between sets. Write these down.  Once a base line or a protective foundation of exercise has been laid down, using a deterministic chaotic variable (usually 4-12 weeks), then the introduction of random - chaotic - novel exercise, fine motor exercise, high repetition exercise, high load low repetition needs to be employed, to improve cognitive, metabolic, emotional, mechanical and ultimately immunological demand on the system. Those fortunate enough to be able to leave their home for exercise, walking and cycling are great activities. Even here, you can challenge yourself with distance, time and hills. If walking, you may wish to use a weighted backpack. If cycling, use higher gears from time to time, so as to add some resistance training into what is essentially an endurance activity. However, these activities do not replace a structured home exercise or gym based regime. Oscillations in another part of the body can be used to establish harmonic frequency elsewhere. For example, arm movements activating the opposite erector spinae activity, pelvic oscillations for scapular control, arm lifts for contra-lateral gluteal activity. Alternate kneading of the hands into something soft activates the abdominal muscles, spinal rotatores and scapula muscles. Oscillations of the pelvis around the hip activates eccentric scapula control. Alternate lifting of the arm off the wall activates the opposite buttock muscle. Alternating arm flexion/extension around the 90 degree angle activates the opposite erector spinae muscles of the low thorax and upper lumbar spine. Moving through the horizontal with a consistent oscillation also has varying effects on those muscles. Importantly, if loading is required to activate a muscle building response, then repetitions need to include tremor. Either fine motor tremor or exhaustion tremor, if we want to include a 'deterministic chaotic variable', which it is hypothesised to create an immune training variable. "In this regard, it is vitally important that we try to maintain our activity levels within recommended guidelines. Not only can exercise have a positive direct effect on the cells and molecules of the immune system, but it is also known to counter the negative effects of isolation and confinement stress on various aspects of immunity. Although no scientific data currently exists regarding the effects of exercise on coronaviruses, there is evidence that exercise can protect the host from many other viral infections including influenza, rhinovirus (another cause of the common cold) and herpesviruses such as Epstein-Barr (EBV), varicella-zoster (VZV) and herpes-simplex-virus-1 (HSV-1). Work from Jeff Woods’ lab at the University of Illinois showed that moderate-intensity exercise training during an active influenza infection protected mice from death. It also promoted a favourable immune cell composition and cytokine shift in the lungs that was associated with prolonged survival. A major focus of our research is to understand how exercise can mitigate the negative effects of stress to maintain immune function, particularly during prolonged periods of isolation and confinement such as space travel. We showed recently that astronauts who had higher pre-flight cardiorespiratory fitness and skeletal muscle endurance before a six-month mission to the International Space Station were less likely to reactivate EBV and VZV during the mission. Copies of EBV viral DNA were also lower in the fitter astronauts, indicating that their ability to infect others is also reduced. Moreover, those astronauts who had lower pre-flight fitness levels and returned to Earth with the greatest levels of cardiorespiratory deconditioning were more likely to have reactivated a virus during the mission. Viral reactivation is a global indicator that our immune system has been weakened, which, in this context, we believe to be largely due to the stressors associated with isolation and confinement. This research indicates that exercise, in addition to the aforementioned direct effects it can have on cells and molecules of the immune system, may be an effective stress-induced countermeasure to help maintain immune function and lower infection risk." (Richard J. Simpson, Ph.D., FACSM | Mar 30, 2020) "Floppies vs Stiffies" consideration when prescribing exercise There are essentially two types of people - the 'floppies' vs 'stiffies'. The forming are hyper-mobile whereas the latter are hypo-mobile. The floppies like to do fast and quick type of exercise such as gymnastics, dance, track and field, etc. The stiffies tend to do slow type of exercise such as marathon running. Hence, not only do these people have different connective tissue type, but also different muscle fibre type. The 'fast' twitch muscles are the ballistic muscles, whereas the stiffies tend to have 'slow' twitch endurance muscles with a joint and posture stabilising function. Stiffies tend to be found in the Pilates class, whilst the floppies are found in the Yoga class. In terms of clinical reasoning and injury management this should probably be the other way around. Another, interesting clinical anecdotal observation, floppies tend to do better in pulling type of exercise ie where energy is brought back into the body, whereas stiffies tend to do better with pushing type of exercise where energy is produced outward away from the body.   Motivators to exercise and to eat Interestingly, research which I undertook in 1992-93, examined the influence of the hypothalamus and the peripheral sympathetic nervous system on fibromyalgia, chronically over-exercised and repeatedly injured female elite athletes. What was exceedingly interesting were the interactions with luteinising and follicle stimulating hormone and immune system. Clinically, these athletes (orienteers, x-country skiers and distance runners) suffered from eating disorders, osteoporosis, dysmenorrhea, late menarche, and were frequently ill with skin infections and upper respiratory infections. Paucity of research on the hypothalamus, at the time and even contemporarily in humans, due to the technical nature of research in this region, means that the majority of investigations are still done in rodents. More recently, leptin, glucose and glut-2 astrocyte and neuron (related to glut-4 muscle) receptors, and neuropeptide Y (NPY) were found to be involved in a complex interaction around the arcuate nucleus (ARC), related to transcriptional regulation of motivated exercise (Good et al 2020, Ex Sp Sc Rev, 48, 2, 74-82). These areas happen to be also related to taste and smell (olfaction), which coincidentally the loss of, is one of the symptoms related to COVID-19. The olfactory system has been used as a conduit for drug and homeopathic administration, directly into the central nervous system (CNS), as there is no blood brain barrier or blood nerve barrier here. New genetically engineered biotechnology products, such as recombinant human nerve growth factor, human VEGF, and interferons, are now possible to be delivered into the brain from the non-invasive intranasal route. For gene therapy, intranasal route is also a promising alternative method to deliver plasmid DNA to the brain. Additionally, anti-biotics are also being trialled via nasal delivery in COVID-19 patients.  Insulin nasal delivery has also been approved by the FDA using a methodology originally developed by (my uncle-in-law) Eric Bechgaard of Denmark (, Interested readers of this modality should see for a review.. It would appear that the same area of the brain relating to eating is also related to initiation or continuation of exercise, at least in rodents. Leptin levels are reduced 1-3 hours after exercise such as running (Zheng et al 1996, Biochem biophys Res Commun, 225, 3, 747-750). In rodents, injecting an expression vector for Leptin receptors increased home cage activity . A wild type mouse had significant reduction in weight using a similar methodology (Coppari et al 2005, Cell Metabol, 1,1, 63-72). Furthermore, it's not just a simple glucose or leptin-sensing mechanism by hypothalamic neurones, but a series of inter-connecting neurones, astrocytes, integrated receptors, adenosine triphospahate (ATP) synthesis and sodium sensing within the brain. Importantly, however, these incredibly complex, areas may also exert an influence, directly or indirectly, on the immune-inflammatory axis, through it's action on muscles, which affects overall health and susceptibility to disease. Importantly, a (un)healthy relationship exists between weight and susceptibility to disease. The review by Good et al (2020) stipulates that it's the flux of leptin, rather than the absolute levels of leptin, which is sensed by the LepR POMC neurones, whereby an increase in leptin levels may signal the need to exercise, so as to remove excess available energy. Specifically, transcriptional gene regulation downstream of the neuronal basic helix-loop-helix transcription factor nascent helix-loop-helix transcription factor nascent-loop-helix 2 (NHLH2/humans, Nhlh2/mouse) in POMC neurones, drives motivation to exercise by increasing melanocortinergic and dopaminergic tone in the hypothalamus and extrahypothalamic brain regions.  Leptin, diabetes and exercise Researchers, using a diabetic mouse model, have demonstrated that decreased leptin, MCP-1, and resistin levels were observed in diabetic mice after moderate exercise training compared with the non-exercised group. Leptin, MCP-1, and resistin levels in diabetic mice+Ex mice were 8.6, 75, and 39% lower, respectively, compared with diabetic mice without exercise training (Liu & Chang 2018, Front Physiol. 9, 636). Monocyte chemoattractant protein-1 (MCP-1/CCL2) is one of the key chemokines that regulate migration and infiltration of monocytes/macrophages. Both CCL2 and its receptor CCR2 have been demonstrated to be induced and involved in various diseases, including fibrosis, arthrosclerosis and systemic inflammation such as psoriasis. Migration of monocytes from the blood stream across the vascular endothelium is required for routine immunological surveillance of tissues, as well as in response to inflammation. Moreover, a metabolic role involves adipocytes secreting various adipokines that may be involved in the negative cross-talk between adipose tissue and skeletal muscle. CCL2 impairs insulin signalling in skeletal muscle cells via ERK1/2 activation at doses similar to its physiological plasma concentrations (200 pg/mL), but interestingly, does not involve activation of the NF-κB pathway. CCL2 significantly reduced insulin-stimulated glucose uptake in myocytes. CCL2 may represent a molecular link in the negative cross-talk between adipose tissue and skeletal muscle assigning a completely novel important role to CCL2 besides inflammation (Sell H et al 2006 Endocrinology. 147, 5, 2458–67Endocrinology. 147, 5, 2458–67). Leptin and diet The first time I heard about leptin was in the mid 90's and it was described as a hormone produced by fat cells. Certain foods stimulate leptin sensitivity (vs leptin resistance and weight gain). These include Apples. Research has shown pectin—as found in apples—may be effective in fighting back leptin resistance. Oatmeal. Rich in fibre and known for decreasing insulin levels, oatmeal can help prevent that “starving” feeling.  Lean proteins. The protein you get in turkey, chicken, and other lean meats can help to raise your metabolism and reduce leptin resistance. The same with fish, a top choice for battling leptin resistance. Green tea. A European study involving mice showed that green tea is effective in decreasing leptin resistance. Almonds. Besides the essential “healthy” fats, fibre, and protein you get from almonds, you also get essential fatty acids that boost metabolism and leptin sensitivity. Broccoli. Also thought to decrease your leptin resistance is broccoli, a vegetable that’s generous in calcium and vitamin C. Eggs. Known for their vitamin B12 and protein contributions, eggs can lift your metabolism and help keep you from becoming leptin-resistant. Generally speaking, keep fruits and vegetables front and centre at your meals. Top choices: grapefruit, watermelon, pears, and blueberries along with purple sweet potatoes, peppers, lettuce, carrots, and zucchini. Exposure "Currently, the greatest risk of COVID-19 infection is exposure. It is paramount that we find creative ways to exercise while maintaining social distancing and proper hygienic countermeasures. While exercise may not prevent us from becoming infected if exposed, it is likely that keeping active will boost our immune system to help minimize the deleterious effects of the virus, ameliorate our symptoms, expedite our recovery times and lower the likelihood that we can infect others with whom we come into contact. This is merely my intuition, but I do expect a large body of exercise immunology research to follow after this pandemic so that we can provide more specific exercise recommendations as they pertain to infection risk and control in both healthy and clinical populations." (Richard J. Simpson, Ph.D., FACSM  Mar 30, 2020) Musculoskeletal Physiotherapy in the recovery from injury Previously, we discussed game theory in terms of adding resources to the VMO through FES (functional electrical stimulation) to moderate anterior knee pain and regain quadriceps cortical representation and function. We also described the need to stress the system to induce the change needed to improve immune health. Those stressors may, if they cross the threshold from functional to dysfunctional at times, need to be managed,. The latter inducing pain, which if it persists, results in clinical or sub-clinical inflammation, thereby creating an immune compromised states. Obvious everyday signs of this are frailty and obesity. Clinically, traditional Manipulative Physiotherapy (now called Musculoskeletal Physiotherapy) used a multitude of questions from the cognitive domain to ascertain a persons dysfunction. Parameters included the stage (temporal), stability (current or past history of ease of recurrence), irritability (time to worsen vs time to ease) and severity (how disabling). Intrinsic to questioning, was establishing a persons normal baseline of activity w.r.t. their age and wellness level, and calibrating that degree pf loading to questions on the triggers of their pain and dysfunction. Multidimensional reasoning on ascertaining perturbations or 'outliers' to an expectation of this persons and the average persons functional capacity, health and physical as well as mental well being. Once, these 'outliers' are correlated into a clinical picture, a reductionist approach to treatment, exercise prescription and goal setting can be achieved within the construct of the persons expectations, values and beliefs. The 'outliers' of the subjective examination are correlated with the 'outliers' of the physical examination. For clinicians, the 'noise' is the average, the 'fidelity' are the answers we receive from the inductive and deductive reasoning. Knowledge is strength. Physiotherapists, Exercise and Sports Scientists, Team managers and Trainers should have the confidence in their construct validity by incorporating their knowledge of the immune system, 'outliers', game theory and deterministic chaos into their treatment, rehabilitation, training regimes and sporting strategies, using a multi-modal reasoning approach. Conclusion Does exercise create a chaotic environment which stimulates and tunes the immune system? I have argued that it does, based on the muscle itself being an endocrine organ, in which multiple immune reactions occur and from which there is an interaction with multiple organs, including the brain, gut, thymus and liver. Additionally, intrinsic to exercise is the use of the lungs, which in essence is an immune interface with pathogens from the outside world. Where does chaos fit in? Chaos could be considered the non-harmonic perturbations of an oscillatory or regulatory system. A system of ratios, higher 'fidelity' as the magnification of the ratios, where perturbations of cytokines creates oscillations and new states of homeostasis through modal jumps. These oscillatory systems also include those of the second law of thermodynamics, motor and metabolic control. Paradoxes exist which allow the seemingly random fluctuation of a homeostatic system. Exercise can be deemed to be an easy tool for us to use in order to push the boundaries of these fluctuations, in order to set the reference points for a dynamic damping mechanism. The greater the fluctuation, the greater the damping needed. Importantly, in any damping system, over-shooting and over-oscillating need greater damping, which could include sound professional advice from physiotherapists and trainers. This may include advice on types of training (eccentric vs concentric, metabolic ), rest, avoidance of over-training, good and varied diet as well as mental strategies for a calm cognitive - psychological state are of paramount importance in the application and dampening of stressors. Moreover, hands on therapy may be required if injury were to occur. Most importantly, exercise can be seen to stimulate muscle, one of the largest organs of the immune system. In such a sense, prophylactic exercising of muscles, makes this strategy an inoculation against immune challenges both now and in the future. In this age of COVID-19, a great opportunity has arisen where people working from home may more easily exercise. Moreover, whilst in shut down it is even more important to exercise, and if the possibility arises walk, run or ride to work, thereby incorporating exercise and deterministic chaos into your daily routine, whilst avoiding confined spaces such as public transport. However, bear in mind that the trip to work shouldn't be exhaustive, as that can lead to immune compromise, for several hours after the cessation of exercise. Justification This article was adapted from a key note guest presentation I made at a conference in Rome in 2005, as well as Post Graduate research on neuro-immune-inflammation in Low Back Pain from 1995, an under-graduate research topic on Bernsteins perspective of motor control and linear oscillatory systems to control degrees of freedom from 1986, inverse dynamics and the Hill model of the mass-spring spring cycle and thermodynamics in calf-achilles problems from 2008, and research into Orienteering on a motor-immune-cognitive control hypothesis from 1998, as well as reading on non-linear dynamics and chaos since 1992. I wrote it, in response to the pandemic, but also as a conceptual framework on which I wish people build deterministic chaos theory into their reasons for motivation to train the mental and physical well being. Hopefully, physiotherapeutic interventions incorporate game theory of 'doves & hawks' into their thinking whilst, bearing in mind that muscle is an endocrine organ of the immune system, with a gut, lung and brain axis. Stay well, stay safe, support yourself, your family and your community Martin Krause April - May 2020 References References can be found within this text and in the original papers published in 1986, 1995, 1998, 2003, 2005 and 2008 and found here elsewhere on this site : - Sarcopenia and the immune system : - Pain and inflammation : - Inverse Dynamics and Hill model of mass spring system : - Degrees of freedom and Bernsteins concept of motor control using a linear oscillatory system : - Orienteering, motor control and the immune system (uncontrolled manifold hypothesis) : - Endurance Training : Uploaded : 3 April 2020 Updated : 31 October 2020 Read More
  • Rotator Cuff Injuries

