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Back to Basics: Keeping Your Shoulders Down

FitSugar — Wed, 18 Jun 2008 03:00:00 -0700

When teaching Pilates, I am always telling clients to keep their shoulders away from their ears. Raised shoulders is a sign of serious tension in the neck and upper back and over time it will create pain. Not only that but it wastes energy and can make surrounding areas not function correctly. Pilates clients aren't the only folks with tense necks and raised shoulders. I see this posture all the time when people are working out with weights, biking and running.

In an effort to keep the shoulders down, people tend to tense their necks even more – as if the sheer weight of their neck will calm the busy shoulder joint. Or people tend to grab in their lats or arm pits, which also increases neck tension and interferes with free movement of the arms.

To effectively relax your shoulders, you need to focus on your shoulder blades (scapula) sliding down your back. The muscle that anchors the blades is the bottom part of the trapezius muscle. You also want to feel your collar bone (clavicle) widening and the scapula sliding slightly toward one another. The end effect is an open chest with relaxed shoulders and neck. Nothing should feel pinched or gripped. Imagine the scapula is a slippery bar of soap sliding up and down the back. Try it next time you do bicep curls, sit in freeway traffic or ride your bike.

Source

How Octomom Slimmed Down to 125 Pounds

FitSugar — Tue, 27 Oct 2009 03:00:37 -0700

Whatever your opinion of Nadya Suleman's decision to carry eight babies at once, most can agree that her quick slim-down is rather astonishing. When her octuplets were born nine months ago, Nadya weighed 270 pounds. In the latest issue of Us Weekly, she admitted she packed on the pounds by "eating everything in sight." Now this five-foot-seven single mom of 14 has lost 145 pounds and 39 inches off her waist and weighs 125 pounds.

How did she do it? To find out, read more.

With her previous pregnancies, the Octomom admitted she had no problems getting back to her pre-pregnancy size 1 or 2, thanks to her skinny genes. This last time around, simply delivering the eight babies in January helped Nadya lose 40 pounds instantly. Losing the rest of the weight, however, wasn't a walk in the park. This mama joined the local gym and sweats it out three times a week at midnight! Yep, after her children go to sleep, a nanny stays with them while she exercises late-night for 90 minutes. Since Nadya gets her cardio from chasing after the kids, her gym workouts are devoted to strength training. She does top-secret crunches (which she hopes to reveal in her own fitness video), tricep kickbacks, bicep curls, shoulder presses, and lunges. Her dumbbell of choice? A set of 12-pound weights. I don't know how she does it, but Nadya claims she gets by on only three hours of sleep a night. She can't possibly keep that up for too long.

A healthy diet also helped Suleman lose her baby weight. Her day is filled with five protein-based meals or snacks, including turkey, sushi, eggs, and lowfat cheese. She also includes whole grains such as oatmeal, and veggies by eating salads and stews. Her favorite snacks include Pinkberry frozen yogurt and cottage cheese with fruit.

Although Nadya needed help to get pregnant and deliver her babies, she boasts that she's slimmed down with diet and exercise alone, and didn't need any surgical help.

Hit the Hay: Back Flying

FitSugar — Thu, 13 Aug 2009 12:30:33 -0700

If you enjoyed stretching your abs and back in bed doing Cobra, then you're going to love this one. You'll not only stretch the muscles in your torso and feel your spine elongate, but you'll also feel this in your neck, chest, and shoulders.

For instructions on how to do this stretch keep reading

Partner Yoga Pose: Reverse Bat to Front Walkover

FitSugar — Fri, 24 Jul 2009 14:30:42 -0700

If you love practicing yoga on your own, why not practice with a friend? Doing partner yoga allows you to do deeper, more creative, poses since you have the support of someone else. Here' a really fun one to try that doesn't take a lot of flexibility, just a love of being upside down.

For detailed instructions on how to do this acrobatic partner pose keep reading

Strike a Yoga Pose: Dolphin Plank

FitSugar — Mon, 20 Jul 2009 03:30:00 -0700

Many yoga poses challenge your core strength, and this one is no exception. Not only will you feel your abs and back muscles engaged, but it will also strengthen your legs and upper body.

Sanskrit Name: Makara Adho Mukha Svanasana
English Translation: Dolphin Plank Pose

To learn how to do this pose read more.

Begin in Downward Facing Dog. Shift your weight forward so that your shoulders are over your wrists.
One at a time, lower your forearms to the floor with your palms facing down. Place your elbows where your hands were, and spread your fingers wide. You want your body to be in one straight line, with your heels over your toes.
It's very important to engage your abs here, so draw your belly button toward your spine. Keep the muscles in your tush relaxed, draw your shoulders away from your ears, and gaze between your hands.
Hold like this for five complete breaths. Then come back onto your hands and press back into Downward Facing Dog.

Hit the Hay: Knee to Chest Back Stretch

FitSugar — Fri, 10 Jul 2009 13:15:25 -0700

After a stressful day at work or a night out on the town, it may be difficult to rest your mind and body enough to get some shuteye. I like to stretch in bed to inspire calmness, and if you liked the spinal twist bed stretch, here's another one that will target the muscles in your lower back. It's not only great for bedtime; I also like waking up and doing this stretch.

For details on how to do this stretch keep reading

Strike a Yoga Pose: King Pigeon

FitSugar — Mon, 15 Jun 2009 04:30:00 -0700

It's so important to include backbends in your stretching routine. Not only do they increase flexibility in your spine and neck, but they also stretch your abs, hip flexors, shoulders, and chest. This pose is a combination of Bow and Cobra and it's one of my favorites.

Sanskrit Name: Raja Kapotasana
English Translation: King Pigeon Pose
Also Called: Cobra Bow

Want to know how to get into it? Then read more.

Lie on your belly. Bring your legs together so your knees are touching. Extend your arms straight out in front of you.
Begin to slowly walk your hands toward your torso, keeping your hips and thighs on the ground, but gently arching your lower back, coming into Cobra. Walk them in as far as you can, keeping your elbows slightly bent. Actively roll your shoulders back and down away from your ears, elongating your neck.
Bend your knees and lower your head between your shoulder blades. Work on touching your toes to your head.
Stay here, opening through your chest, and take five deep breaths. Then slowly lower your chest back to the ground.

Carpal tunnel syndrome

FitSugar — Wed, 08 Oct 2008 17:34:56 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Overview

Several medical conditions can increase the risk for, or even cause, carpal tunnel syndrome (CTS). Diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy are the main conditions associated with CTS. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

Most workers who use their hands and wrists repetitively are at risk for CTS. This is especially true if they work in cold temperatures and have medical conditions that make them susceptible to CTS.

Being overweight consistently turns up as a risk factor for CTS and may play a direct causal role in CTS.

Treatment News:

Several physical therapy techniques have been shown to improve hand strength and function in patients with mild-to-moderate CTS.
Short periods of traction have also been successful in producing long-term relief in patients who have failed other conventional treatments.
Injections of botulinum toxin (Botox) show promise in treating carpal tunnel syndrome.

Risk Factors:

A Swedish study of neurological diseases found CTS to be the second most commonly occurring nerve, nerve root, and nerve plexus disorder among siblings hospitalized with the same condition. Although the study could not distinguish between genetic and environmental causes, clusters of CTS in families may suggest an inherited predisposition.

Introduction

Carpal tunnel syndrome (CTS) is a disorder marked by weakness and pain in the hand and wrist. CTS occurs in the nerves of the hands -- not the muscles, as some people believe. The symptoms of CTS can be incapacitating.

To understand how carpal tunnel syndrome arises, it is important to know the parts of the hand and wrist that are involved.

The Carpal Tunnel. The carpal tunnel is a passageway that forms beneath the strong, broad transverse ligament. This ligament is a bridge that extends across the lower palm and connects the bones of the wrist (carpals), which form an arch below the tunnel.

The Median Nerve and Flexor Tendons. The median nerve and nine flexor tendons pass under the ligament bridge and through the carpal tunnel (similar to a river). They extend from the forearm and up into the hand:

The flexor tendons are fibrous cords that connect to muscles of the fingers (two to each finger) and one to the thumb. They allow flexing of the fingers and clenching of the fist.
The median nerve plays two important roles. It supplies sensation to the thumb, index, middle, and ring fingers, and to the flexor tendons. It provides function for the muscles at the base of the thumb (the thenar muscle).

The median nerve travels through a compartment in the wrist called the carpal tunnel. The ligaments that transverse the nerve are not very flexible. Any swelling within the wrist compartment can put excessive pressure on structures such as the blood vessels and the median nerve. Excessive pressure can constrict blood flow and cause nerve damage. The symptoms from the compression cause pain, loss of sensation, and decreased function in the hand.

It is not completely known how the process leading to carpal tunnel syndrome actually evolves, and how nerve conduction (the passing of the nerve signal) through the wrist becomes changed. In general, carpal tunnel syndrome develops when the tissues around the median nerve swell and press on the nerve. Early in the disorder, the process is reversible. Over time, however, the insulation on the nerves may wear away, and permanent nerve damage may develop.

The following events have been observed in the hands of people with carpal tunnel syndrome:

The protective lining of tendons (called the tenosynovium) swells within the carpal tunnel. Some research suggests that this swelling is caused by build-up of fluid (called synovial fluid) under the lining. Synovial fluid lubricates and protects the tendons.
The transverse ligament, the band of fibrous tissue that forms the roof over the median nerve, becomes thicker and broader.
The swollen tendons and thickened ligament compress the median nerve fibers, just as stepping on a hose slows the flow of water through it. The effect is to reduce blood flow and oxygen supply to the nerve, slowing the transmission of nerve signals through the carpal tunnel. Some cases of carpal tunnel syndrome may be due to enlargement of the median nerve rather than compression by surrounding tissues.

The result is pain, numbness, and tingling in the wrist, hand, and fingers. Only the little finger is unaffected by the median nerve.

Click the icon to see a depiction of carpal tunnel syndrome.

Symptoms

Symptoms of carpal tunnel syndrome usually progress gradually over weeks and months and sometimes years. Anyone with recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a doctor for a diagnosis. Symptoms often develop as follows:

Initial symptoms include pain in the wrist and hand. Symptoms commonly occur in both hands. (Even when only one hand is painful, the other hand often shows signs of nerve conduction abnormalities on testing.)
Early on, the patient also usually reports numbness, tingling, burning, or some combination on the palm side of the index, middle, and ring fingers. (Typically the fifth finger has no symptoms.) Such sensations may radiate to the forearm or shoulder.
Over time, the hand may become numb, and patients may lose the ability to feel heat and cold. Patients may experience a sense of weakness and a tendency to drop things.
Patients may feel that their hands are swollen even though there is no visible swelling. This symptom may actually prove to be an important indicator of greater severity.