    Rotator Cuff Injuries

    Rotator Cuff Blogg Hey everyone! This month’s blog focuses on the shoulder, more specifically the rotator cuff muscles and some common conditions we regularly treat here at Back in Business Physiotherapy. The shoulder is one of the most common regions of the body that we treat. One of the main reasons the shoulder gets injured is that it’s a super mobile joint. It is the most movable joint in the body in fact! In order to have so much mobility, the joint has to sacrifice stability, and the lack of stability in the shoulder leaves it susceptible to injury. Efficient movement in the shoulder largely relies on the proper functioning of the rotator cuff muscles. Read on to find out what they are, what they do, and what can sometimes go wrong with them.  What is the rotator cuff? The rotator cuff is a group of four muscles – the Supraspinatus, Infraspinatus, Teres Minor and Sub-scapularis. If you have trouble remembering the names, just think ‘SITS’. Easy-peasy! Each muscle at-taches from the shoulder blade (scapula) to the arm bone (humerus) and has a specific function to play in shoulder movement. What does it do? In a nutshell, the supraspinatus helps to take the arm away from the body (abduction), the infraspinatus and teres minor help to rotate the arm outwards (external rotation), and the subscapularis helps to rotate the arm inwards (internal rotation… Other muscles also help with these movements too). Collectively, the four muscles work together to keep the ‘ball’ of the arm bone centred over the ‘socket’ of the shoulder blade. By doing this, it allows us to have a relatively free and large range of motion in the shoulder in all directions of movement. But remember, lots of mobility is only achievable by sacrificing stability, and this is where the shoulder and rotator cuff sometimes come unstuck. Common conditions Here is a brief overview of some common rotator cuff disorders: • Rotator cuff tendon injury: Who remembers what tendons do? We’ll give you a clue… They at-tach muscles to bones. A tendon may become injured acutely (known as tendinitis) or in a chron-ic way through degeneration (known as tendinopathy). This commonly occurs due to impact to the shoulder or through repetitive movements as seen with throwing sports in the initial stages. If the movements continue over a long period of time and healing doesn’t occur fully, the tendon tissue can degenerate, leading to tendinopathy. • Rotator cuff tear: If the above process continues over an even longer time period, the tendon will degenerate more and eventually it may reach a point where the tendon tears. This can cause significant loss of movement and pain with shoulder movements. • Subacromial impingement: Between the ball of the arm bone and the tip of the shoulder (a.k.a The acromion) sits a small space called the subacromial space. Several structures run through this very small space, including the tendon of the supraspinatus and part of the biceps muscle. There is also a fluid filled sac called the subacromial bursa which helps to keep movement smooth in the shoulder joint. Repetitive movements can lead to any of these structures becoming irritated and inflamed, making an already small space even smaller. The shoulder then cannot function to its full movement capability and movement becomes painful. Rotator cuff tendinitis is one cause of subacromial impingement. All of the above conditions share some common signs and symptoms. The main symptom experienced is pain with shoulder movement, particularly when raising the arm above the head, in front or out to the side of the body. Acute tendinitis, chronic tendinopathy and a tear can all lead to weakness during shoulder movements, although weakness associated with a tear is usually more severe. You may also experience pain when lying on the affected shoulder at night-time. Sometimes it can be difficult to determine from the outset what condition is developing, but we will make an informed decision based on the information you give us and what signs and symptoms you have when we assess you. Treatment All of the above conditions can be managed well with manual treatment and exercise. With the exception of severe tears, which may need a shoulder specialist/surgical opinion if the injury doesn’t respond well to conservative treatment, rotator cuff injury is commonly managed from start to finish by us here at Back in Business Physiotherapy, so always come to us as a first port of call. Acute injuries will always need time for the body to deal with the inflammation that has occurred. Then a combination of massage, shoulder and spinal joint mobilisation and mobility and strengthening exercises are what is required to get over these painful conditions. The exercise program will start simple and grad-ually progress over time; it aims to return the muscle and tendon to full strength, as well as re-train efficient shoulder and spinal movements that may have been lost during the injury process. We may decide to use other treatment techniques including taping, needling under guided ultrasound, therapeutic ultrasound to aid in the healing process. Most rotator cuff injuries respond very well to manual treatment. Even small tears can be well managed this way. If you have shoulder pain and need some help, please get in touch today, so we can get you back on the dancefloor, shimmying to your heart’s content! Uploaded : 1 April 2020 Read More
  • Family stress during the time of COVID-19

    Family stress during the time of COVID-19

    Managing stress as a multitasking mother in the time of COVID-19 Are you a working mum? Or perhaps a full-time mum trying to manage kids, a house and everything that comes with it? Or maybe the events of the world right now are forcing you to wear both these hats – all at once! Being a parent can be very stressful. Between waking up and going to bed each night, there is a list as long as your arm of daily chores and jobs to do. Many of us have been there and totally sympathise with just how hard it is to juggle all of these elements of life. Here at Back in Business Physiotherapy, it is not uncommon for us to see mums in pain, stressed out and struggling to balance family, work and life. Of course, there are dads out there juggling all these elements as well, so if you’re a dad reading this, take note! There isn’t an easy solution to this problem, but there are many things you can try to do to begin making this process more manageable. Have a read through these five tips to see if they might work for you: 1. Set a consistent routine: This is a very handy thing to have in place. Busy schedules can be hectic and difficult to stay on top of. There are certain daily events that we can keep to a strict schedule, which can help to limit stress by managing each task. Try and keep wake-up and bed-times, bath times, mealtimes and story times to the same time every day. This gives you less to think about and frees up some brain space for concentrating on the day ahead, which may include an important work presentation that needs focus. Most children respond well to routine, so getting one established can mean more settled children and a more chilled mother. 2. Exercise regularly: We know that exercise is beneficial for staying fit, healthy and strong. There is also countless evidence for the effect of exercise on the mind and helping to reduce stress levels. Exercising regularly can help to reduce fatigue by improving sleep, concentration, mood levels and overall brain function. When we exercise, our bodies produce increased levels of the happy hormone (a.k.a endorphins) which help us to both tackle and stave off the effects of life’s stressors (bored screaming child). If you can’t get out for a walk or run, try some at-home exercises, a YouTube clip, or better yet, turn up the volume, and have a dance party with the kids. It lets them burn some steam, while you get some activity in. And it builds connection – win, win! 3. Consume a healthy diet: Stress hormone release is controlled by our adrenal glands. High stress situations over time can lead to increased levels of stress hormones coursing through our bodies. What we eat can help control the effects of stress. Controlling blood sugar levels is pivotal in maintaining good control of adrenal gland function. We recommend a balanced diet containing high amounts of natural, whole foods and keeping intake of sugary, nutrient-poor foods to a minimum. Foods rich in vitamins C and B are particularly important for supporting adrenal function. Try to include red bell peppers, nuts, seeds and leafy green vegetables to ensure you are getting a good supply of essential nutrients. 4. Stay hydrated: This is a simple and easy method to implement. It takes nothing to pour yourself a glass of water from the tap. Water is life-giving to humans. Without it we die quickly. All of our bodily processes and tissues rely on it to function efficiently. This includes proper function of the brain and all of the organs in our body. When we become dehydrated, the levels of cortisol (a stress hormone) increase. Stay ahead of the game and keep a bottle of water with you through-out the day. Sip regularly and your body will stay well-hydrated and ready to deal with any of those stressful scenarios that might pop up during the day. 5. Take time for yourself: We think this is the most important one of all. With being a parent comes enormous responsibility, but if you do not look after yourself above all, there is no possibility of looking after one or a whole troop of other family members. Set aside time when you can to read a book, do some exercise, meditate or do whatever makes you happy. Take a trip to the zoo or a museum on your own every now and then. If you organise these things in advance to ensure the kids are looked after by a friend or family member, then these things are easily achievable and help to keep you sane and grounded. 6: Home gym: if you have the space and a place to roll gym equipment out onto a balcony or verandah, you can keep up your fitness levels whilst in 'lock-down'. Multiple equipment will allow everyone to exercise at once. Elliptical Trainer, Plyometrics Box, Stationary Bikes, Treadmill, Rower, Punching Bag, Heavy Rope, Chin up bar, Swiss Ball, etc, etc. In these uncertain times, a pandemic which keeps on giving, potential worlwide economic collapse, home schooling, working from home, restrictions of liberty will all test our humanity. Emotional and physical stress will make parenting more difficult than ever before. We don’t think for one minute it is as easy as ABC to get all of this going alongside all this madness. Planning now, especially if there is a complete shut-down. It also looks like we are in for the long haul, potentially up to several months. But try to implement things slowly and steadily to make sure it fits well into your new daily routine. There is no handbook in such an unprecedented scenario for stress-free parenting, but we hope we’ve given you some food for thought! Isolate and keep up a routine. Uploaded : 1 April 2020 Read More
  • COVID-19


    Dear Clients, Update on our policy regarding COVID-19. This is a work in progress, with reflection of old information and the introduction of new information, which explains our reasoning for closing and re-opening of our practice. What are the rates of infection? What happens when we do nothing? How do we get herd immunity? Hospitalisation rate? Death rate of 1%, sickness rate of 20% and intensive/special care rate of 5%.Which countries are doing best? What is the political context of doing nothing? Should we wear masks? Can hot weather reduce the rate of infection? Economics versus health when closing the economy and re-opening gradually from a low base, using data, versus political expediency? Why people should not be complacent? On-going health and immune compromise? What are the symptoms in young versus old? Is this a hoax? Is this just another influenza? What are the signs and symptoms? What is Kawasaki disease? Is it just in the lungs? What are the mechanisms and treatments? COVID-19 growth : 29 April 2020 Flattening and Delaying the Curve : 30 March 2020 The reasoning for flattening the curve is to avoid over-whelming the health system. This strategy, has been advocated by the Imperial College Response Team. They have shown that those countries which isolated early, tested frequently and used personal protective equipment (PPE) liberally and appropriately had fewer deaths. Early in the pandemic, countries such as Taiwan, Singapore and Hong Kong were able to maintain a functioning economy by selectively isolating people who were testing positive for COVID-19. In countries, where recognition of the pandemic came too late, such as Italy, Spain and France, they required total shut down of peoples movements. Staggering death rates of 800 people in Bergamo alone and the death of 50 doctors in Northern Italy demonstrate the veracity of this virus, especially in the presence of inadequate personal protective equipment (PPE). Millions of face masks arrived today (30 March 2020) in Venice. Britain who commenced late, hoping for herd immunity, was on the precipice and still has rising fatalities. The PM himself, late to the party and a denier, also contracted the disease, and recovered just before the birth of his child. Those countries with a high sense of civic duty, such as Germany, who were airlifting Italian and French intensive care patients to Germany for treatment, where their mortality rate sat around 0.5%. Taking a 'nothing approach' such as advocated by President Trump in the USA and Bolsonaro, in Brazil, are showing high and prolonged mortality rates. However, these figures were likely to be skewed from lack of testing. Which brings us to Australia's measured response, of  working from home and only essential services encouraged to be working outside of home. Isolation and testing, testing and testing. For the time being, this appears to have worked. Hence the regrettable decision to shut down of Back in Business Physiotherapy on 22 March 2020, could be partially reversed, with a gradual recommencement of services from the 5 May 2020. However, on 3 August, Victoria announced a 6 week stage 4 hard shut down. We will continue to monitor the situation locally, as well as head public health warning advice. We are taking all precautions, with regular cleaning, etc. All our staff are wearing masks. We'd like our clients to do so as well. Which countries have isolated best? 29 April 2020 The scary thing about this graph is that it shows that we'll be dealing with this for quite some time. 100 days is just over three moths, whilst 250 days is closer to 8 months! This brings the Northern Hemisphere back into the autumn/winter traditional influenza cycle! COVID-19 infection rates (17 July 2020) and those of influenza InfectionsCOVID-19: The first cases appeared in China in late 2019 and the first confirmed case in the United States appeared in January 2020. Approximately 13,832,242 cases have been confirmed worldwide. There have been 3,576,430 cases in the U.S. as of July 17, 2020.* Flu: The World Health Organization estimates that 1 billion people worldwide get the flu every year. In the U.S., for Oct. 1, 2019 – Apr. 4, 2020, the CDC estimates that there were 39 million to 56 million cases of flu. (The CDC does not know the exact number because the flu is not a reportable disease in most parts of the U.S.) DeathsCOVID-19: There have been approximately 590,608 deaths reported worldwide. In the U.S, 138,360 people have died of COVID-19, as of July 17, 2020.* On 3 August 2020, total deaths were 697,189. A large jump from 17 July 2020! Flu: The World Health Organization estimates that 290,000 to 650,000 people die of flu-related causes every year worldwide. In the U.S., from Oct. 1, 2019 – Apr. 4, 2020, the CDC estimates that 24,000 to 62,000 people died from the flu. (The CDC does not know the exact number because the flu is not a reportable disease in most parts of the U.S.) The COVID-19 situation is changing rapidly. Since this disease is caused by a new virus, people do not have immunity to it, and a vaccine may be many months away. Doctors and scientists are working to estimate the mortality rate of COVID-19, but at present, it is thought to be substantially higher than that of most strains of the flu. 140 institutions world wide are working on a vaccine. Two likely candidates are mRNA vaccines being developed at Finders University in South Australia and another one from The University of Queensland.  *This information comes from the Coronavirus COVID-19 Global Cases map developed by the Johns Hopkins Center for Systems Science Herd Immunity : 29 May 2020 vs 12 July 2020 The coronavirus pandemic has shown clearly what happens when a new pathogen gets loose in a population where no one has had it before: It spreads like wildfire. Long-familiar viruses, even ones that are every bit as contagious, can’t do that, because of a phenomenon called herd immunity. It works like this: The more people there are in a community who have protective antibodies, either through vaccination or past exposure, the less likely an infected patient is to encounter someone who lacks them and pass the virus along. Above a certain threshold, the virus can’t spread readily enough for an outbreak to grow. That’s why diseases like measles and chickenpox have become rare in countries like Australia and the United States even though not everyone gets vaccinated: if enough people do, then we achieve herd immunity. Notably, 90% of the population needs to have immunity for certain diseases such as Measles. Scientists and policymakers hope the world will get to that point with the coronavirus, too. But a crop of new studies suggests that herd immunity is still very far away. Additionally, thanks to the bush fires keeping tourists away, which meant keeping our COVID-19 numbers low, together with our isolation means, we'll be reliant on the rest-of-the-world for herd immunity. Gradual re-opening of our borders will be a tricky thing. Similarly, our nearest neighbour, New Zealand, went for eradication, so we won't be getting our herd immunity from there. The USA went down the politically expedient pathway of early re-opening without heading CDC guidelines. On the 12 July 2020 the USA had 62,653 new cases of COVID-19. Total confirmed infections were 3.29M with 137 000 deaths. Suggestions are that the number of unconfirmed : confirmed cases is 80 : 1, meaning that the total number of potential cases are 263.2M in a population of 328M. This is about 66% of the population which some people suggest that herd immunity may commence to take effect. Time will tell. Never-the-less, with the current infection rates, around 20% of positively tested and probably symptomatic people end up needing hospitalisation, 5% of those requiring ventilation or respiratory aid and around 1% die. Ideally, we can identify why some people remain asymptomatic, whilst others become critically ill. Furthermore, which young people are susceptible to blood vessel inflammation and megakaryocyte infiltration needs to be ascertained. However, concurrently, if the susceptible people are identified, those non-susceptible individuals should be considerate of those less fortunate, and maintain social distancing, use of masks, hand sanitation, etc. Interestingly, it appears that the death rate curve, in the USA, has started to flatten, or even trending downward. Comparing the infection and death rates in areas affected early by COVID-19, such as New Jersey and New York with Texas and Arizona, it may be that the treatment and preparedness for the pandemic has improved, and/or the virus is less virulent? However, on 19 July 2020, hospital bed capacity, in Arizona, had reached 100% occupancy and people were being moved to neighbouring states. Initially, clinicians considered it to be a respiratory disease, however now it's also considered a vascular disease. ICU survival rates in Australia are approx 85%, in the UK approx 60%, whilst in the USA it's as low as 30%. Apparently, it's been very hard to ween people off ventilators, so positive airways pressure masks, as used traditionally for sleep apnoea, and developed by ResMed, Australia, are preferred to intubation. International death rate : 14 July 2020   Interestingly, china appears in the 'rest of Asia' category. A medical case presentation in a NHS health care worker: early April 2020 The following is from a online clinical forum to which i belong. This pertains to emergency medical treatment, of a 47 year old RN (registered nurse). Although it is not describing physiotherapy, I feel it contains a lot of useful information for those who have been confused by social media..  The ensuing discussion related to the use of anti-biotics such as erythromicin. The consensus was to use it in case of secondary bacterial infection. However, one clinician pointed out that at least one publication demonstrated it's use for viral infections as well as significant anti-inflammatory side effects in the lungs. '#Azithromycin and erythromycin are unusual — for example erythromycin is given to increase gastric emptying time for GI issues. In the case of #Azithromycin, it might be that in addition to being anti inflammatory, it also has antiviral properties: Gielen V, Johnston SL, Edwards MR. Azithromycin induces anti-viral responses in bronchial epithelial cells. Eur Respir J. 2010 Sep;36(3):646-54. However, erythromycin may be treating co-morbidity factors due to increased vulnerability, to bacterial infections, in a compromised immune system? ' The reduced gastric emptying is also interesting as the gastric biome is one of largest sources of immune material in the body. The patient was later transferred to a special care unit. Let's hope that this front line care worker, as many others, survive. COVID-19 is not just a pulmonary disease - digestive symptoms : 7 May 2020 Breathlessness due to vascular complications in younger people : 11 April 2020 Breathlessness is a symptom that occurs 5-10 days into the disease. A gradual build up of hypoxia has been reported which may be accompanied by a loss of taste and smell, culminating in 50% oxygen saturation when people were turning up at hospitals. Pulse oxcimeters have been recommended. An example made, was Germany, where people diagnosed with COVID-19 are tested daily in their homes, hereby predicting morbidity, and resulting in the lowest mortality rates in the world. Other symptoms may include a temperature and sore throat, which can be accompanied by headaches, deep aches and pains. In some younger people stroke like symptoms such as drowsiness, slurred speech and paralysis. Additional symptoms are now evolving which include skin reactions and frostbite like rashes on the toes. "Of the first 200 reports analysed for the study, out of a total of 300 in the registry today, about half were toe rashes. The other skin conditions reported include hives, those itchy red bumps that are usually a sign of an allergic reaction; water blisters; and something that looks a lot like chickenpox". ( ). Federal government Health Direct website allows people to answer questions on symptoms and gives them a course of action.   Kawasaki disease in very young people during COVID-19 Although very rare, worldwide there have been around 100 reported deaths in children with Kawasaki syndrome (26 May 2020 Vancouver Health Official - Dr Henry Minister Dix). This appears to be a post viral syndrome. Additionally, there appears to be children to adult cross infection, rather than vice versa. Most likely, the very low incidence of COVID-19 in children is due to the limited number of ACE 2 angiotensin receptors in children compared with adults. These ACE 2 receptors are found in the upper respiratory tract, lungs, heart, intestines and kidneys (responsible for blood pressure). The conversion of angiotensin II to angiotensin which lowers blood pressure occurs here. Unfortunately, ACE 2 receptor sites are an entry point for COVID-19. Angiotensin II and ACE 2 receptor - Wikipedia 26 May 2020 ACE2 lowers blood pressure by catalysing the hydrolysis of angiotensin II (a vasoconstrictor peptide) into angiotensin (a vasodilator).  As a transmembrane protein, ACE2 serves as the main entry point into cells for some coronaviruses, including HCoV-NL63, SARS-CoV (the virus that causes Severe Acute Respiratory Syndrome ) and SARS-CoV-2 (the virus that causes COVID-19). ACE2 mRNA expression is also found in the cerebral cortex, striatum, hypothalamus, and brainstem. The expression of ACE2 in cortical neurons and glia make them susceptible to a SARS-CoV-2 attack, which was the possible basis of anosmia and incidences of neurological deficits seen in COVID-19. As anosmia and dysgeusia (loss of smell and taste) are seen early in many COVID-19 patients, it was suggested to be considered to be a heralding clue in COVID-19, which subsequently was declared as "significant symptoms" in COVID-19 by the American Academy of Otolaryngology–Head and Neck Surgery. ACE 2 Practice Closure As you may be aware, the practice was closed from 6 March 2020 until 4 May 2020. It was a tough decision to make, however we were unable to be sure that we would not contribute to cross contamination of our clients with COVID-19. Although we are deemed an essential service, in the light of the Ruby Princess, we believed in the Australian Government and NSW Government policy of a shut down of non-essential services. When there was some loosening of these restrictions we were prepared to treat our clients so long as they were using the COVIDsafe app, and we are able to gain access to PPE (Personal Protective Equipment) and sanitising agents. At the time of closure, these latter resources were scant, and were better used at 'coal face' settings, whose role in fighting this virus was of a higher priority, than us.  The practice re-opened on 4 May - with limited sessions and COVID-19 procedures in place. 'Normal' opening occurred after the Queens birthday long weekend, June 2020. We require all of our clients to be symptom free and to be using the COVIDSafe app. We also request all clients to wear masks. Projected deaths 26 March 2020 Look at the North American and world numbers and compare them to these real numbers on 29 April 2020. Deaths vs number of infections is worrying and suggests a large number of unconfirmed cases. Compared to 22 June 2020. Exponential growth, with an extra million in the past month and many countries, such as Brasil, Russia, China and the USA, deliberately under-reporting the numbers, whereas other countries don't have the epidemiology tools to analyse let alone test symptomatic and asymptomatic people.  Importantly, compare these numbers with those predicted by the Imperial College shown above. The fact that the USA has 120,000 deaths (23 June 2020) would suggest that the asymptomatic or untested population is much higher (over 17,730,000) or that the disease may be more deadly than predicted?   