Symptoms may occur not only when the hand is being used but also at night when the patient is at rest. Even in cases where work is suspected as the cause, symptoms typically first occur outside of work. In fact, the disorder may be distinguished from similar conditions by pain occurring at night after going to bed.

Causes

Biologic Causes. Carpal tunnel syndrome (CTS) is considered an inflammatory disorder caused by repetitive stress, physical injury, or medical conditions. It is often very difficult, however, to determine the precise cause of carpal tunnel syndrome. No tests are available to identify a specific cause. Except in patients with certain underlying diseases, the biologic mechanisms leading to carpal tunnel syndrome are unknown. Although an overactive immune response that causes inflammation and damage in the joints or muscles is responsible for a number of arthritic conditions, similar problems are not likely to play an important role in CTS. More likely, reduced blood flow and lack of oxygen are important in the process leading to progressive swelling and scarring.

Working Conditions versus Medical Problems. Although some studies suggest that more than half of CTS cases are associated with workplace factors, there is no strong evidence of a cause and effect relationship. In fact, most studies now strongly suggest that carpal tunnel syndrome is primarily associated with medical or physical conditions such as diabetes, osteoarthritis, hypothyroidism, and rheumatoid arthritis. CTS also tends to occur in people with certain genetic or environmental risk factors such as obesity, smoking, alcohol abuse, or significant mental stress. Of all nerve, nerve root, and nerve plexus disorders, CTS has one of the highest familial risks, implying some type of genetic origin. When such susceptible people are subjected to repetitive hand or wrist work, the risk for CTS can become significant. CTS, then, is very likely to be due to convergences of factors that lead to nerve damage in the hand.

Worker's Compensation and CTS. The issues surrounding workers' compensation are particularly troubling in determining accurately whether labor conditions cause carpal tunnel pain. CTS is a major contributor to workers' compensation cases.

High Force and Vibration. Even though medical and physical conditions may be the initial culprits leading to CTS, certain working conditions are especially related to nerve damage -- if not to pure cases of CTS. Work that involves high force or vibration is particularly hazardous, as is repetitive hand and wrist work in cold temperatures.

In addition to CTS, other disorders of hand and wrist result from these work-related movements. They include the following:

Hand-arm vibration syndrome -- tingling and numbing that persist even after the vibration stops
Cumulative trauma (repetitive stress) disorder
Overuse syndromes
Chronic upper limb pain syndrome

All of these problems are generally associated with repetitive and forceful use of the hands, resulting in damaged muscles and bones of the upper arms.

Psychosocial Factors in the Workplace. Studies indicate that psychosocial factors in the workplace, such as intense deadlines, a poor social work environment, and low levels of job satisfaction, are major contributors to carpal tunnel pain. Such psychosocial conditions are more likely to be important factors in contributing to CTS in office workers, although they also complicate the condition in workers whose work is primarily physical.

A number of medical conditions increase the risk for or even cause CTS. The main conditions associated with CTS are diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

Diabetes. CTS is a very common feature of diabetic neuropathy, one of the major complications of diabetes. Neuropathy is decreased or distorted nerve function; it particularly affects sensation. Symptoms include numbness, tingling, weakness, and burning sensations, usually starting in the fingers and toes and moving up to the arms and legs. About 6% of patients with CTS have diabetes. A 2005 study reported that an estimated 85% of patients with type 1 diabetes develop CTS. Development of CTS was related to the patient's age and the length of time they had diabetes. The development of diabetes-related complications, such as kidney disease, is not related to the development of CTS in people with diabetes.

Autoimmune Diseases. In autoimmune diseases, the body's immune system abnormally attacks its own tissue, causing widespread inflammation, which, in many cases, affects the carpal tunnel of the hand. Such autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, and hypothyroidism. Some experts believe that CTS may actually be one of the first symptoms in a number of these diseases. Studies also suggest that CTS patients with these disorders are more likely to have severe CTS that requires surgery.

Diseases that Affect Muscle and Bones. Arthritis, gout, and other medical conditions that damage the muscles, joints, or bones in the hand may cause changes that lead to CTS. In fact, in one 2000 study, susceptibility to muscle and bone diseases was the major risk factor for CTS in British women. Osteoporosis (loss of bone density), although not a direct cause of CTS, increases the risk for wrist fractures that can lead to CTS.

Injuries and Previous Surgeries. Injuries, fractures, and operations that affect the forearm, wrist, or hand may lead to CTS, sometimes many years after the event.

Structural Abnormalities. Inborn abnormalities in the bones of the hand, wrist, or forearm may contribute to CTS.

Chronic Kidney Insufficiency. People who undergo hemodialysis for chronic kidney damage often experience a build-up in the hand of a certain type of protein called beta 2-microglobulin. This build-up can result in CTS. The longer the person has been receiving hemodialysis, the greater the risk of CTS. Certain drugs and procedures (particularly one procedure called hemodiafiltration) are being investigated as having the potential to reduce microglobulin build-up. It is hoped such new methods will delay the need for carpal tunnel surgery in patients undergoing long-term hemodialysis.

Other Diseases. A number of other medical conditions may cause or increase susceptibility to CTS:

Down syndrome
Amyloidosis (a progressive disorder of the connective tissues)
Acromegaly (a disease that leads to abnormally large hands and feet due to excessive growth hormone)
Tumor on the median nerve (removal of the tumor often resolves the CTS in such cases)

Medications. According to case reports, a number of medications may increase the risk for temporary CTS. They include certain medications that affect the immune system (such as interleukin-2), and anticlotting drugs (such as warfarin). There has been conflicting evidence as to whether corticosteroids and hormone replacement therapy may increase risk. More research is warranted before a causal association can be established.

Bone dislocations and fractures can narrow the carpal tunnel, thereby exerting pressure on the median nerve.

Being overweight consistently turns up as a risk factor for CTS and may play a direct causal role on CTS. Greater body mass appears to reduce nerve flow speed into the hand. Obesity is also related to poor physical fitness, which may also increase risk. A 2005 analysis indicated that weight is strongly linked to the onset of CTS in patients under the age of 63 years, but may be a less important factor as they get older.

Hormonal fluctuations in women play a role in CTS. Such fluctuations may cause fluid retention and other changes in the body that cause swelling. Fluid retention is one reason that CTS may develop during pregnancy.

CTS is strongly associated with a family history of the disorder. Many of these cases can be attributed to physical characteristics or medical conditions associated with CTS, which also run in families. However, in one study, 17% of family clusters of CTS were not associated with any such medical conditions, suggesting the genetic factors may be important in some people. Carpal tunnel syndrome that develops in young people is most likely to have a genetic component.

A 2000 study suggested that some patients with CTS may have a genetic defect that produces higher levels of a certain collagen subtype. Collagen is the protein used to build all connective tissue, muscle, bones, and ligament. The collagen found in CTS patients tends to produce stiffness.

Other genetic factors that may contribute to this disorder include abnormalities in certain genes that regulate myelin, a fatty substance that serves as insulation for nerve fibers.

Risk Factors

Evidence suggests that about 3% of women and 2% of men will be diagnosed with carpal tunnel syndrome during their lifetimes, with peak prevalence in women older than 55. Still, determining how many people actually have CTS is very difficult. Many people report CTS symptoms and have normal test results. Other people have no symptoms and abnormal results. Furthermore, some evidence suggests that, after an apparent a decline in cases, the prevalence of CTS is rising.

A large 2005 study of more than 1,000 patients found that the severity of CTS was mild in 42% of patients, moderate in 18%, and severe in 40%. Patients were an average of about 48 years old. More than five times as many women then men participated in the study.

Older people are at higher risk than younger adults. It is very rare in children.

Many studies indicate that women have a significantly higher risk for carpal tunnel syndrome than men do. According to the National Institutes of Health, women are three times more likely than men to experience carpal tunnel syndrome. The explanation for this greater risk is unknown but may be related to the smaller size of women's carpal tunnel.

Hormonal changes appear to play a major role in CTS.

A 2005 study reported that 17% of pregnant women had CTS. Nearly one-quarter of those had it in both wrists. Early studies have presented conflicting reports regarding when CTS is most likely to occur during pregnancy. One found that most cases occurred in the third trimester, and weight gain increased the risk. Another concluded that CTS developed at any point during the pregnancy. New-onset CTS during pregnancy that is severe and persistent enough to require treatment is uncommon. Most cases go away on their own after delivery. However, in one study, 11% of women reported CTS six months after delivery, and 4.3% of them still had the condition a year afterward.

Breastfeeding has also been linked to flare-ups of inflammatory disorders such as CTS. Breastfeeding temporarily lowers the level of natural steroid hormones.

CTS has also been shown to increase during:

The postpartum period
Menopause

Other conditions that are more specific to women than men may increase their risk for carpal tunnel syndrome:

The hand-intensive nature of housework and typing may contribute to a higher incidence of CTS in women.
Women are also at a much higher risk for autoimmune disorders than men are; such disorders are significantly linked to CTS.

People with close relatives who have carpal tunnel syndrome have a higher risk of developing CTS themselves. This risk may be due to family histories of medical conditions associated with CTS, obesity, or genetic factors.

A number of illnesses, skeletal abnormalities, and injuries can predispose individuals to carpal tunnel syndrome, including autoimmune diseases and arthritic conditions.

At high risk are those whose occupations combine force and repetition of the same motion in the fingers and hand for long periods.

Virtually all workers who use their hands and wrists repetitively are at risk for CTS, particularly if they work in cold temperatures and have factors or medical conditions that make them susceptible.

Computer Users and Typists. Repetitive typing and key entry is highly associated with missing work due to CTS. The risk for CTS in this group, however, is still much lower than with occupations involving heavy labor. Although more than 10% of the computer users complain of CTS symptoms, the evidence implicating computer use as a major cause of CTS is weak. One small 2001 study reported that nerve conduction tests on frequent computer users showed the same rate of CTS (3.5%) as in the general population.

A 2003 study found an association between mouse-use (not keyboard use) and CTS. Typing speed may affect risk in some cases, however. For example, the fingers of typists whose speed is 60 words per minute exert up to 25 tons of pressure each day. In one study, typists with CTS struck the keys with greater force than those without the disorder. A large Danish study showed no increased risk of CTS among people who use computers at work. Another study of workers who used computers heavily (up to 7 hours per day) found no increased risk of CTS among them.