Compare these results with those of America on 12/06/2020 where these numbers doubled in just over 6 weeks. This is in the midst of the Black Lives Matter protests. Considering that the infection takes 2 weeks to incubate, it is interesting to watch these numbers as America moves into summer, where in theory the virus should be less virulent. The following demonstrates that those 'hot' states are still showing high rates of infection as well as high rates of hospitalisation (Texas was at 97% capacity in early July).  USA death rate almost 160 000 : 3 August 2020 - height of summer! Texas daily infection rate : 14 July 2020 Florida daily infection rates : 14 July 2020 Daily infection rates USA : 19 July 2020 USA death rate : 16 September 2020 Trump - do nothing approach - 5% of the world population but almost 20% of the world deaths Worldwide Status of COVID-19 - 30 March 2020 vs 30 April 2020 (1 million recoveries) vs 29 May 2020 vs 23 June 2020 (Opening, Post Shut Down) vs 1 August 2020 vs 16 Sept 2020   Heartening, are the number of 1 million recovered cases on 30 April. However, testing in many countries is still woefully inadequate and many people have now shown mild and severe symptoms which weren't previously associated with COVID-19. Big jump in numbers with testing and gradual opening up of the movement restrictions. In countries, such as Brasil and the USA, their presidents discourage social distancing and wearing of masks. Wearing a mask : 14 July 2020 Health authorities, in Australia, don't recommend wearing a mask, in all states, except Victoria. Reasons for this vary, but the major one, is that people gain a false sense of security and that they play, with their hands, with their masks. Worldwide, where there has been a significant outbreak and where a sensible health care administration exists, mask wearing has been recommended in places where social distancing cannot be practised. Australian Cases : 29 May 2020 vs 23 June 2020 vs 19 July 2020 vs 3 August 2020 Sudden increase in infection rates in Victoria, resulting in resumption of total stage 4 lock down, to stop the spread.    Australian Cases : 8 April 2020 vs 22 June 2020   Bush Fires Australia is doing extremely well. Some of this can be attributed to the closing of borders and partial closure and social distancing measures. However, the borders weren't closed until the end of March. This was extremely late. By this time, the virus was rampant in Europe and other parts of the world. We also know that the virus existed since at least November 2019. The first death from COVID-19 in France was in December and evidence suggests that the virus was present in Washington State and California in late December. During November 2019 through to February 2020 Australia suffered the worst bush fires in history. A billion dead animals and 19 million hectres of burnt countryside. This meant that overseas tourists didn't come and visit Australia. Moreover, Australians themselves didn't move around to the usual holiday spots. Furthermore, thanks to the appalling smoke haze, most people avoided going outside. We were quarantining and self isolating, even though we weren't aware of this, at the time. Social Distancing : 10 April 2020 vs 19 July 2020 Note that the curve of new incidents is going down, which means social distancing is working. Clearly, we need to maintain this. Then, unfortunately, due to two security guards, doing the wrong thing, whilst guarding hotel quarantine people, a sudden surge of infections in Victoria : 19 July 2020 Recovery vs Death Rate - 15 April 2020 Australia The flattening curve in Australia  24 April 2020 Social distancing and partial shut down had been working. The curve of new cases was flattening. Then the tricky situation was the gradual re-opening. Testing testing and testing is critically important to contain areas of focal contagion. The other big question was what will happen as we go into winter? well as what happens when we gradually re-open? Active New Cases : 29 May 2020 Thanks to social distancing and government policy we were gradually able to re-open. But we became complacent. Letter from Spain - 7 April 2020 Hi Martin, thanks for your facebook message. We are going through a nightmare of which it will take time to wake up.I look after infected patients at my hospital, most of them frail and elderly. This disease is a death sentence for many of them.It is not particularly challenging in my context from a clinical point of view, as you give them support and little else, either they survive or not. The problem are young people at general hospitals sometimes without availability of critical care beds and ventilators. There are many reasons to understand why Italy and Spain are hit so badly. I just wish your country does not get into this ordeal. Aside from purely clinical aspects, logistics and psychological topics are the problem: lock down, isolation, lack of equipment at the hospitals and long-term facilities, giving bad news through the telephone instead of face to face, people die alone, consequences of all this for mental health ...We still have quite a few weeks of lock down ahead and the social and economic consequences of all this are going to be catastrophic, but we shall have to manage somehow. Political situation is highly unstable and deeply worrying. Hope we shall survive that aspect too.How are you getting on yourselves and your relatives?I´m not aware of the situation in your continent, to be honest, but I do not think anywhere in the world will be spared, under very effective countermeasures are timely taken in the places where it has not set foot yet.Take care and keep social distancing and ancillary measures, for now we do not have any other approach. Politicians ignored all advice and did not realise that a pandemic was approaching and it could have devastating consequences. From an infectious diseases keen student as I am, this virus compounds the perfect storm.All the best for now from Spain,Angel Optimism : 31 March 2020 Currently, there is room for optimism. Last night's (31 March 2020) new cases were down from double digits to around 9%. Australia has one of the highest rates of testing in the world. Social distancing, self isolation and isolation of people testing positive seems to be finally having an effect  Work on using blood 'pin prick' testing kits is demonstrating a result within 15 minutes of testing and should become more readily available shortly. Unfortunately, there seems to be an unacceptable high rate of false negatives (up to 48%), which may give people a false sense of security. However, apart from the upside of 'ease of use', this type of testing allows people to monitor the production of anti-bodies to COVID-19. Such production, is synonymous with a persons immune system actively fighting the virus. In people, who have recovered or who only had mild symptoms, it may be possible to harvest their blood plasma and use those in transfusions for people who are critically ill. It's a similar principle to the methodology used, in the past, for immunisation against Hepatitis A.  Antimalarial drugs based on chloroqine were showing some potential benefit, but should only have been prescribed under medical supervision. For some odd reason, the president of the USA thought it was OK to recommend it to the general public!!!! However, a gin and tonic to calm the nerves, at the end of day may be used, as the tonic contains a small amount of quinine.......ha ha In theory, chloroquine could be used as a prophylactic against COVID-19, as it has been used as a prophylactic against Malaria and is used in people with auto-immune inflammatory disorders. We do know, that people who do badly, are the ones who have a compromised immune response, where there is an over-activity of immune substances creating a 'cytokine storm' in older individuals, or platelet over-activity resulting in blood clots in younger people.  Anti viral drugs will probably be paramount in the fight against this virus. Anybody watching the news from the United States will notice the immunologist Dr Anthony Fauci. He was at the forefront of AIDS research in the infancy of that epidemic back in the 1980's. He's advised every president on pandemics and epidemics since then. Considering that the man is in his early 80's, he's an incredibly tough and brilliant guy and a sane sight at Trumps hopeless press conference briefings.   Another reason for optimism is the use of the TB antigen. The TB vaccine has been shown to reactive the innate immune system and has been used over the past few years in the treatment of bladder cancer. In fact, a few years ago, my mother-in-law, was diagnosed with an inoperable tumour, sitting on the kidney and next to the aorta. Over the following month, the tumour continued to grow, when suddenly it began to shrink, without any form of intervention. The diagnosis was never clear, however, all the puzzled specialists felt that it could have shrunk thanks to the fact she had had TB as a child!? The innate immune system is the one we're born with. As we go through life, we are exposed to various pathogens, which create an innate immune reaction which produces the anti-bodies of the acquired immune system. Unfortunately, as we age, we have less protein in our body to produce such anti-bodies. The classic immune substances involved with this process are heat shock proteins (HSP). These are the basic building blocks of multi-cellular life. In mammals, the HSP's act with muscle protein to produce immune conversion. Unfortunately, after the 3rd decade of life, sedentary adults lose 1% muscle mass per year and after the 6th decade of life they lose 2% of their muscle mass. This process is called sarcopenia. To avoid sarcopenia individuals need to do at least 40 minutes of quality exercise, around twice a week.  Hence, stay healthy, keep exercising and maintain muscle mass so that you have the reservoir of protein needed to fight infections and decay. Furthermore, regular exercise in this age of partial shut down is another good way to maintain mental health. mRNA vaccines : 3 August 2020 Just like normal vaccines, RNA vaccines are intended to induce the production of antibodies which will bind to potential pathogens. The RNA sequence codes for antigens, proteins that are identical or resembling those of the pathogen. Upon the delivery of the vaccine into the body, this sequence is translated by the host cells to produce the encoded antigens, which then stimulate the body’s adaptive immune system to produce antibodies against the pathogen. mRNA vaccines have never been used before. They differ to traditional vaccines, in that they encode the protein sequencing to produce antibodies (IgG) identical to those found in people who have immunity to novel corona viruses. They may also have a potential role in the treatment of cancer. Novovax : Australia  For Phase 1 only. Additional information will be provided if Phase 2 is implemented. 2019nCoV-101 is a 2-part, randomized, observer-blinded, placebo-controlled, Phase 1/2 trial designed to evaluate the immunogenicity and safety of SARS-CoV-2 rS nanoparticle vaccine with or without Matrix-M adjuvant in healthy participants ≥ 18 to 59 (inclusive) years of age. The study will be conducted in 2 parts. In Part 1, at least 1 and up to two SARS-CoV-2 rS constructs will be evaluated in up to 2 cohorts, which may be enrolled in parallel. An interim analysis of Part 1 safety and immunogenicity data will be performed prior to an optional expansion to Part 2. University of Queensland University Queensland COVID19 Trial Vaccine  Astra Zenica, UK WHO A possible concern could be that some mRNA-based vaccine platforms induce potent type I interferon responses, which have been associated not only with inflammation but also potentially with autoimmunity. Thus, identification of individuals at an increased risk of autoimmune reactions before mRNA vaccination may allow reasonable precautions to be taken. Exercise and the immune system Your muscles are a major endocrine organ of the immune system. Their lean muscle bulk, is of utmost importance to ensure a sufficient reservoir of protein, which is needed to mobilise an immune defence. People should exercise muscles regularly, not only to prevent sarcopenia, but also to mobilise and fine tune your immune system, as well as maintain a healthy BMI Progressive resistance exercise and endurance training Physiotherapy and the enhancement of perception of musculoskeletal and hence immune health Investigation into combined drug treatment : Chloroquine and Azithromycin : 20 March 2020 Chloroquine and hydroxychloroquine have been found to be efficient on SARS-CoV-2, and reported to be efficient in Chinese COVID-19 patients. They evaluated the role of hydroxychloroquine on respiratory viral loads. Patients and methods French Confirmed COVID-19 patients were included in a single arm protocol from early March to March 16th, to receive 600mg of hydroxychloroquine daily and their viral load in nasopharyngeal swabs was tested daily in a hospital setting. Depending on their clinical presentation, azithromycin was added to the treatment. Untreated patients from another centre and cases refusing the protocol were included as negative controls. Presence and absence of virus at Day 6-post inclusion was considered the end point. Results Six patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms. Twenty cases were treated in this study and showed a significant reduction of the viral carriage at D6-post inclusion compared to controls, and much lower average carrying duration than reported of untreated patients in the literature. Azithromycin added to hydroxychloroquine was significantly more efficient for virus elimination. Conclusion Despite its small sample size our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin. Philippe Gautret et al (20 March 2020) Importantly, this small n=6 investigation is what the president of the USA and Fox News were basing all their hopes on. It could also be dangerous to treat some patients in this manor. As we've outlined on our FB page, we suggest people follow the facts and not believe in an orange Buffoon. President George W Bush predicted and prepared for a pandemic in 2005.  The orange buffoon and taking prophylactic hydroxychloroquine - 26 May 2020 Chloroquine - 12 June 2020 After WHO discontinuing research into Chloroquine, they have reversed that decision as it is thought that that the above investigation was flawed. It might be best to take the medical interventions and directions of research out of the hands of non-specialists and the media! The orange buffoon - recommending internal UV and disinfectants - 26 April 2020 This is 'fake news' ?......but continues on with the appalling handling of COVID-19 by the President of the United States. President Obama continued along this path for preparing the USA for pandemics by creating a global pandemic detection and deterrent department in the CDC.  The orange buffoon dismantled all these things!!!! Additionally, it would appear he was given warnings of the impending pandemic as early as January 2020. But since he watches Fox, for his news, he remained ignorant of them. The key to good leadership is knowing when you aren't the smartest person in the room. The warning, (in late January 2020) written in a memo by Peter Navarro, President Trump’s trade adviser, is the highest-level alert known to have circulated inside the West Wing as the administration was taking its first substantive steps to confront a crisis that had already consumed China’s leaders and would go on to upend life in Europe and the United States “The lack of immune protection or an existing cure or vaccine would leave Americans defenceless in the case of a full-blown coronavirus outbreak on U.S. soil,” Mr. Navarro’s memo said. “This lack of protection elevates the risk of the coronavirus evolving into a full-blown pandemic, imperilling the lives of millions of Americans.” ( ) The orange buffoon and World Health Organisation (WHO) WHO was warned by Taiwan, in late November 2019 about an N!H1 like virus in Wuhan. WHO ignored this, as Taiwan isn't a part of WHO. Additionally, Taiwan is considered by China as a part of it's sovereignty. The Washington Post, Taipei desk, warned of a H1N1 like virus (SARS) coming out of Wuhan on 6 December 2019. WHO declared a pandemic after Chinese New Year (mid January 2020) to pander to China's sensitivities. Never-the-less, a pandemic was declared by the end of January 2020.   Apart from letting a precarious situation fester for two months and get out of control, it's given the orange buffoon someone to blame!!! Basically, all of February was lost with inaction by him, 'it's a hoax", "it will go away, just disappear", This narcissistic attitude, as well as posturing by his sycophants, has not only exposed health care workers to unacceptable danger, it probably has resulted in tens of thousands of potentially avoidable deaths. Lack of PPE and ventilators, institutions specifically for such a crisis having been dismantled, being some of his many failings. Just listen to the governor of New York, Andrew Cuomo.   Then, the incredible news in mid April, when WHO gave the green light for the wet market in Wuhan to re-open. Clearly, WHO has to walk a political tight rope, considering various cultural sensitivities and needing to appease many disparate parties with varying geopolitical considerations. Ultimately what is of paramount importance is the health and well-being of the worlds population. Hopefully, going forward, a constructive relationship can be developed by all parties within and outside of WHO, in the fight against the virus. Erythromycin Erythromycin is an antibiotic which has been used for many decades. Unlike many antibiotics, people do not develop resistance to it's effect. Classically, the drug was used for lung conditions. Interestingly, my father, Norbert Krause, is probably the last living person in Australia who knows the industrial process of making erythromycin. He was involved, as an industrial chemist, in it's production, at Abbott Laboratories, in Kurnell, NSW, Australia, until production was shut down some time in the 1980's, for cheaper options overseas. Another victim of globalisation.    Heat Shock Protein 90 (HSP-90), Geldanamycin and COVID-19 : 19 May 2020 An intersting artcile on drug repositioning (defined as the use of approved drugs for new indications), offering an unmatched opportunity to offer novel therapeutics to treat SARS family of coronaviruses (SARS-FCoVs); Reaserchers analyzed, a dataset of patients who presented with SARS during the 2003 outbreak whereby they established a gene signature that defines differential gene expression in patients who were sick with SARS vs. healthy controls and convalescent patients. They used a robust platform to conduct drug repositioning based on clustered gene expression and pathway enrichment to identify best matching drugs. They identified 55 agents of potential benefit. In most of these drugs they were able to establish a link to previous related research, use as antiviral, or at least a hypothetical role in treating SARS-FCoVs. Most notably, the heat shock protein 90 (hsp90) emerged as a major component that enables viruses to hijack infected cells through the process of autophagy. Almost half of the drugs identified could be linked to hsp90. As such, they propose using hsp90 inhibitors, mainly geldanamycin and its derivatives, to treat COVID-19. ( Based on their findings, they suggest adding more drugs to the experimental arsenal deployed against SARS-FCoVs. They suggested using nontoxic drugs that are readily available for wide scale prophylaxis or the treatment of mild cases of COVID–19. These drugs would include omeprazole, nonsteroidal anti-inflammatory drugs, colchicine, sulfoanamide antibiotics, antimalarial drugs and clozapine/chlorpromazine. For patients with serious COVID–19 illnesses, the above drugs can be combined with immune modulators like sirolimus, and direct Hsp90 inhibitors under well-designed clinical trials. Given the high pathogenicity of the current ongoing epidemic, they suggested that it seems prudent to attempt to use multiple drugs in combination if low risk for toxicity and drug-drug interaction is established. Choosing a combination of drugs identified in this study or other drug-repositioning studies and careful reporting of the efficacy of these experiences can result in rapid accumulation of knowledge.(Iyad Sultan, Scott Howard, Abdelghani Tbakhi (2020, DOI : 10.21203/ Added Complication - 27 April 2020 Pulmonary embolus and venous pulmonary clots Growing clinical evidnece is finding severe clotting in some individuals with COVID-19. Moreover, pulmonary clots and even strokes have been reported in young individuals (aged 20-40) by an Australian physician in New York (Washington Post 26 April 2020), In fact, the clotting was so profound that re-clotting was occuring during clot busting surgery. Pulmonary venous clotting has also been described by French physicians. A research letter from Hôpitaux Universitaires de Strasbourg published today in Radiology reported that of 106 pulmonary CT angiograms performed for COVID-19 patients over a one-month period in a tertiary care centre in France, 32 patients (30%) had acute pulmonary embolus (PE). This rate of PE is much higher than usually encountered in critically ill patients without COVID-19 infection (1.3%,) or in emergency department patients (3 to 10%). In the study, a D-dimer threshold of 2660 μg/L detected all patients with PE on chest CT.  A second research letter published today described a study from Centre Hospitalier Universitaire de Besancon in France pointed to high proportion (23%) of COVID-19 patients with contrast CT had PE. PE was diagnosed at mean of 12 days from symptom onset. Patients with PE were more likely require care in the critical care unit and to require mechanical ventilation. ( Therefore, there is strong evidence of a combined airway-vascular response leading to organ failure. Such a combination of a 'cytokine storm' and thrombocytic events incorporating auto-immune responses leading to respiratory failure and the need for intubation and ventilation, even in young people.    Obesity and COVID-19 in younger people : 5 May 2020 Health Minister announcement 31 March 2020 The Australian minister of health announced the take over of private hospitals with the already announced cancellation of elective surgery. This will bring the total capacity of beds in Australia to 35000, of which 2200 are ICU beds. Currently, 47 ICU beds are occupied by a COVID-19 patient. Furthermore, respirators for anaesthesia are being remodelled to become ventilators, bringing the total number to around 5000 ventilators. ResMed is currently building more ventilators to bring the total number to around 7500 by the end of April. Additionally, CPAP masks, normally used for sleep apnoea, will be manufactured and deployed, as their positive pressure should help prevent lungs from collapsing. Countries begin to re-open : 16 April 2020 Denmark and Germany have announced partial re-opening of the country from quite strict shut-down implementation. Denmark announced that pre-schools and primary schools would begin to re-open. The thinking here, is that children and parents of young children, who are generally part of the younger population are more resilient to COVID-19. Speaking with my wife's cousin, whose a GP in Denmark, he said that there was still a general lack of PPE, even in his practice, let alone in the general population. He also stated that if there wasn't a relaxation of the restrictions, there could be social issues, such as alcoholism, domestic violence and even civil unrest. On the other hand, Germany has gone the furthest with testing, PPE, health implementation and even taken patients from France and Italy. Their confidence for a general but gradual re-opening is because of their high rates of testing and epidemilogical capabilities. Australian re-opening : 29 May 2020 Looks like there is a predicted gradual re-opening in Australia around mid May is going ahead as scheduled. NRL played their first game post lock down. Community sports have been given the green light to start training with no more than 10 people in a group. Matches may start as early as July. No doubt, some parts of the country will re-open at different rates to others, depending on active cases. Until a vaccine is found, it's also possible that roll back and shut downs will also occur along the way. Interestingly, this week an anti-viral Remdesivir, a vaccine out of Baltimore, is being trialled in Victoria. Early days, but wouldn't it be great if Australian becomes part of the cure. In NSW, two clinical trials and peer consensus recommended approach to treatment are the current policy. Assurance Please bear with us in this time of crisis. Rest assured, we have begun to re-open as as we feel it is safe to do so. However, remember, North Sydney has a working population from all over Sydney, making it even more prudent to be cautious with our re-opening. We are cleaning morning and night as well as between each client. We are also keeping the number of people at anyone time, in the practice to 5 in 84m2.  In the mean time, don't hesitate to contact us via email or make a booking on-line. Additionally, you can stay up-to-date using our Facebook Page : Download the tracking app - 26 April 2020 Today I downloaded the tracking app for COVID-19. Testing, testing, testing is super important to track and contain the virus. It is impossible to test everyone, and even if someone who has tested negative one day, can still test positive a week later. Therefore, downloading the tracking app will allow authorities to notify us if we've inadvertently been in contact with someone who has tested positive. If there isn't universal download of this app, then further spreading and ensuing deaths could occur. The alternative would be to have more 'shut downs' and even more serious restrictions of our liberty, re-imposed! Unfortunately, at the end of May only 6 million people have downloaded the app. I've downloaded the COVID-19 tracking app. It's imperative that we all do so. It makes our invisible mortal enemy visible. Not knowing that we've been in contact with the virus is disconcerting enough, let alone if the authorities are powerless to act, because they don't have the knowledge, to know where, to contain it. This becomes even more important as we begin to open up the country. Do everyone a favour and download the App Opening - 4 May 2020 Currently, at Back in Business Physiotherapy, we are considering A VERY LIMITED OPENING of 2 DAYS PER WEEK, with very strict 1 client per hour schedule. This should minimise any client overlap as well as give us sufficient time to clean all surfaces and the treatment room. Stay tuned, but it could be as early as 1 May 2020. Currently, 14 July 2020, we are open 4 days a week, whilst still maintaining a strict cleaning regime. I also do wear a mask. Psychiatric issues amongst health workers who had contracted COVID-19 - 28 April 2020 There was very sad news of a young previously healthy doctor who went back to work after recovering COVID-19 and subsequently took her own life!! "She went down in the trenches and was killed by the enemy on the front line," Philip Breen said. "She loved New York and wouldn't hear about living anywhere else. She loved her coworkers and did what she could for them.""I just want people to know how special she was," he added. Health care workers face a mental health crisis as they battle the coronavirus pandemic. Philip Breen is a retired trauma surgeon, and he and his daughter would speak frequently about work, he said. Lorna Breen told her father that her colleagues were putting in 18-hour days and sleeping in hallways, and that ambulances couldn't get in because it was so busy. She worked in the emergency department and had been on the front lines for weeks, handling the onslaught of cases, her father said. New York City has been the US' pandemic epicentre, recording nearly 300,000 cases and more than 22,000 deaths as of Tuesday morning. Breen contracted Covid-19 and took a week and a half off to recover, but when she went back to work, she couldn't last through a 12-hour shift, her father said. Still, she felt like she had to get back in there to help her colleagues. "Frontline healthcare professionals and first responders are not immune to the mental or physical effects of the current pandemic," said Charlottesville Police Chief RaShall Brackney. "On a daily basis, these professionals operate under the most stressful of circumstances, and the Coronavirus has introduced additional stressors.""Words cannot convey the sense of loss we feel today," the New York City hospitals where Breen worked said in a statement."Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department," they said. "Our focus today is to provide support to her family, friends, and colleagues as they cope with this news during what is already an extraordinarily difficult time." Dr Fauci comes under attack - 13/05/2020 Unbelievably, the Trumpster and his favourite TV organisation FOX, attacked Dr Fauci's opinion on children return to school timetable. During a senate hearing testimony, Dr Fauci suggested that it would be more prudent to wait for a vaccine before children return to school. FOX suggested that Dr Fauci was unqualified as he wasn't elected to do so. They also suggested that he is a mouthpiece of the democrats. This is unbelievable in the face of the increasing prevalence of Kawasaki Disease during COVID-19. Additionally, a former Trump administration official who was controversially removed from his post has warned that the US faces its "darkest winter in modern history" unless the federal government develops a coordinated response to the coronavirus. Dr Rick Bright, the former head of the Biomedical Advanced Research and Development Authority, was in charge of the federal agency responsible for developing a vaccine and therapeutic treatments for COVID-19 until he was reassigned to a less significant position in April. Bright has filed a whistleblower complaint accusing the Trump administration of improperly pushing unproven treatments such as hydroxychloroquine and failing to grasp the seriousness of the outbreak until it was too late. The real heroes are the health officials and front line care workers not narcissistic self serving politicians, surrounded by their sycophants.. Health Care Workers being attacked There have been very disturbing reports of health care workers being attacked, doused in bleach and chlorine, evicted from their homes, etc. THIS IS TOTALLY UNACCEPTABLE - THE DEPRAVITY OF HUMANITY AT ITS WORST!! But when people are scared for their survival, those primival instincts come to the fore.  .......and to all our 'coal face' front line health workers - a tribute to them   Potentially, the virus has been around since October 2019 A novel research approach by Harvard University, using satellite images of car parking movements of a Wuhan car park, suggest that some kind of epidemic was already commencing much earlier than we thought. Correlation doesn't necessarily mean causality, so in the abscence of Chinese openess to researching the origins of the COVID-19 virus, these results should be taken with a grain of salt. Exercise and the immune system, especially when ageing If you would like to understand how exercise affects the immune system, please take a look at this page, on another part of this website.  Uploaded : 30 March 2020 Updated : 16 September 2020 Read More
  • Corona Virus Policy