Other Very High-Risk Workers. Workers in the meat and fish packing industries and those who assemble airplanes have the highest risk for CTS, according to one study. Meat packers complained of pain and loss of hand function as long ago as the 1860s. Even today, the incidence of carpal tunnel syndrome in the meat, poultry, and fish packing industries may be as high as 15%. A 2005 study of automobile assembly workers found that the estimated annual rate of CTS ranged from 1 - 10%.

Musicians. Musicians are at very high risk for CTS and other problems related to the muscles and nerves in the hands, upper trunk, and neck. In one study, 20% reported CTS or other nerve disorders in the hands and wrists.

Highest to Lowest Numbers of CTS Events by Job. The following is a list of occupations published by the Bureau of Labor Statistics in 2002 rating workers with highest to lowest total numbers of CTS-related events:

Assemblers
Cashiers
Secretaries
General office clerks
Laborers, non-construction
Bookkeepers, accounting, and auditing clerks
Welders and cutters
Data-entry employees
Textile sewing machine operators
Order clerks
Supervisors and proprietors, sales occupations
Machine operators (unspecified)
Truck drivers
Insurance adjusters, examiners, and investigators
Electrical and electronic equipment assemblers
Packaging and filling machine operators
Janitors and cleaners
Bank tellers
Production inspectors, checkers, and examiners

SOURCES: Bureau of Labor Statistics, U.S. Department of Labor, April 2002

At Home and At Play. People who intensively cook, knit, sew, do needlepoint, play computer games, do carpentry, or extensively use power tools are at increased risk for CTS. Long-distance cycling may make symptoms of carpal tunnel syndrome worse.

Square Wrists. Some (but not all) studies have reported a higher risk for CTS in people with square wrists (the thickness and width are about the same) than in those with the more common rectangular wrists.

Palm Shape. In one study, patients with palms that were both shorter and wider than average, and who also had shorter third fingers, were more likely to have CTS than those without these hand characteristics.

Poor Upper Back Strength. Some researchers claim that poor upper back strength makes people more susceptible to poor posture and injuries in the upper extremities, including carpal tunnel syndrome.

Cigarette smoking slows down blood flow, so that smokers have worse symptoms and slower recovery than nonsmokers do. Increased alcohol intake has been associated with CTS in people with other risk factors.

Poor nutrition, previous injuries, and stress can increase one's risk for carpal tunnel syndrome. In addition, high levels of so-called “bad” cholesterol (low-density lipoprotein, or LDL) have also been linked to an increased risk of CTS.

Prognosis

Carpal tunnel syndrome can range from a minor inconvenience to a disabling condition, depending on its cause and persistence and the individual characteristics of the patient. Many cases of CTS are mild, and when symptoms are of short duration, they often resolve (disappear) on their own. Once a woman with pregnancy-associated CTS gives birth, for instance, the swelling in her wrists and other symptoms almost always subside. Proper treatment of other medical conditions that cause CTS can often help reduce wrist swelling.

In severe untreated cases, however, the thenar muscles at the base of the thumb may whither, and loss of sensation may be permanent. CTS can become so crippling that people can no longer do their jobs or even perform simple tasks at home.

Carpal tunnel syndrome exacts a psychological toll. Anyone who cannot use his or her hands is likely to be depressed and suffer from low self-esteem. People may suffer from daily pain. In severe cases, they may be unable to perform ordinary tasks, such as driving a car or carrying groceries. And equally or even more distressing, they may have to give up enjoyable sports and hobbies.

According to a 2005 report from the Bureau of Labor Statistics, among the major disabling diseases and illnesses, carpal tunnel syndrome was associated with the longest average time away from work (28 days).

Employees with CTS who try to work through the disorder often put more stress on the wrists to compensate for the weakness and pain. The end result is to make the condition worse and impair work performance.

Eventually, the worker with CTS may be forced to give up his or her livelihood. In one study, nearly half of all patients with CTS changed jobs within 30 months of an initial diagnosis. And because of the controversy surrounding the issue of carpal tunnel syndrome and workers compensation, it is not always certain that the worker will receive compensation payments.

Prevention

Because multiple factors may cause carpal tunnel syndrome, there is no single mode of prevention. Treating any underlying medical condition is certainly important. Simple common sense may help minimize some risk factors predisposing a person to work-related CTS or other cumulative trauma disorders. A patient can learn how to adjust the work area, handle tools, or perform tasks in ways that put less stress on the hands and wrists. Proper posture and exercise programs to strengthen the fingers, hands, wrists, forearms, shoulders, and neck may help prevent CTS.

Many companies are now taking action to help prevent repetitive stress injuries. In a major survey, 84% reported that they were modifying equipment, tasks, and processes. Nearly 85% were analyzing their workstations and jobs, and 79% were buying new equipment. It should be stressed, however, that there has been no evidence that any of these methods can provide complete protection against CTS. The optimal corporate approach, if possible, is to reallocate workers suffering from repetitive stress injuries to other jobs.

Altering the way a person performs repetitive activities may help prevent inflammation in the hand and wrist from progressing into carpal tunnel syndrome. For example, replacing old tools with ergonomically designed new ones can be very helpful.

Rest Periods and Avoiding Repetition. Anyone who does repetitive tasks should begin with a short warm-up period, take frequent breaks, and avoid overexertion of the hand and finger muscles whenever possible. Employers should be urged to vary tasks and work content.

A 2001 study conducted by the National Institute for Occupational Safety and Health reported that even taking multiple "microbreaks" (about 3 minutes each) reduces strain and discomfort without decreasing productivity. Such breaks may include the following:

Shaking or stretching the limbs
Leaning back in the chair
Squeezing the shoulder blades together.
Taking deep breaths

Good Posture. Good posture is extremely important in preventing carpal tunnel syndrome, particularly for typists and computer users.

The worker should sit with the spine against the back of the chair with the shoulders relaxed.
The elbows should rest along the sides of the body, with wrists straight.
The feet should be firmly on the floor or on a footrest.
Typing materials should be at eye level so that the neck does not bend over the work.
Keeping the neck flexible and head upright maintains circulation and nerve function to the arms and hands. One method for finding the correct head position is the "pigeon" movement. Keeping the chin level, glide the head slowly and gently forward and backward in small movements, avoiding neck discomfort.

Good Office Furniture. Poorly designed office furniture is a major contributor to bad posture. Chairs should be adjustable for height, with a supportive backrest. Custom-designed chairs, made for people who do not fit in standard chairs, can be expensive. However, the costs are often offset by the savings in medical expenses that follow injuries related to bad posture.

Voice Recognition Software. For CTS patients who must use a computer frequently, a variety of voice recognition software packages (ViaVoice, Voice Xpress, Dragon NaturallySpeaking, IListen) are now available, enabling virtually hands-free computer use.

Keyboard and Mouse Tips. Anyone using a keyboard and mouse has some options that may help protect the hands.

The tension of the keys should be adjusted so they can be depressed without excessive force.
The hands and wrists should remain in a relaxed position to avoid excessive force on the keyboard.
A 2003 study suggested that mouse-use poses a higher risk than keyboard use. Replacing the mouse with a trackball device and the standard keyboard with a jointed-type keyboard are helpful substitutions.
Wrist rests, which fit under most keyboards, can help keep the wrists and fingers in a comfortable position.
Some people recommend keeping the computer mouse as close to the keyboard and the user's body as possible, to reduce shoulder muscle movement.
The mouse should be held lightly, with the wrist and forearm relaxed. New mouse supports (ErgoCat) are also available that relieve stress on the hand and support the wrist.
Some people cut their mouse pads in half to reduce movement.

Innovative keyboard designs may reduce hand stress:

Alternative geometry keyboards (Microsoft Natural Keyboard, Apple Adjustable Keyboard) allow the user to adjust and modify hand positions as well as adjust key tension. Most have a split or "slanted" keyboard that places the wrists at an angle. Studies suggest they are useful in promoting a neutral position for the wrist.
The continuous passive motion (CPM) keyboard lifts and declines gently and automatically every three minutes to break tension on the hands and wrist. A report of a clerical worker with CTS who used this device found an overall improvement of 10 words per minute in the typing tests, a decrease in disability score and symptom severity, and an improvement in function.
A keyless keyboard (orbiTouch) is an innovative device that uses two domes. The typist covers the domes with his or her hands and slides them into different positions that represent letters.

The force placed on the fingers, hands, and wrists by a repetitive task is an important contributor to CTS. To alleviate the effect of force on the wrist, tools and tasks should be designed so that the wrist position is the same as it would be if the arms dangled in a relaxed manner at the sides.

No task should require the wrist to deviate from side to side or to remain flexed or highly extended for long periods.
The handles of hand tools such as screwdrivers, scrapers, paint brushes, and buffers should be designed so that the force of the worker's grip is distributed across the muscle between the base of the thumb and the little finger, not just in the center of the palm.
People who need to hold any tools (including pencils and steering wheels) for long periods of time should grip them as loosely as possible.
In order to apply force appropriately, the ability to feel an object is extremely important. Tools with textured handles are helpful.
If possible, people should avoid working at low temperatures, which reduces sensation in hands and fingers.
Power tools and machines should be designed to minimize vibrations.
Wearing thick gloves, when possible, may lessen the shock transmitted to the hands and wrists. One 2001 study found, however, that wearing gel-padded gloves clearly increased comfort but did not actually protect against compression-induced CTS.

Hand and wrist exercises may help reduce the risk of developing carpal tunnel syndrome. Isometric and stretching exercises can strengthen the muscles in the wrists and hands, as well as the neck and shoulders, improving blood flow to these areas. Performing the simple exercises described below for 4 to 5 minutes every hour may be helpful.

Wrists

Exercise 1.

Make a loose right fist, palm up, and use the left hand to press gently down against the clenched hand.
Resist the force with the closed right hand for 5 seconds. Be sure to keep the wrist straight.
Turn the right fist palm down, and press the knuckles against the left open palm for 5 seconds.
Finally, turn the right palm so the thumb-side of the fist is up, and press down again for 5 seconds.
Repeat with the left hand.

Exercise 2.

Hold one hand straight up shoulder-high with fingers together and palm facing outward. (The position looks like a shoulder-high salute.)
With the other hand, bend the hand being exercised backward with the fingers still held together and hold for 5 seconds.
Spread the fingers and thumb open while the hand is still bent back and hold for 5 seconds.
Repeat five times for each hand.

Exercise 3. (Wrist Circle)

Hold the second and third fingers up, and close the others.
Draw five clockwise circles in the air with the two finger tips.
Draw five more counterclockwise circles.
Repeat with the other hand.

Fingers and Hand

Exercise 1.