    Corona Virus Policy

    Uploaded 4 March 2020 Read More
  • Bushwalking, hiking and rambling for cardiovascular and mental health

    Bushwalking, hiking and rambling for cardiovascular and mental health

    Hiking, bushwalking and rambling – it’s so much more than a view! Do you love the outdoors? Fresh air, sunshine, wind, rain, wildlife and nature… Blissful! We don’t know about you, but we absolutely love to get outside and immerse ourselves in the natural environment. Just you, a backpack, some energy food, a water bottle and for the organised ones, a compass and a map. Oh, and don’t forget those hiking boots. Prion Beach and Precipitous Bluff, South Coast Track, Tasmania (Dec 2019) If you’ve never considered hiking before, but like the thought of immersing yourself in nature while getting some great exercise, then maybe you need to. With technology leading the way these days, it’s easy to get bogged down with binging on TV shows and playing your favourite video games after a long week at work. We’ve all felt it before, the urge to just put our feet up for the weekend and chill. That’s okay every now and then, but we as humans need to move more, and hiking is a great way to do that. Other than a few initial costs with getting yourself a decent pair of walking boots and a backpack for all of your supplies, it’s basically a free activity. And, it comes with a heap of benefits. Read on to find out more. The advantages Hiking is primeval. We used to walk from food source to food source, building muscle mass and exposing our immune systems to pathogens on the way. Hence, it's great for our neurocognitive immune complex, which means it's good for our overall well-being. It's also a great exercise in bonding, parenting and mateship. South Coast Track, Tasmania (Dec 2019) The benefits of hiking include: • Increased muscle strength: Hiking is essentially walking, but tends to involve walking over different terrain which may range from flat forest pathways to rocky mountainous passes. Either way, getting yourself out and about is going to get those trunk and lower limb muscles engaged and pumping. This type of exercise will help to improve strength in your glutes, quads, hamstrings, calves and trunk muscles which will provide stability to your skeleton and joints, and help keep away potential joint problems like osteoarthritis.• Improved cardiovascular health: The planet is becoming more obese as each year passes, which is seeing an increase in heart-related disease. A great reason to try hiking as it could help you to control or lose weight, reducing stress on the cardiovascular system. Regular exercise of this type has been shown to lower blood pressure and blood-sugar levels, reducing the risk of developing heart disease and conditions like type-2 diabetes. Challenging yourself to walk up and down difficult terrain is a fantastic way to improve your aerobic fitness and keep everything in check.• Improved core stability and balance: Walking over rocky and uneven terrain is a great way to challenge those core stabilising muscles and work at improving your balance. Walking on flat, even surfaces doesn’t provide the body with that side to side component of movement that walking on an uneven surface can do.• Improved mental well-being: There is evidence that spending time in green, natural environments away from urban jungles can help to reduce stress levels in people. The outdoor, rural landscape can provide you with a sense of peace and quietness, calming the mind of all of life’s worries. This is something you just don’t realise when you are constantly in the hustle and bustle of city life where noise and pollution are rife throughout.• A chance to socialise: Humans are social beings. We like to engage with others (there are always exceptions to this rule!) and be with them to really enjoy the benefits of living. If family time is short mid-week because of work, school and other engagements, hiking gives you the perfect opportunity to be with the ones you love. You can talk, move and have fun together in a beautiful environment. What else do you need?! Ironbound Range, South Coast Track, Tasmania. (Dec 2019) Suggestions for hiking If we’ve said enough to get you on board (hooray!), there are a few little pointers we want to bring to your attention before you get going. 1. Get equipped: Ensure you get fitted with a good pair of walking boots, grab a backpack and if you are just starting out, a hiking stick or pole may be of benefit to help you through trickier terrain (especially if you have any knee issues).2. Pack water and food: Have enough with you to keep your energy and hydration levels up throughout your hike.3. Find a route that fits your abilities: If you are just beginning, we suggest you don’t go straight for the most mountainous route out there. Try an easy track or nature reserve walk before attempting K2 or Everest (you need extra training for these by the way!).4. Take a friend or family member: It’s sometimes good to get out on your own for ‘you’ time, but hiking is great when done with someone else. Having more than one person means that if you get injured or help is needed, you are not stranded alone with nowhere to turn to. Keeping in mind, some hikes may be in areas with little cellular reception. Invest in some kind of emergency beacon device eg Garmin InReach5. Let someone know you are going: It is safer to tell someone at home or a neighbour that you are heading out. The outdoors is sometimes unpredictable so letting someone know where you are going and when to expect you back is another safety measure worth having in place. South Coast Track, Tasmanai (Dec 2019) So what are you waiting for? Get out there and really enjoy what the world has to offer. We live on a beautiful planet, so make sure you get to experience it and improve your health whilst doing so. Ready. Set. HIKE! (You can reward yourself with an episode of your favourite show when you get back!) ........and if this isn't enough, later you can take on canyoning and rock climbing Blue Mountains, NSW, Australia (Jan 2020) Uploaded : 23 February 2020 Read More
  • Sleep Deprivation and Muscle Recovery