Clench the fingers of one hand into a fist tightly.
Release, fanning out the fingers.
Do this five times. Repeat with the other hand.

Exercise 2.

To exercise the thumb, bend it against the palm beneath the little finger, and hold for 5 seconds.
Spread the fingers apart, palm up, and hold for 5 seconds.
Repeat five to 10 times with each hand.

Exercise 3.

Gently pull the thumb out and back and hold for 5 seconds.
Repeat five to 10 times with each hand.

Forearms (stretching these muscles will reduce tension in the wrist)

Place the hands together in front of the chest, fingers pointed upward in a prayer-like position.
Keeping the palms flat together, raise the elbows to stretch the forearm muscles.
Stretch for 10 seconds.
Gently shake the hands limp for a few seconds to loosen them.
Repeat frequently when the hands or arms tire from activity.

Neck and Shoulders

Exercise 1.

Sit upright and place the right hand on top of the left shoulder.
Hold that shoulder down, and slowly tip the head down toward the right.
Keep the face pointed forward, or even turned slightly toward the right.
Hold this stretch gently for 5 seconds.
Repeat on the other side.

Exercise 2.

Stand in a relaxed position with the arms at the side.
Shrug the shoulders up, then squeeze the shoulders back, then stretch the shoulders down, and then press them forward.
The entire exercise should take about 7 seconds.

Diagnosis

Carpal tunnel syndrome (CTS) is most accurately diagnosed using the patients' descriptions of symptoms, and electrodiagnostic tests that measure nerve conduction through the hand. If electrodiagnostic testing is not available, then symptom descriptions and a series of physical tests are useful.

Diagnosing CTS, however, is not straightforward. Only a small fraction of patients exhibit all three factors necessary for a clear diagnosis:

Classic CTS symptoms
Specific physical findings
Abnormal electrodiagnostic test results

Many people have abnormal electrodiagnostic test results without classic symptoms or any symptoms at all. Furthermore, about 15% of the population has symptoms consistent with CTS, but most do not show test results indicating the disorder. In fact, in a 2001 study, some patients who had symptoms, but whose nerve and physical tests were normal, still experienced relief after CTS surgery.

Many cases of CTS are a combination of a medical problem exacerbated by repetitive stress factors at work. The patient should give the doctor a detailed history and description of any complaints, in any part of the body. The patient should report in detail any daily activities that require repetitive hand or wrist actions, abnormal postures, or other regular situations that could affect the nerves in the neck, shoulders, and hands. The patient should report whether the symptoms are more likely to appear at night, or after particular tasks.

Questionnaires. The use of specific questionnaires that score results are quite accurate in assessing the severity of the condition.

Hand Diagram. A diagram of the hand and wrist, usually divided into six regions, is a very useful diagnostic tool. Patients are asked to indicate where their symptoms are, including pain, numbness, or tingling, by locating the affected areas on the diagram. They may also be asked to rate the severity of their symptoms. A diagnosis is probable if at least two of fingers 1, 2, or 3 have these symptoms, and if there is pain in or near the wrist. CTS is possible if at least one of these fingers has symptoms. It is unlikely if there are no symptoms in these fingers, the palm, or the wrist.

One of the most important first steps in diagnosing CTS is to rule out any underlying medical disorders that may be contributing to the condition. Experts emphasize the need to fully examine patients presenting with symptoms of CTS. Relying only on CTS symptoms, and personal or work histories may result in the failure to detect (and thus properly treat) underlying medical conditions that could be serious. If the doctor suspects that an underlying medical condition may be exacerbating the symptoms, laboratory tests will be performed. The doctor may take an x-ray, for example, to check for arthritis or fractured bones.

Raynaud's Phenomenon. A diagram of the hand and wrist, usually divided into six regions, is a very useful diagnostic tool. Patients are asked to indicate the location of their symptoms -- including pain, numbness, or tingling -- by locating the affected areas on the diagram. They may also be asked to rate the severity of their symptoms. A diagnosis is probable if at least two of fingers 1, 2, or 3 have these symptoms, and if there is pain in or near the wrist. CTS is possible if at least one of these fingers has symptoms. It is unlikely if there are no symptoms in these fingers, the palm, or the wrist.

Arthritic Conditions. Arthritic conditions, including rheumatoid arthritis, gout, and osteoarthritis, can all cause pain in the hands and fingers that may mimic carpal tunnel disease. The treatment for these conditions, however, is different.

Muscle and Nerve Diseases. Any disease or abnormality that affects the muscles and nerves, including those in the spine, may produce symptoms in the hand that mimic carpal tunnel syndrome.

About 25% of patients with suspected work-related cumulative trauma or repetitive stress disorders have evidence of other conditions that resemble, but are not, carpal tunnel syndrome. A definitive diagnosis is often difficult. Most require treatments similar to those used for CTS: rest, immobilization, steroid injections, and even surgery if conservative management is unsuccessful.


Location	Description
The Median Nerve in Other Locations	Repetitive work can cause pressure on the median nerve in locations other than the wrist and can also affect other nerves in the arm and hand. The branch of the median nerve that runs through the palm of the hand can be damaged directly by repeated pounding or by the use of certain tools requiring a strong grip using the palm, such as needle-nosed pliers. The median nerve can also be pinched in the forearm.
Guyon's Canal Syndrome (Commonly called ulnar tunnel syndrome)	The ulnar nerve can, like the median nerve, can be trapped as a result of repetitive stress. When this nerve is trapped, the condition is sometimes referred to as ulnar tunnel syndrome. It is more correctly known as Guyon's canal syndrome, however, since this is the name of the passage through which the ulnar nerve passes. General symptoms are similar to carpal tunnel syndrome, but patients experience loss of sensation in the ring and little finger and in the outer half of the palm. It can be a separate problem, although it commonly occurs with CTS. In such cases, release surgery for CTS usually also relieves the ulnar nerve entrapment. The ulnar nerve can also be affected at the elbow.
De Quervain's Tenosynovitis	Tenosynovitis is swelling of the slippery covering of the tendons that move the thumb. When it causes pain on the side of the wrist and forearm right below the base of the thumb, it is known as De Quervain's tenosynovitis. (Finklestein's Test may help identify this. Make a fist that encloses the thumb, and bend the wrist sideways and down away from the thumb. If it causes pain, it is likely to be De Quervain's tenosynovitis.) It may be treated with splints or corticosteroid injections. In severe cases release surgery is effective.
Digital Flexor Tenosynovitis (Trigger or Snapping Finger)	Digital flexor tenosynovitis, commonly called trigger or snapping finger, is brought on when a tendon thickens, leaving the finger or thumb in a bent position. This disorder usually occurs when the tendons thicken and form a knot and may arise in those with hypothyroidism, diabetes, gout, rheumatoid arthritis, or connective tissue disorders. It can cause pain and a clicking sound when the trigger finger or thumb is bent and straightened. It can be effectively treated with corticosteroid injections.
Thoracic Outlet Syndrome	Thoracic outlet syndrome is caused by compression of nerves and blood vessels running down the neck into the arm. It can produce symptoms very similar to CTS. Other symptoms may include Raynaud's phenomenon (changes in sensation and temperature in the hand). The compression occurs at the first rib in the front of the shoulder. This may happen after an accident or simply from chronic slouching posture. A doctor may be able to diagnose the condition by detecting diminished blood flow in the arm as the patient raises the affected hand and turns his or her head toward the opposite side. Although the condition is uncommon, a correct diagnosis is important to differentiate it from CTS, since treatments differ. Surgery may be required to relieve pressure on the nerves and blood vessels.

The following findings are helpful in identifying carpal tunnel syndrome:

Less sensitivity to pain where the median nerve runs through to the fingers
Thumb weakness
Inability to tell the difference between one and two sharp points on the fingertips (this is a late sign of carpal tunnel)

Flick Signal. One important and simple test of carpal tunnel is the "flick" signal:

The patient is asked, "What do you do when your symptoms are worse?"
If the patient responds with a motion that resembles shaking a thermometer, then the doctor can strongly suspect carpal tunnel.

Testing for Thumb Weakness. Two questions are useful in determining thumb weakness:

Can the thumb rise up from the plane of the palm?
Can the thumb stretch so that its pad rests on the pad of the little finger pad?

Provocation Tests. Certain tests are conducted to produce symptoms:

Phalen's Test. In Phalen's test, the patient rests the elbows on a table and lets the wrists dangle with fingers pointing down and the backs of the hands pressed together. If symptoms develop within a minute, CTS is indicated. (If the test lasts for more than a minute even patients without CTS may develop symptoms.) This test may be particularly important in determining the severity of CTS and assessing the results of treatment.
Tinel's Sign. In the Tinel's sign test, the doctor taps over the median nerve to produce a tingling or mild shock-sensation.
Pressure Provocation Test. The doctor presses over carpal tunnel for 30 seconds to produce tingling or shock in the median nerve.
Tourniquet Test. This test employs an inflatable cuff that applies pressure over the median nerve to produce tingling or small shocks.
Hand Elevation Test. The patient raises their hand overhead for 2 minutes to produce symptoms of CTS. The test was recently proven to be accurate and may provide useful information when combined with the Tinel's and Phalen's tests.

Electrodiagnostic tests analyze the electric waves of nerves and muscles. These tests can help detect median nerve compression in the carpal tunnel.

Electrodiagnostic tests are the best methods for confirming a diagnosis of CTS at this time. Doctors who perform these tests should be certified by the American Board of Electrodiagnostic Medicine, which uses rigorous standards in qualifying doctors. Specific electrodiagnostic tests, called nerve conduction studies and electromyography, are the most common ones performed:

Nerve Conduction Studies. To perform nerve conduction studies, surface electrodes are first fastened to the hand and wrist. Small electric shocks are then applied to the nerves in the fingers, wrist, and forearm to measure how fast a signal travels through the nerves that control movement and sensation. In suspected cases of CTS, nerve conduction tests can identify over 85% of true carpal tunnel syndrome cases and eliminate 95% of those that are not true CTS. They are less accurate in identifying mild CTS, however. Patients should be sure their practitioners perform tests that compare a number of internal responses -- not just routine testing that records only the responses of muscles located in the palm at the base of the thumb), and those on the second or third fingers.

Nerve conduction tests can also detect causes of symptoms that mimic CTS but should be attributed to other problems, such as pinched nerves in the neck or elbow or thoracic outlet syndrome.

Electromyography. To perform electromyography, a fine, sterile, wire electrode is inserted briefly into a muscle, and the electrical activity is displayed on a viewing screen. Electromyography can be quite painful and is less accurate than nerve conduction. Some experts question, in fact, whether it adds any valuable diagnostic information. They suggest it be limited to unusual cases or when other tests indicate that the condition is aggressive and may increase the risk for rapid, significant injury.
Portable electrodiagnostic testing. Portable electronic devices (such as NC-Stat, Neurosentinel, and the Nervepace digital electroneurometer) are being evaluated for measuring nerve conductivity. They are relatively quick and easy to use on a large scale in an industrial facility. However, the Advancing Association of Neuromuscular and Electrodiagnostic Medicine maintains that these devices are experimental and are not effective substitutes for standard electrodiagnostic studies.

Limitations. Electrodiagnostic studies are not well standardized, and certain conditions can skew the results of either test:

Obesity can slow the speed of electrical conduction.
Anxiety can slow the speed of electrical conduction.
Women and the elderly normally have slower conduction times than younger adult men.
Temperature also affects nerve conduction speed. When undergoing testing, doctors should strictly control room temperature to lessen its impact.

Ruling out other causes is extremely important in order to avoid unnecessary surgery for CTS. Modifications and improvements of these tests are continually being made.

Note: People with abnormal results who have no CTS symptoms are at no higher risk for CTS than those with normal results and no symptoms.

A diagnosis of carpal tunnel syndrome may follow testing the affected hand for numbness, tingling, weakness or pain in specific areas. Muscle and nerve conduction tests may also help affirm or rule out carpal tunnel syndrome.

Ultrasound. Ultrasound imaging, a relatively inexpensive technique that uses sound waves, is showing promise. Studies indicate that it can identify up to 85% of CTS cases, and some suggest it is as effective as electrodiagnostic tests. It may be effective for ruling out other causes of hand pain, such as tendon injuries, tenosynovitis (swelling of the tendon lining), cysts, and blood clots in the median artery (a rare complication that can cause the sudden onset of CTS symptoms). However, results are mixed on its accuracy. Newer color Doppler ultrasound and other technological advances are improving the results achieved with this technique. A 2005 study comparing high-resolution ultrasonography with electromyography found that ultrasonography may be helpful for estimating the symptom severity and problems with nerve conduction.

MRI. Magnetic resonance imaging (MRI), an advanced imaging technique, is being adapted to distinguish weak nerve signals from surrounding tissue, so that eventually it may be able to precisely diagnose CTS. However, studies in 2002 note that it requires special expertise, has limited diagnostic accuracy, and is still too expensive at present for routine use. MRI is accurate in diagnosing carpal tunnel syndrome about 80% of the time, compared to about 85% using electrodiagnostic tests, which remains the preferred method of diagnosis. MRI may be most effective for detecting any internal injuries, tumors, arthritis, or joint damage that might be causing the problem. It may also be valuable in selecting surgical candidates when electrodiagnostic tests produce unusual results or indicate more severe disease than expected. Additionally, an MRI may be useful for evaluating patients if surgery fails to bring relief.

Treatment

It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder.

Nevertheless, relapse is common, and studies suggest that surgery is a better option for severe CTS. In one study, 89% of patients who had conservative treatments suffered a recurrence of symptoms within a year. Conservative treatments work best in men under 40. They do not work as well in young women. The conservative approach is also most successful in patients with mild carpal tunnel syndrome. Even among these patients, however, one study found that 60% of patients can expect a relapse. Some researchers are reporting better results when specific exercises for carpal tunnel syndrome are added to the program of treatments.

Limiting Movement. If possible, the patient should avoid activities at work or home that may aggravate the syndrome. The affected hand and wrist should be rested for 2 to 6 weeks. This allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. If the injury is work related, the worker should ask to see if other jobs are available that will not involve the same actions. Few studies have been conducted on ergonomically designed furniture or equipment, or on frequent rest breaks. However, it is reasonable to ask for these if other work is not available.

Conservative Treatment Approach. In a major analysis, the following conservative approaches were shown to provide symptom relief:

Wrist splints
Corticosteroids (steroids). Injected or short-term oral corticosteroids may be tried if other methods fail.
Yoga. In one study, 8 weeks of regular yoga practice reduced pain significantly more than splinting.
Manual therapy, a type of physical therapy

A major analysis of other conservative approaches found that patients had no significant relief from nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include common pain relievers such as aspirin and ibuprofen (Advil). The same report also found no benefits from diuretics, magnet therapy, laser acupuncture, vitamin B6, exercise, or chiropractic care. Other approaches being investigated include omega-3 fatty acid supplements and cognitive-behavioral therapy.

Underlying Conditions. It is important to treat any underlying medical condition that might be causing carpal tunnel syndrome. For example, reducing inflammation in rheumatoid arthritis or other forms of inflammatory disorders that directly cause CTS is very helpful.

Hypothyroidism and diabetes are diseases that are associated with an increased risk of CTS. The treatments for such diseases may offer some relief for CTS symptoms. For example, insulin helps nerves heal. A study of patients with CTS and type 2 diabetes found that patients who had an initial steroid injection followed by 7 weekly insulin injections had significantly less pain than those who received sham therapy (placebo). More research is needed on the effects of insulin injections in patients with CTS.

Wrist splints are used to keep the wrist from bending. They are not as beneficial as surgery for patients with moderate to severe CTS, but they appear to be helpful in specific patients. In one study, the best success rates were in patients with mild to moderate nighttime symptoms of less than a year's duration. In selected patients, up to 80% reported fewer symptoms, usually within days of wearing the splint.

Although typically the splint is worn at night or during sports, one 2000 study reported that wearing it full time is most beneficial. (In the study, few patients actually complied with the regimen and wore them full time, but any regular use appeared to improve nerve function and symptoms.) The splint is used for several weeks or months, depending on the severity of the problem, and may be combined with hand and finger exercises. A 2005 study reported that a 6-week course of at-night splinting reduced symptom severity in people with CTS and that the benefits were still evident after 1 year.

Corticosteroid Injections. Corticosteroids (also called steroids) reduce inflammation. If restriction of activities and the use of painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel. Some experts recommend them for patients with CTS whose symptoms are intermittent, and there is no evidence of a permanent injury. In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. Evidence strongly suggests that they offer relief in more than 75% of CTS patients. It should be noted that the pain may increase for a day or two after the injection, and skin color may change.

A study comparing the benefits of two steroid injections (8 weeks apart) to a single injection in the treatment of CTS found the patients did not significantly benefit from the second shot. One injection is therefore enough to achieve the maximum benefit of this treatment.

Unfortunately, in most cases, steroid injections provide only temporary relief, although studies comparing steroid injection to surgery have produced conflicting results. In a major analysis, after 1 month, injections were no more effective than placebo (sham) injections.

However, a recent analysis compared the effects of local steroid injection versus surgery in patients with new CTS of at least 3 months' duration. Over the short term, local steroid injection was better than surgery for relieving symptoms of CTS. And after 1 year, local steroid injection was as effective as surgery. Another study compared steroid injection with open-release surgery and found that the surgery resulted in better outcomes, but not improved grip strength, in patients with CTS over a 20-week period.

Most doctors limit steroid injections to about three per year, since they can cause complications, such as rupture of tendons, nerve irritation, or more widespread side effects such as hypertension or elevated blood sugar levels.

Low-Dose Oral Corticosteroids. Oral corticosteroids are medicines taken by mouth. Short-term (1 to 2 weeks), low-dose use of corticosteroids may provide long-term relief. People with diabetes should not take oral corticosteroids.

Yoga. Some evidence suggests that yoga practice may be specifically very helpful for carpal tunnel, since yoga postures are designed to stretch, strengthen, and balance upper body joints. In one study, people who practiced yoga for 8 weeks experienced significantly reduced symptoms compared to wrist splints or no treatment at all. Two other small studies also reported improvement in pain relief. Positive effects may take a few weeks of regular practice of at least two sessions a week.

General Exercise Program. Some experts have reported that people who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. Although there is no evidence that exercise can directly improve CTS, a regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being. In one 2001 study, CTS patients experienced symptom relief and signs of improved nerve conduction after 10 months of participation in an aerobic exercise program (such improvements appeared to be due to both weight loss and higher oxygen levels in the blood). One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture. People with any chronic medical condition or with risk factors for heart disease should check with their doctors about an appropriate exercise regimen.

If symptoms subside, the patient may proceed with a supervised program of joint mobilization and hand and wrist strengthening and stretching, usually offered by physical or occupational therapists. Hand and wrist exercises may be most beneficial for patients with mild to moderate disease who are also treated with splints and other conservative measures. Graston Instrument-Assisted Soft-Tissue Mobilization (GISTM) and Soft-Tissue Moblization (STM) techniques have been shown to improve nerve conduction, wrist strength, and wrist motion.

Ultrasound employs high-frequency sound waves directed toward the inflamed area. The sound waves are converted into heat in the deep tissues of the hand, which opens the blood vessels and allows oxygen to be delivered to the injured tissue. A major analysis suggested this approach may be effective when used for seven weeks or more.

Nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen (Advil), are the most common pain relievers used for CTS. They block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Unfortunately, as with most other medications used for carpal tunnel syndrome, there are few well-conducted studies to determine their role in CTS. To date, there is no evidence that they offer any significant relief, and regular use can have serious side effects.

NSAIDs Used. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to relieve joint pain and inflammation. There are dozens of NSAIDs. The following are the most common:

Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), and ketoprofen (Actron, Orudis KT).
Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), dexibuprofen (Seractil), and indomethacin (Indocin).

Regular use of even over-the-counter NSAIDs may be hazardous for anyone. Long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems. In April 2005, the Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular events and gastrointestinal bleeding. NSAIDS have been associated with the following side effects:

Ulcers and gastrointestinal bleeding are the major danger with long-term use of NSAIDs.
Increased blood pressure -- most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). Sulindac has the smallest effect; aspirin has no risk. People with hypertension, severe vascular disease, kidney, or liver problems, and those taking diuretics, must be closely monitored if they need to take NSAIDs.
Delay in emptying of the stomach -- this could interfere with the actions of other drugs. The elderly are at special risk.
Kidney abnormalities -- these have been reported in people taking NSAIDs, which resolve when the drugs are withdrawn. Report any sudden weight gain or swelling to a doctor. Anyone with kidney disease should avoid these drugs.

Other side effects include:

Dizziness
Tinnitus (ringing in the ear)
Headache
Skin rash
Depression
Confusion or bizarre sensation (in some higher-potency NSAIDs, notably indomethacin)
Possible higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception)
There is a slight risk for liver abnormalities.