    Sleep Deprivation and Muscle Recovery

    Effects of Sleep Deprivation and Acute Muscle Recovery For many years sleep deprivation has been known to affect brain function, whereby 48-72 hours of sleep deprivation has been used as a means of torture. As in the famous novel by George Orwell, 1984, acute psychosis can be induced with sleep deprivation. Additionally, sleep deprivation can induce metabolic dysfunction including a blood spectrum similar to metabolic syndrome in otherwise young healthy individuals.   Any of us who have undergone intense unfamiliar exercise know the uncomfortable feeling of DOMS (delayed onset muscle soreness) and restless sleep. A combination of lack of sleep, over-training and inadequate recovery can result in the 'three bastards in a day". Read to the end to know who these three bastards are. Taking into account the many layered affects of sleep deprivation, it should come as no surprise that muscles may also be affected. Dattilo et al (2020, Med Sc Sp Ex,52, 2, 507-514) examined the effect of total sleep deprivation on muscle recovery after eccentric exercise induced muscle damage(EEIMD). They found that, in 10 healthy untrained males, sleep deprivation did not affect muscle recovery but modifies inflammatory and hormonal response. More precisely, sleep deprivation increases blood IL-6 levels and modifies the blood hormone balance by increasing IGF-1, cortisol, and the total cortison/testosterone ratio. Significantly, acute IL-6 elevation is known to stimmulate hypertrophic signalling and myogenesis through regulation of muscle stem cells. However, chronic elevation of IL-6 can be very detrimental to skeletal muscle such as seen in cachexia. Muscle damage alone stimulates an immune-nervous system response   Normally functioning balance between pro-inflammatory and anti-inflammatory substances and neuro-immune modulation is referred to as allostasis   An interesting hypothesis is how sleep deprivation affects the cognitive evaluation of 'danger signals' in the presence of heightened arousal in a 'milieu' of an already stimulated immune-hormonal response to muscle damage Commonly, the sympathetic nervous system is viewed in terms of the 'fight-flight' response to perceived and real danger. Top down modulation or conversely bottom up modulation? A Pyschologist may think top-down wheras a physiotherapist, exercise physiologist or sports trainer should think in both directions, especially since we are muscle specialists.  Commonly, over-training or over-reachiing is associated with non-restorative sleep and nitrogen imbalance. This can affect catabolic processes such as those induced by cortisol and attenuate anabolic (muscle building) processes such as that induced by testosterone. Symptoms of over-training and sleep deprivation are nitrogen imbalance and the "three bastards in a day' rule. So who are these three bastards? If you meet a person who you really don't care to meet again, then that is fine. If you meet a second person like that on the same day, you might be very unlucky or in group company. If you meet a third person like this, and they aren't part of group, it's not them but you!!! Commonly, when people have asked me 'how do I know when I am in over-training?' I say, just ask your partner or spouse or have you met three bastards in a day lately??!!! Uploaded : 22 February 2020 Slides used are from a presentation I made at a conference in Rome in 2005.  Read More
  • The use of exercise therapy post cancer treatment to attenuate Doxorubicin-induced cardiotoxicity

    The use of exercise therapy post cancer treatment to attenuate Doxorubicin-induced cardiotoxicity

    The use of exercise therapy post cancer treatment to attenuate Doxorubicin (DOX)-induced cardiotoxicity One of the complications of cancer treatment is the loss of weight. Some of this occurs due to the loss of appetite but also as a result of reduced volition to exercise. The therapeutic benefits of exercise include the improvement in muscle mass, which is important for maintaining a reservoir of protein, for the immune system. Additionally, the benefits of strength and endurance are reduced fatigue and enhanced functional capacity. Furthermore, improved oxidative capacity, through exercise, maintains healthy mitochondria, reducing oxidative stress. Animal models suggest that tumour bearing mice who are wheel exercised, have improved functional indices of cachexia, without mitigating tumour number or size (Brandon BN et al 2020, Med Sc Sp Ex, 52, 11, 2320-2330). These results weren't dependent upon exercise duration, but rather on exercise threshold. The use of Anthracylcines for chemotherapy have been commonly found to have cardiac complications. It is thought that a reduction in autophagy may be responsible. Autophagy is the process whereby lysosomes remove damaged cell material such as folded proteins, damaged lipids, dysfunctional organelles and even mitochondria.  DOX induced cardiotoxicity may be due to dysfunction of this lysomal regulation.  Evidence suggests that this may be due to the accumulation of Reactive Oxygen Species (ROS), especially NOX-2 (NADPH oxidase). Exercise has been shown to improve the bodies ability to 'mopp up' ROS. However, the period between the diagnosis and onset of chemotherapy is frequently short. Given the harrowing nature of cancer treatment, it is frequently unrealistic to ask someone to commence an exercise regime during this time. However, there has been a long held belief that life long exercise may not prevent cancer but may improve the persons tolerance to the side effects of treatment.  Another, intriguing suggestion is that post treatment exercise could reduce the risk of cardiotoxicity. Lee et al (2020, Med Sc Sp Ex, 52, 1, 25-36) examined this notion in animals (mice). They found that exercise prevents DOX-induced tissue damage and apoptosis.Their findings included attenuation of extensive cytoplasmic vascuolization and loss of myofibrils, reduced cleavage of CASPASE 3 and reduced elevation of proapoptotic protein BNIP3. Finally a reduction in chemotherapy induced upregulation of the % of TUNEL cells was also observed. Exercise intervention also had profound effects on left ventricle autophagy with increases of LC3-II in parallel with p62 reduction. Additionally, exercise promotes mitochondrial turnover (mitophagy), as well as preventing oxidative damage by modulating NOX subunits and lowering IL-1Beta. This investigation by Lee et al (2020) demonstrates for the first time that the negative impact of multiple DOX treatment cycles can be attenuated through a post treatment exercise regime (albeit in mice). Extrapolation to humans would suggest that a graded exercise regime over a 4 -12 week period, including 4 weeks of pre-conditioning may be a useful adjunct in improving recovery from chemotherapy. Alternatively, Kirkham et al (2020, Med Sc Sp Ex, 52, 2, 278-286) have recommended 'chemotherapy-periodised' exercise to accommodate for cyclical variation in fatigue. Furthermore, suggestions have been made that exercise, such as walking, reduces the rate of recurrence by up to 57% in some cases of cancer, such as after radical prostatectomy (Richman et al 2011, Cancer Res, 71, 11, 3889-95; referenced by Swain et al 2020, Med Sc Sp Ex, 52, 2, 296-302) . A meta-analysis of individual patient data of 31 RCT's found significant beneficial effects of exercise on fatigue in patients with cancer. Moreover, supervised exercise intervention was found to be superior to unsupervised exercise (Van Vulpen et al 2020, Med Ex Sp Sc, 52, 2, 303-314). Further, some of the calming effects of exercise may also have a therapeutic effect, which hasn't been covered here. Uploaded : 22 Feb 2020 Updated : 24 November 2020 Banned by Google Adwords as they reckon physiotherapists aren't allowed to discuss exercise in people receiving cancer treatment!!!! Go Figure!!!!??? Read More
  • Ketogenic diets and Exercise

    Ketogenic diets and Exercise

    Ketogenic diets and Exercise Ketogenic diets have become popular in the decade of the teens. It involves fasting up to 16 - 18 hours between meals (Dinner at 7 and lunch the following day at 1pm) as well as maintaining a strict low carbohydrate diet. In principle, this methodology, similar to repeated acute bouts of exercise, presumably encourages the fat mobilising/oxidative pathways whilst sparing glucose. Although, investigations into liver metabolic pathways to ketogenic diet and exercise, in mice, have shown them not to be additive, they have found both enhanced liver enzymes and pancreatic enzymes used to metabolise fat (Huang et al 2020, Med Sc Sp Ex, 52,1 37-48). Anecdotal evidence suggest that this glycogen sparing diet can be beneficial even in ultra-endurance type of events.  When working at high intensities, carbohydrates provide the most efficient source of fuel for ATP per volume of oxygen, in the mitochondria. The size of carbohydrate stores are limited, however they can be acutely manipulated, expecially in prolongied sustained or high intensity exercise, maintenance of carbohydrate availability enhances performance. Carbohydrate plays direct and indirect roles in the muscles adaptation to training. An example of the latter is the commencement of a second bout of training before the restoration of carbohydrate stores results in a co-ordinated up-regulation of the transcriptional and post transcriptionsl responses to exercise. Additionally, carbohydrate restriction during exercise can alter and improve mitochondrial oxidation of lipids. Periodization of training and of carbohydrate loading and unloading are techniques used to manipulate athletes performance.  Short term restriction of carbohydrate (CHO), when using a ketogenic diet, were shown to effect iron deficiences via the modulation of interleukin-6 (IL-6) and hepcidin levels. Acutely, the iron levels of a ketogenic diet were lower than in the CHO rich group. This may be partly due to the removal of the large iron content in the western CHO rich diet, but also as a result of a positive change to functional iron use such as increased erythropoiesis, DNA synthesis, and oxidative enzyme production. After a 3 week adaption of elite walkers to a ketogenic diet, the CHO rich diet group showed a greater decrement to serum ferritin despite greater IL-6 and hepcidin responses in the ketogenic diet group (McKay et al Med Sc Sp Ex, 51, 3, 548-555). Such a paradoxical response suggests the need to periodically check ferritin levels. Patency of blood vessels may be critical to good joint health. Elevated cholesterol levels are thought to affect blood vessel patency, as the formation of plaques within the vessels results in the relationship of blood particle number (Reynolds Number) and blood flow becoming critical causing stasis and end vessel infarction. The articular joints tend to be at the end of the line for blood vessels and hence their small diameter may be critically compromised by elevated cholesterol levels. Hence, supplementation with anti-cholesterol agents such as 1000mg of EPA and DHA in Fish Oil, the use of Co-enzyme Q10 may go some way to mitigating the effects of cholesterol. Uploaded : 18 Feb 2020 Read More
  • How to be productive in the gym

    How to be productive in the gym

    How to be productive in the gym We’re a time-poor world these days and unfortunately for a lot of people, spending time looking after their bodies is not always a priority. Whether it’s because their lives are packed with work, families or a busy social calendar, most people get very little ‘me’ time. Even for those who do ‘gym it’, we regularly see an attitude of get in, get it done and get out in time to take the kids to gymnastics. We regularly get asked what a person can do to maximise their time in the gym, and lucky for you – that is exactly what this blog is about! We appreciate that life is busy, but read on for some handy tips on keeping a productive gym schedule: • Go with a friend or family member: Many people hate going to the gym alone because they find it hard to motivate themselves. Having a gym partner means you can motivate each other during those really hard slogs on the exercise bike or pushing for that last rep. If you’re time poor, this allows you to kill two birds with one stone by getting in some socialising whilst working out (no animals were hurt during the writing of this blog). • Get a P.T: What better way to be productive in the gym than having a personal trainer to guide you along the way and keep you motivated. You’ll also have the benefit of having someone there to offer advice on technique, so you avoid injury. Obviously PTs cost money, but if you can’t afford a one-on-one, think about small group classes, where you still have personalized attention, but with less impact on the wallet.• Sign up for a class: There are heaps of class types out there to cover all bases of exercise. Try a HIIT class (which stands for High-Intensity-Interval-Training) if you’re after a big calorie burn in a short space of time.• Train smart: If you want to maximise the burn and time is short, then be smart with your exercise choices. Choose an exercise that targets several muscle groups (i.e. squats into overhead press), or perform two exercises that focus on the same or different muscle groups, one after the other (called ‘super-setting’ - i.e. squats then lunges, or squats then push-ups).• Avoid peak times of business: Hit the gym during a quiet time to avoid having to deal with long queues for equipment, allowing you to get your routine done in minimal time.• Have a plan: If you know what you are doing before you go to the gym then you’ll be less likely to find yourself wandering around between exercises mulling over what to do next. Write down your routine on paper so you can tick off the list as you go along.• Have water on hand: We recommend having your favourite, eco-friendly water bottle with you at all times. Keeping hydrated throughout will mean you’ll be able to see your routine through to the end without having to stop several times to queue for the water dispenser.• Switch devices to airplane mode: Text messages, emails and phone calls are potential distractions from your workout. Simply switch to airplane mode and you’ll be working out distraction-free, which means more time for dedicated exercise.• Listen to music: Music has been shown to enhance people’s performance during exercise. It’s personal preference but if you’re looking for motivation, having a playlist of up-tempo tracks could be just what you need to keep the energy levels up. We hope these handy tips mean your future gym sessions will now be as productive as possible. And if you’ve held off from the gym in the past because of a lack of time, we hope we have convinced you that time doesn’t have to be a factor if you’re organised. Hit us up at Back in Business Physiotherapy if you have any further questions. See you next month! Uploaded : 4 February 2020 Read More
  • How to protect muscles as we age