COX-2 Inhibitors (Coxibs). COX-2 inhibitors block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in patients taking the drugs. At the time of this update, Celecoxib (Celebrex) was still available, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.

Ice and Warmth. Ice may provide benefit for acute pain. Some patients have reported that alternating warm and cold soaks have been beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.)

Anesthetic Injections. In some cases, injections of an anesthetic (such as lidocaine) may be helpful. A recent small study compared a painkilling lidocaine patch with a combination lidocaine-steroid injection. The study found the daily use of a 5% lidocaine patch reduced pain as well as the injections. More patients in the patch group reported satisfaction with their treatment. The lidocaine patch is less painful than injections because it is worn on the skin and doesn't require a shot. Doctors noted improvements in 88% of the patients in the patch group, compared with 74% of the patients in the injections group.

Pheresis. The word "pheresis" means to carry. In the case of carpal tunnel, pheresis is a technique being investigated to deliver (to carry) a corticosteroid cream deep within the wrist. One such technique called iontophoresis uses an electrical current, and another called phonophoresis uses ultrasound. One study recently found steroid injections to be superior to iontophoresis and phonophoresis in the treatment of CTS.

Diuretics. Diuretics such as trichlormethiazide reduce fluid in the body. They are sometimes used to treat CTS. However, studies have not reported any significant benefits with these agents.

Low-Level Laser Therapy. Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless, but studies are mixed on whether it is any more effective than sham treatment. One major analysis reported that laser therapy was more effective over time than steroid injections (although it does not appear to provide much immediate relief.) A 2004 study comparing LLLT with a sham (inactive) therapy reported no significant differences in outcomes between the two groups.

Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax until the process is completed. Discomfort is minimal. Small studies are reporting some help in relieving a number of conditions that cause chronic pain, including carpal tunnel syndrome.

Traction. Small studies of a hand traction device showed improvement in some patients. The device, called C-TRAC, significantly improved pain, tingling, and numbness in patients who had failed a minimum of 4 months of therapy with conservative treatments such as NSAIDs, night hand splinting, acupuncture, and hand therapy. Patients used the C-TRAC device for 5 minutes three times daily for four weeks, then as needed to maintain long-term improvement.

Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Few, however, have any proven benefit. People should carefully educate themselves about how alternative therapies may interact with other medications or impact other medical conditions, and should check with their doctor before trying any of them.

Vitamin B6. Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.

Acupuncture. Acupuncture may be beneficial. New techniques employing painless laser acupuncture may prove to be particularly effective. The National Institutes of Health issued a Consensus Statement on Acupuncture in 1997, which declared this ancient form of treatment useful as a supplement to standard treatment or even as part of a comprehensive management program for CTS.

Chiropractic Therapies. Chiropractic techniques have been useful for some people whose condition is produced by pinched nerves. In one small study, the technique was as effective as medications or wrist splints for relief of pain, though further research is needed.

Magnets. Magnets are a popular but unproven therapy for pain relief. One small study of patients who wore magnets attached to their wrists showed no benefits over those who wore a nonmagnetic placebo (sham) device, although both groups did experience pain relief, perhaps due to a placebo response.

Botulinum toxin type A. Intracarpal injections of botulinum toxin type A (Botox) have been reported to relieve carpal tunnel syndrome in more than half of the small number of patients tested. The product has been safely used to relieve headaches, myofacial pain, and other neuropathic pains.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Several herbal and homeopathic remedies are sold for pain relief. A small 2002 British study suggested that preparations containing arnica, a popular remedy for swelling and bruising, may ease discomfort following surgery for carpal tunnel, but a 2003 study reported no advantages compared to placebo (an inactive substance).

Research indicates that anxiety, depression, and even pain related to CTS can be relieved to some extent with cognitive behavioral therapy. The focus of this therapeutic approach is to change negative thinking about one's ability to manage pain. Cognitive behavioral therapy is particularly helpful in defining and setting limits. It may be expensive and not covered by insurance, although the therapy is usually of short duration, typically six to 20 one-hour sessions, plus homework, which usually includes attempting a task that the patient has avoided because of negative thinking. Even if people cannot afford this type of therapy, support groups for carpal tunnel syndrome and other sufferers of repetitive stress injuries can be very helpful for exchanging information, specific advice, and solace. Stress management techniques can also be useful in dealing with the psychological and emotional issues accompanying these injuries.

Surgery

Every year more than 200,000 people in the US undergo surgeries for carpal tunnel syndrome. Surgery for CTS is among the most common hand surgeries. In various trials, 70 - 90% of patients who underwent surgery were free of nighttime pain afterward.

Although evidence strongly suggests that surgery is more effective than conservative approaches (at least in patients with moderate to severe CTS), the decision about whether to have surgery to correct CTS, and when to have it, is a troubling one for patients. Electrodiagnostic and other tests used to confirm the presence of CTS are not very useful in determining the best candidates for surgery. For example, results suggesting severe CTS may not relate at all to surgical success or the lack of it.

In general, patients with the following characteristics are less likely to respond to conservative treatment and, therefore, might benefit from surgery:

Older than 50 years of age
Symptoms lasting 10 months or longer
Continual numbness
Muscles in the base of the palm have begun to shrink
Symptoms occur within 30 seconds during a Phalen's test

According to a 2002 study, if none of these factors are present, conservative therapies (splinting and anti-inflammatory agents) are effective in two thirds of patients. However, the conservative approach was ineffective in 60% of patients if only one of these factors were present, in 83% with only two of them, and in virtually all patients who had three or more.

Surgery does not cure all patients, and because it permanently cuts the carpal ligament, some wrist strength is often lost. A number of experts believe that release surgery is performed too often. They recommend aggressive conservative treatment (such as splints, anti-inflammatory agents, and physical therapy) before choosing the more invasive option (surgery). Nevertheless, other experts argue that CTS is often progressive and will worsen over time without surgery. Furthermore, evidence now shows that surgery is better than splints and conservative measures for the relief of pain. Factors that may increase the chances for successful surgery:

Having surgery performed within 3 years of the diagnosis of the disorder
Being in good general health
Having very slow nerve conduction results, but also having some muscle strength before surgery
Symptoms are worse at night than during the day

Factors that may reduce the chances for success:

Being elderly may affect the chances of successful surgery. However, a study found that the majority of patients over age 65 who had surgery were either completely or very satisfied.
Having very severe symptoms before surgery may reduce the chance for successful surgery.
Performing heavy manual labor, particularly working with vibrating tools, may lead to a less successful surgery. Medical evidence has found that only slightly more than half the people who used vibrating hand-held tools were symptom-free 3 years after a CTS operation.
Having very poor nerve conduction results before surgery may reduce the chance for successful surgery. However, some patients with severe symptoms who have normal neurological and physical test results, could still experience significant relief from CTS surgeries.
Patients who are on hemodialysis have good initial success, but approximately half deteriorate in about a year and a half.
Alcohol abuse can negatively affect the results of CTS surgery.
Poor mental health can lead to less successful surgery.
Patients with diabetes and high blood pressure may be more likely to require a second operation.

Factors that make no difference in results:

Patients whose CTS is due to nerve damage from medical conditions, such as diabetes, rheumatoid arthritis, or hypothyroidism. Such patients appear to have the same outcome as those without such conditions, and such disorders should not preclude them from surgery.

Open Release Surgery. Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. The pressure on the median nerve is therefore relieved. The surgery is straightforward.

In treating carpal tunnel syndrome, surgery may be required to release the compressed median nerve. The open release procedure involves simply cutting the transverse carpal ligament.

The Mini-Open Approach. In recent years, more surgeons have adopted a "mini" open -- also called short-incision -- procedure. This surgery requires only a one-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach may allow for quicker recovery while avoiding some of the complications of endoscopy, although few studies have investigated its benefits and risks. In a 2005 report, the mini-open approach was directly compared with open release surgery. The recovery time in patients receiving the mini-open approach was shorter than with the open approach, and results were about the same 30 months after the surgery.

Endoscopy. Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release.

A surgeon makes one or two 1/2-inch incisions in the wrist and palm, and inserts one or two endoscopes (pencil-thin tubes).
The surgeon then inserts a tiny camera and a knife through the lighted tubes.
While observing the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.

Patients report less pain than those who had the open release procedure, and return to normal activities in about half the time. Nevertheless, at this time the best evidence available does not show any significant long-term advantages of endoscopy over open release in terms of muscle or grip strength or dexterity. The endoscopic approach may even carry a slightly higher risk of pain afterward. This may be due to a more limited view of the hand with endoscopy. (In the open release procedure, the surgeon has a full view of the structures in the hand.) One report indicated a nearly 3-fold increased risk of reversible nerve injury with endoscopic carpal tunnel release, compared with open carpal tunnel release. On the other hand, a recently published review of 486 patients, who had a total of 753 endoscopic release procedures, showed an extremely low number of complications following the procedure. This study calls into the question the widely held belief that endoscopy carries a higher risk of complications. The study also noted that 90% of the patients returned to their original line of work.

Timing for Recovery. Patients should expect the following course:

For some patients, release surgery relieves CTS symptoms of numbness and tingling immediately.

People who have the operation on both hands are completely incapacitated for about two weeks and must have someone to help them at home.
Returning to strenuous work right after surgery may cause the symptoms to return. Patients generally stay out of work for at least a month and often much longer, depending upon the type of surgery and severity of the condition. Recovery time appears to be faster with endoscopy than with open release.
Immediately after surgery patients usually experience a decline in grip strength and dexterity. Studies have reported a wide range of recovery in this area. In one study, grip and pinch strengths reached better levels than before surgery within 6 weeks. In another study, however, grip strength and dexterity did not return to before-surgery levels until 25 weeks after open surgery. The scar may remain tender for up to a year.
Peak improvement (the best level of improvement a patient can reach) may take a long time; in one study, it took an average of almost 10 months.

Physical Therapy. Physical therapy is very important to help rebuild wrist strength. While physical therapy does not reduce the recurrence (return) of symptoms or improve the long-term benefits of surgery, it does accelerate recovery after surgery. Hand exercises can help restore circulation, muscle strength, and joint flexibility in the hand and wrist. Wearing a splint to immobilize the wrist after surgery has no benefits.

Treatment failure and complication rates of CTS surgery vary.

Complications after surgery may include the following:

Nerve damage with tingling and numbness (usually temporary)
Infection
Scarring
Pain
Stiffness. Loss of some wrist strength is a complication that affects between 10% and a third of patients. Endoscopy may have better results than open release. Some patients who have jobs requiring significant strength of the hand and wrist may not be able to perform them after surgery. Such workers may also have problems in other parts of the upper body, including elbows and shoulders. These problems do not go away with surgery and can persist. Studies indicate that between 10 - 15% of patients change jobs after a CTS operation.