    How to protect muscles as we age

    How to protect muscles as we age Welcome readers! This month we are going to talk to you about an important subject we all need to think about as we get older. The health of our muscles is important as we move through life into our later years. The body is made up of a host of different systems: the nervous, vascular and musculoskeletal systems are all examples. The skeleton is made up of bones that fit together forming joints. Muscles attach to bones and provide movement at the joints, all under supervision of the vascular (i.e. the ‘blood’ system) and immune-nervous system (i.e. muscles, the brain, spinal cord and nerves). It’s a little bit more complicated than that, but you get the gist. Our bodies rely on movement for countless different internal processes to occur, and for us to maintain function and be able to get around and stay alive. Movement keeps our bones strong, our digestion and toilet habits regular, and provides the force required for fluids to move around the body, just to name a few examples. If you look at an average person’s lifespan, we grow and get bigger and stronger until the age of 30 (give or take). After this, if we don’t work towards keeping it all, we start to lose muscle mass, bone strength and joint health, which forces our body to decline as we reach the elder years. Naturally, we start to move less and our injuries, stiffness and pain increase… Joyous thoughts I know, sorry! But… It doesn’t have to be all doom and gloom. If we spend time on our bodies throughout life, exercising, feeding it the right stuff and living a stress-less approach each day, it is very possible to move into our later years with a good body that will keep us moving well. If we take control of our bodies early on and not abuse them, it gives us the best opportunity to have a problem-free life down the line. Goodbye expensive medical bills. How nice would it be to not have to rely on our private health insurance or Medicare services?! Food for thought. Let’s recap… Muscles are movers, and we need movement to be healthy and alive. So naturally, we need to look after our muscles. “What can we do?" I hear you ask. The answer is, LOTS! • Exercise regularly: In order for our muscles to stay strong, we need to use them. The saying goes ‘if you don’t use them, you lose them’. And this is very true. Look at someone who has broken their leg and are immobilised in a cast for a six-week period. Once the cast comes off, look at the size of their muscles on that leg compared to the non-injured side. Through lack of use, the muscles have got smaller and weaker (i.e. they have ‘atrophied’). Losing muscle due to aging is a slightly different process (known as ‘sarcopenia’), but the same rules apply… If you want to increase the size and strength of your muscles, you need to be doing some regular and progressive resistance training. Whether you are using your own bodyweight, resistance bands or free weights, to be progressive means to increase gradually. In this context, you can gradually increase weight or the number of repetitions or sets in order to gain strength and continue to do so. Remember that in order for muscles to get stronger, they also need rest and recuperation, so be sure to include rest days in your plan. • Look at your diet: So you’ve ticked off regular exercise and now you need to tick off a healthy diet to back up all the good work you do getting your pump on. A muscles favourite food is protein. When we eat protein, our body breaks it down into smaller pieces (called ‘amino acids’) which our body uses to build muscle tissue. It is a good idea to give your body a protein boost following your resistance exercise routine, but if you aim to take on protein with each meal in some form, then you should be giving the muscles the food they need. You have many options… We recommend getting a good mix of fish, poultry, yoghurt, milk, cheese and eggs to ensure you hit the protein goal each day. Beans, peas, nuts and seeds are also a great source of protein. • Drink lots of water: A piece of advice we will keep coming back to time after time. It is simply a must for everyone, every single day. Our bodies are predominantly water and pretty much every process carried out inside the body needs it in order to function. The muscles are no different. Muscle tissue is full of blood. It relies on the blood to feed it all the nutrients it needs to stay healthy and to continue strengthening. Blood is largely made up of water (shocking I know!), so stay hydrated for good blood. Good blood equals a good transport system for food to get to the muscles. This is our advice to you. We know it is tough trying to figure all this out on your own, but the good news is, you are not alone… Our team here at Back in Business Physiotherapy are here to answer any queries you may have about your body and how to age as gracefully as possible. Although the body is a very complex machine, it’s not rocket science when it comes to looking after it. Just be kind to it every day and let us worry about the scientific stuff. This is what we spent years studying for. For more detailed information on improving your muscle health for the future, including exercise and dietary advice, please call us on +61299226806 to make an appointment. P.s. Please remember to drink water every day (this won’t be the last time you read this!). Uploaded :4 February 2020 Read More
  • Resistance workouts for bone health

    Resistance workouts for bone health

    Resistance workouts for bone health Hello everyone! We hope you have had a fantastic break and are raring to go for 2020. We’re go-ing to kick off proceedings this year with a blog topic we think is becoming more and more im-portant. It’s no secret that people are living longer and with an ageing population comes higher rates of certain conditions and diseases, such as osteoarthritis (i.e. the degeneration of joints) and osteoporosis (i.e. weakening of the bones). Did you know that exercise is good for the bones and can help keep your skeleton strong as you age? Read on to find out more… Good news people, exercise is great for bone health! In fact, it is widely accepted that exercise is one of the most effective ways of keeping your bones strong and healthy. So, there you have it. Say no more. Blog ends… Just kidding! We’ll give you a bit more than that 😉. There are several different types of exercise, and while all types will benefit your body in some way, if you want to target bone health and par-ticularly strength, then resistance type exercises are up there as some of the best. What is resistance exercise? Resistance exercise is any exercise that has the body working against an external force and will often involve the use of fitness equipment including weights (either free or machine weights), re-sistance bands, cables and medicine balls. Different examples of resistance exercises include: • Pushing against a wall• A weighted bicep curl or lunge• Banded or cable shoulder strengthening• Riding on a static bike with varying intensities  Why resistance exercise? So why resistance over other types of exercise we hear you ask? Quite simply, when we exer-cise, we place forces or loads on the body which help to build our muscles which in turn place stress on the skeleton (remember, muscles attach to bones via tendons). This stress placed on the skeleton is what is needed to activate the bone building cells of the body (they are called ‘os-teoblasts’ if you really want to know). Some forms of exercise lead to lots of activation of these cells, other forms to a lesser degree. Performing our everyday activities such as washing, walking, cooking and dressing is not enough to create lots of cell activation, so keeping ourselves working at this level will not necessarily build strength in our bones (although it may help them from becoming weak - a good reason to not be a couch potato). If we want to build bone, then we need to regularly exert ourselves over the limit of everyday life tasks. This is where exercise and especially the resistance type comes into play. Resistance exercise will place a variety of force on the skeleton through the muscular system, and therefore lead to increased bone cell activation and eventually stronger bones. Will other types of exercise help my bones too? As we mentioned above, different exercises lead to different bone cell activation rates. Re-sistance exercise is not the only type that is good for building bone strength. Other examples in-clude stair climbing, hill walking and high impact exercises such as basketball and aerobics. Whilst swimming is an awesome form of exercise for the body, it has been shown to be less ef-fective at building bone strength, even though the water provides some resistance against the body as you swim. Good to know! The type of exercise you do will also be dependent on many things. Age, for example, is a big factor. Someone who is elderly and has a history of bone fractures due to osteoporosis would not be put on a program of heavy weightlifting. However, they could very much benefit from perform-ing regular light banded or cable exercises, combined with walking or gentle dancing. Whereas a middle-aged person with good fitness levels could benefit from a more intense weight program to ensure good bone health in their later years. Bones need more than just exercise It is important to remember that bone health is dependent on more than just exercise. Having a good diet which includes adequate amounts of vitamins and minerals is also a must. If you didn’t know already, Vitamin D and Calcium are two nutrients which are very important for ensuring your bones stay healthy from birth, all the way into your wise years. Get what you need by mak-ing sure you include a regular intake of spinach, kale, salmon, mackerel, cheese and milk. Many breakfast cereals will often have these nutrients added to them too. So, don’t skip your breakfast people!  To conclude… The bottom line is bones need exercise to stay healthy for life. If you are unsure of what is right for you, then we are only a stone’s throw away. Please call us on 02 9922 6806 to make an ap-pointment and we’ll be happy to design a resistance program that will be unique to you and your needs. Now go and get your best gym lycra out and get ready for strong bones! References: 1. Hong, AR. and Kim, SW. 2018. Effects of resistance exercise on bone health. Endocrinology and metabolism. 33 (4). 435-444. Available from: Benedetti, MG. et al. 2018. The effectiveness of physical exercise on bone density in osteo-porotic patients. BioMed research international. v. 2018, 4840531, 10 pages. Available from: Osteoporosis Australia. 2013. Exercise - consumer guide. [Online]. Available from: [Accessed 12 Dec 2019]4. WebMD. 2019. Top foods for calcium and vitamin D. [Online]. Available from: [Accessed 13 Dec 2019] Uploaded : 20 December 2019 Read More
  • High Intensity Interval Training (HIIT)

    High Intensity Interval Training (HIIT)

    HIIT workouts for all Alright people, it’s a new year which means it’s time to get a move on and start ticking off those resolutions. We know for a lot of us this will include exercising more, getting healthy, or losing weight. And we also know for most of us, once normality resumes, it will be the same old story of not having enough time in the day to do it. Well we may have a solution for you! HIIT stands for? High-intensity interval training. And if you are one of those time poor people we described above, this type of training could be just what you are looking for. It’s a form of exercise that has become incredibly popular in recent years and is a great way for people to get their burn on, within a short space of time. So, if you can barely find time to think between kids, work, cooking, washing and sleeping (hang on… there is such thing as sleeping???), then read on to learn more. What is HIIT? HIIT is a type of workout that follows a repeated pattern of vigorous exercise over a short time period, followed by a rest or recovery period of less vigorous exercise. This repeated pattern will usually take place over a period of up to 30 minutes. Thirty minutes is all you need! And it has been shown that the effects on the body after performing this type of exercise are similar to that of double the amount of medium-intensity exercise. Starting to see why it is so popular? Let’s give you a little example of what you could do. Try running as fast as possible on an inclined treadmill for 30-40 seconds, followed by a light jog with no incline for 4-5 minutes. Repeat for 30 minutes. Sounds hard, right? Well it is, but that’s OK. You’ll feel goooood afterwards! What are the benefits of HIIT? There are several positive effects of HIIT on the body. These include: High calorie burn - you’re sure to burn loads of calories even when performed over a short period of time Increased metabolism - you’ll keep b