If pain and symptoms return, the release procedure may be repeated.

Reasons for procedure failure include:

Incomplete release of the ligament
Extensive scarring
Recurrence of the disorder due to underlying medical conditions

Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.

Neurolysis. In severe cases or when scarring is extensive after surgery, surgeons may choose to sever the nerves that are responsible for the pain, using a procedure called external or internal neurolysis. The procedure may extend recovery time substantially, and the need for repeat surgeries may be higher in those who undergo the procedure. One report indicated that neurolysis should be considered if there has not been any recovery within 3 months after surgery, after which improvement is unlikely. It is unclear if this approach offers any benefits over conservative measures to free the nerve from surrounding scar tissue.

Implants. In another procedure for recurrent carpal tunnel syndrome, doctors may take muscle flaps or even fatty tissue from other parts of the body and implant them at the site of the nerve injury. Such flaps enhance the development of new blood vessels, provide padding, and possibly serve as a bed for nerve regrowth. These implants may be used with or without cutting the nerve. Another procedure called vein wrapping uses grafts taken from veins to help protect the scarred nerves.

Resources

www.aanem.org -- Advancing Association of Neuromuscular and Electrodiagnostic Medicine
www.apta.org -- American Physical Therapy Association
www.aoec.org -- The Association of Occupational and Environmental Clinics
www.aaos.org -- American Academy of Orthopaedic Surgeons
www.assh.org -- American Society for Surgery of the Hand
www.ampainsoc.org -- American Pain Society
www.iasp-pain.org -- Association for the Study of Pain
www.aan.com -- American Academy of Neurology
www.nih.gov/niams -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.nlm.nih.gov/medlineplus/carpaltunnelsyndrome.html -- Information on CTS
www.cdc.gov/niosh/homepage.html -- National Institute for Occupational Safety and Health
www.workerscompensationinsurance.com -- Resources for injured workers
www.keybowl.com -- orbiTouch keyboard
www.ergodevices.com -- Hand and wrist support keyboard

References

Tsai CP, Liu CY, Lin KP, Wang KC. Efficacy of botulinum toxin type a in the relief of carpal tunnel syndrome: A preliminary experience. Clin Drug Investig.2006;26:511-515.

Burke J, Buchberger DJ, Carey-Loughmani MT, et al. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther.2007;30:50-61.

Hemminki K, Li X, Sundquist K. Familial risks for nerve, nerve root and plexus disorders in siblings based on hospitalizations in Sweden. J Epidemiol Community Health. 2007;61:80-84.

Porrata H, Porrata A, Sosner J. New carpal ligament traction device for the treatment of carpal tunnel syndrome unreposnive to conservative therapy. J Hand Ther. 2007;20:20-28.

Review Date:
3/14/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Find Your Chi and Run With It at ChiRunning Workshop

FitSugar — Mon, 27 Apr 2009 12:00:00 -0700

Dealing with some troubling knee pain, I decided to focus on my running gait. I had the pleasure of taking an all day workshop with the running master Danny Dreyer, the founder of ChiRunning.

I'd like to say my running was transformed during the hours I spent with about 30 other runners from all walks of life, but I must admit I have a lot to work on. The workshop was slow going at the beginning, since the first rule of Chi Running is good posture. We practiced standing for well over an hour, which I know sounds odd for a running workshop, but if your body isn't organized when it is still, it definitely won't be efficient in motion. Being a Pilates posture geek, I loved this attention to detail.

Details on the rest of the workshop when you read more.

After adjusting our posture and learning how to find it on one foot, we headed outside to play with gravity in the parking lot. Overlooking Golden Gate Bridge, all 30 runners learned how to run leaning forward. The lean comes from the ankles not the hips or shoulders. But before you can run, you need to learn how to walk. Slowly we peeled our feet off the pavement and leaned forward feeling our low abs engaged, trying to relax everything else. We looked like zombies marching to an inaudible drummer.

Walking was followed with a review of arm swings. You bend your elbow at a 90-degree angle and move your elbow behind your body, with arm swing ending when the elbow returns inline with the torso. The hands angle in, since the shoulder joint is directed slightly forward rather than directly to the side. However, your hands shouldn't cross your center line; imagine holding a volleyball to find the appropriate hand positioning. Then came the moment of truth - we got to run, albeit slowly at first, but we were running. It felt different and very self-conscious. There is a lot of unnecessary tension to let go of, in order to move forward with ease. Like Pilates, you take the tension and direct it to your core to keep your limbs relaxed and your spine long.

An all day Chi Running workshop is broken into two parts. The first half, all taught before lunch, is what I have described. The second half involves learning warm ups and cool down, how to deal with hills, and how to pick up your speed - more on all this later. All and all, I think this technique will help my knee tremendously.

Danny said that he hoped we would all think of running as a practice like meditation, not like a sport. In light of that he suggested that we all pick the runs where we planned to practice Chi Running and keep those separate from the runs where we listen to our iPods or chat with friends. This technique is a mind body practice so you have to "listen to your body."

I highly recommend these workshops, for folks dealing with injuries or newbies trying to learn how to love running. Check here for upcoming workshops in your area. The price for a workshop with Danny is $225, which may seems steep. I would say if you can learn to run injury free, well that's simply priceless.

Source

Exercise

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

In This Report

Highlights
Introduction
Recommended Exercise Method...
Exercise's Effects on the H...
Exercise's Effects on Diabe...
Exercise's Effects on Bones...
Exercise's Effects on the L...
Exercise's Effects on Weigh...
Exercise's Effects on Other...
Complications
Motivation
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Chronic Conditions and Exercise:

A new study found that aerobic and resistance training significantly reduced fatigue in men undergoing radiation treatments for prostate cancer. Fatigue is a common side effect of such treatments.
Doctors at the Mayo Clinic found that exercise improves the physical and emotional well-being of patients with Alzheimer's disease. The patients exercised for as little as 60 minutes each week. Doctors noted improvements in areas ranging from depression to wandering.

Exercise and Smoking:

A 2007 review of existing studies found that moderate exercise, for as little as 5 minutes, can help combat the nicotine withdrawal symptoms people experience when they try to stop smoking.

Exercise and Aging:

A 2006 report found that older and elderly adults who exercised twice a week for 4 months significantly increased their body strength, flexibility, balance, and agility. The average age of the study participants was 83.5.

Before and After Exercising:

You should do warm-up exercises for 5 - 10 minutes at the beginning of an exercise session. Low-level aerobic exercise is the best warm-up.
To cool down, you should walk slowly until your heart rate is 10 - 15 beats above your resting heart rate. Stopping too suddenly may sharply reduce blood pressure or cause muscle cramping.
You must be careful when stretching during your warm-up to avoid injuring cold muscles.

Definitions:

Aerobic exercise: Aerobic exercise forces the heart and lungs to work harder for longer periods. It builds endurance, improves blood flow throughout the body, and increases the levels of "good" cholesterol.
Resistance Training: Resistance training works muscles against a force (usually weights). It burns fat and builds muscle.

Introduction

Everyone's goal of living a long and healthy life should include a healthy diet, regular exercise, and maintaining normal weight. The combination of inactivity and eating the wrong foods is the second most common preventable cause of death in the United States (smoking is the first).

Most research on the benefits of exercise focuses on heart protection. Studies clearly show that exercise helps the heart. In addition, new studies are reporting that even people at higher risk for heart disease may lower their risk of dying from it if they exercise.

Evidence suggests that our genes evolved to favor exercise. In other words, during prehistoric times, if a person couldn't move quickly and wasn't strong, he or she died. Those who were fit survived to reproduce and pass on these "fitter" genes. Some researchers believe that with our current inactive lifestyle, these genes produce a number of bad effects, which can lead to many chronic illnesses.

The benefits of exercise include:

Improved oxygen delivery throughout the body
Improved metabolic processes - the way the body breaks down and builds necessary substances
Improved strength and endurance
Decreased body fat
Improved movement of joints and muscles
Improved sense of well-being

In addition, exercise can help change other dangerous lifestyle habits. A 2007 review of existing studies found that moderate exercise, for as little as 5 minutes at a time, can help combat the nicotine withdrawal symptoms people experience when they try to stop smoking.

No one is too young or too old to exercise. The United States Surgeon General recommends at least 30 minutes of moderate exercise, such as brisk walking, nearly every day. However, vigorous exercise carries risks that people should discuss with a doctor. You should always check with your doctor before starting a new exercise program, especially if you have any of the following risk factors:

History of smoking
Obesity
Family history of a long-term disease
A symptom you haven’t told your doctor about
Chest pain
Shortness of breath
Heart palpitations
Blood clots
Infections
Fever
Unexplained weight loss
Foot or ankle sores that won’t heal
Joint swelling
Pain or trouble walking after a fall
Eye injury or eye surgery
Hernia
Hip surgery

Fifty percent of all people who begin a vigorous training program drop out within a year. The key to reaching and maintaining physical fitness is to find activities that are exciting, challenging, and satisfying.

Recommended Exercise Methods

A few simple rules are helpful as you develop your own routine.

Don't eat for 2 hours before vigorous exercise.
Drink plenty of fluids before, during, and after a workout.
Adjust your activity level according to the weather, and reduce it when you are fatigued or ill.
When exercising, listen to the body's warning symptoms, and consult a doctor if exercise causes chest pain, irregular heartbeat, undue fatigue, nausea, unexpected breathlessness, or light-headedness.

Heart rate is the standard guide for determining aerobic exercise intensity. It can be determined by counting one's own pulse or with the use of a heart rate monitor. To feel your own pulse, press the first two fingers of one hand gently down on the inside of the wrist or under the jaw on the right or left side of the front of the neck. You should feel a faint pounding as blood passes through the artery. Each pounding is a beat.

Click the icon to see how to take a radial pulse

Click the icon to see how to take a carotid pulse.

There are different types of heart rates.

Resting heart rate. The average heart rate for a person at rest is 60 - 80 beats per minute. It is usually lower for people who are physically fit, and often rises as you get older. You can determine your resting heart rate by counting how many times your heart beats in one minute. The best time to do this is in the morning after a good night’s sleep before you get out of bed.

Maximum heart rate. To determine your own maximum heart rate per minute subtract your age from 220. For example, if you are 45, you would calculate your maximum heart rate as follows: 220 - 45= 175.

Target heart rate. Your target rate is 50 - 75% of your maximum heart rate. You should measure your pulse off and on while your exercise to make sure you stay within this range. After about 6 months of regular exercise, you may be able to increase your target heart rate to 85% (but only if you can comfortably do so).

Certain heart medications may lower your maximum and target heart rates. Always check with your doctor before starting an exercise program.

Note: Swimmers should use a heart rate target of 75% of the maximum and then subtract 12 beats per minute. The reason for this is that swimming will not raise the heart rate quite as much as other sports because of the so-called "diving reflex," which causes the heart to slow down automatically when the body is immersed in water.


Age	Low	High
	(50% max.)	(75% max.)
20	100	150
30	95	142
40	90	135
50	85	127
60	80	120
Source: American Heart Association

VO2 Max. Serious exercisers may use a VO2 max calculation, which measures the amount of oxygen consumed during intensive, all-out exercise. The most accurate testing method uses computers, but anyone can estimate V02 without instrumentation (with an accuracy of about 95%):

After running at top pace for 15 minutes, round off the distance run to the nearest 25 meters.
Divide that number by 15.
Subtract 133.
Multiply the total by 0.172, then add 33.3.

Olympic and professional athletes train for VO2 max levels above 80. But for the average person interested in fitness, a VO2 max equaling between 50 and 80 is considered an excellent score for overall fitness.

Click the icon to see an image on exercise and heart rate.

Warming up and cooling down are important parts of every exercise routine. They help the body make the transition from rest to activity and back again, and can help prevent soreness or injury, especially in older people.

Warm-up exercises should be practiced for 5 - 10 minutes at the beginning of an exercise session. Older people need a longer period to warm up their muscles. Low-level aerobic exercise such as brisk walking, swinging the arms, or jogging in place, is the best approach.
To cool down, you should walk slowly until the heart rate is 10 - 15 beats above your resting heart rate. Stopping too suddenly can sharply reduce blood pressure, and is dangerous for older people. It may also cause muscle cramping.
Stretching may be appropriate for the cooling down period, but it must be done carefully for warming up because it can injure cold muscles. (There is no clear evidence, however, that stretching reduces muscle injuries.)

Warming up before exercise and cooling down after is just as important as the exercise itself. By properly warming up the muscles and joints with low-level aerobic movement for 5 - 10 minutes, one may avoid injury and build endurance over time. Cooling down after exercise by walking slowly, then stretching muscles, may also prevent strains and blood pressure fluctuation.

For most people, exercise may be divided into three general categories:

Aerobic or endurance
Strength or resistance
Flexibility

A balanced program should include all three. Speed training is also a major category, but generally only competitive athletes practice it.

Benefits of Aerobic Exercise. Regular aerobic exercise provides the following benefits:

Builds endurance
Keeps the heart pumping at a steady and high rate for a long time
Boosts HDL ("good") cholesterol levels
Helps control blood pressure
Strengthens the bones in the spine
Helps maintain normal weight
Improves one's sense of well-being

Types of Aerobic Exercise. Aerobic exercise is usually categorized as high or low impact. Examples of each include the following:

Low- to moderate-impact exercises: Walking, swimming, stair climbing, step classes, rowing, and cross-country skiing. Nearly anyone in reasonable health can engage in some low- to moderate-impact exercise. Brisk walking burns as many calories as jogging for the same distance and poses less risk for injury to muscle and bone.
High-impact exercises: Running, dance exercise, tennis, racquetball, squash. High-impact exercises should be performed no more than every other day, and less often for those who are overweight, elderly, out of condition, or have an injury or other medical problem that would rule out high-impact.

Click the icon to see an image of aerobic exercise.

Aerobic Regimens. As little as one hour a week of aerobic exercises is helpful, but 3 - 4 hours per week are best. Some research indicates that simply walking briskly for 3 or more hours a week reduces the risk for coronary heart disease by 65%. In general, the following guidelines are useful for most individuals:

For most healthy young adults, the best approach is a mix of low- and higher-impact exercise. Two weekly workouts will maintain fitness, but three to five sessions a week are better.
People who are out of shape or elderly should start aerobic training gradually. For example, they may start with 5 - 10 minutes of low-impact aerobic activity every other day and build toward a goal of 30 minutes per day, three to seven times a week. (For heart protection, frequency of exercises may be more important than duration.)
Swimming is an ideal exercise for many elderly and certain people with physical limitations, including pregnant women, individuals with muscle, joint, or bone problems, and those who suffer from exercise-induced asthma.
People who seek to lose weight should aim for six to seven low-impact workouts a week.

One way of gauging the optimal intensity of exercise is to aim for a "talking pace," which is enough to work up a sweat and still be able to converse with a friend without gasping for breath. As fitness increases, the "talking pace" will become faster and faster.

Shoes. All that's really necessary for a workout is a good pair of shoes that are made well and fit well. They should be broken in, but not worn down. They should support the ankle and provide cushioning for impact sports such as running or aerobic dancing. Airing out the shoes and feet after exercising reduces chances for skin conditions such as athlete's foot.

Clothing. Comfort and safety are the key words for workout clothing. For outdoor nighttime exercise, a reflective vest and light-colored clothing must be worn. Bikers, roller bladers, and equestrians should always wear safety devices such as helmets, wrist guards, and knee and elbow pads. Goggles are mandatory for indoor racquet sports. For vigorous athletic activities, such as football, ankle braces may be more effective than tape in preventing ankle injuries.

Aerobic-Exercise Equipment. Home aerobic exercise machines can be adapted to any fitness level and used day or night. Before investing in any exercise machine, however, it is wise to first test it at a gym. In addition, initial supervised training when using these machines can reduce the risk of injury that might occur with self-instruction.

Very inexpensive exercise machines tend to be flimsy and hard to adjust, but many sturdy machines are available at moderate prices. The higher-end models may utilize computers to record calories burned, speed, and mileage. While their readouts may provide motivation and gauge the intensity of a workout, however, they are not always accurate.

The following are a few observations on specific equipment:

A good floor mat is important to provide cushioning for all home exercises.
A simple jump rope improves aerobic endurance for people who are able to perform high-impact exercise. Jumping rope should be done on a floor mat plus a surface that has some give to avoid joint injury.
For burning calories, the treadmill has been ranked best, followed by stair climbers, the rowing machine, cross-country ski machine, and stationary bicycle. (Elliptical trainers, however, may be even better than treadmills for increasing heart rate, calorie expenditure, and oxygen consumption.)
Stationary bikes condition leg muscles and are fairly economical and easy to use safely. The pedals should turn smoothly, the seat height should adjust easily, and the bike's computer should be able to adjust intensity.
Stair machines also condition leg muscles. They offer very intense, low-impact workouts and may be as effective as running with less chance of injury.
Rowing and cross-country ski machines exercise both the upper and lower body.


Aerobic dancing	Sufficient cushioning to absorb shock and pressure that are many times greater than ordinary walking. Arches that maintain side-to-side stability. Thick upper leather support. Toe-box. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combination hiking/cycling shoes may be sufficient for casual bikers. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Sufficient traction on sole to prevent slipping. Consider insoles or orthotics with arch support for problem feet.
Tennis	Allow side-to-side sliding. Low-traction soles. Snug fitting heels with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch ankle bone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Benefits of Strength Exercise. While aerobic exercise increases endurance and helps the heart, it does not build upper body strength or tone muscles. Strength-training exercises provide the following benefits:

Build muscle strength while burning fat
Help maintain bone density
Improve digestion

It is also associated with a lower risk for heart disease, possibly because it lowers LDL (the so-called "bad") cholesterol levels.

Click the icon to see an image of cholesterol.

Strength exercise is beneficial for everyone, even people in their 90s. It is the only form of exercise that can slow and even reverse the decline in muscle mass, bone density, and strength that occurs with aging. Please note: People at risk for cardiovascular disease should not perform strength exercises without checking with a doctor.

Types of Muscle Contractions. There are three types of muscle contractions involved in strength training:

Isometric contractions do not change the length of the muscle. An example is pushing against a wall.
Concentric contractions shorten muscles. An example is the "up" phase of a bicep curl.
Eccentric contractions lengthen muscles. An example is the "down" phase as weights are lowered.

Click the icon to see an image of isometric exercise.

Strength-Training Regimens. Strength training involves intense and short-duration activities. For beginners, adding 10 - 20 minutes of modest strength training two to three times a week may be appropriate. The following are some guidelines for starting a strength regimen:

The sequence of a strength training session should begin with training large muscles and multiple joints at higher intensity and end with small muscle and single joint exercises at lower intensities.
Both shortening and lengthening muscle actions should be performed. Emphasizing the movements that lengthen muscles is of increasing interest. This approach involves slowing and increasing the duration of these "down" movements. It appears to significantly increase blood flow, and some evidence suggests it may achieve stronger muscles more quickly. It may also improve heart function compared to standard movements. Exercises that lengthen muscles may be particularly beneficial for older people and some people with chronic health problems. This type of training increases the risk for muscle soreness and injury, however, and this approach is still controversial.
Strength training involves moving specific muscles in the same pattern against a resisting force (such as a weight) for a preset number of times. This is called a repetition. Students should first choose a weight that is about half of what would require a maximum effort in one repetition. In other words, if it would take maximum effort to do a single repetition with a 10-pound dumbbell, the person would start with a five-pound dumbbell. In the beginning, most people can start with one set of 8 - 15 repetitions per muscle group with low weights. As individuals are able to perform one or two repetitions over their routine, weights can be increased by 2 - 10%.
Breathe slowly and rhythmically. Exhale as the movement begins. Inhale when returning to the starting point.
The first half of each repetition typically lasts 2 - 3 seconds. The return to the original position lasts 4 seconds.
An alternative technique called "super slow" training stretches out one repetition to a 14-second count. This method places far more stress on the muscle group, so fewer repetitions are needed. A full week of recovery is required before repeating this workout. The goal is to initiate changes in the muscles so that the body continues to burn calories after the exercise. Some people report dramatic results from this approach, but scientific proof of these claims is not available. It is a very tedious workout, and people have a hard time sticking with it. People with high blood pressure should not use this approach.
Joints should be moved rhythmically through their full range of motion during a repetition. Do not lock up the joint while exercising it.
For maximum benefit, one should allow 48 hours between workouts for full muscle recovery.

Click the icon to see the proper way to breathe during exercise.

Strength-Training Equipment. Unlike aerobic exercise, strength training almost always requires some equipment. Strength-training equipment does not, however, have to cost anything.

Any heavy object that can be held in the hand, such as a plastic bottle filled with sand or water, can serve as a weight.
Dumbbells (1 - 10 pounds) and resistance bands are inexpensive, portable, and effective.
Wearable weights help strengthen and tone the upper body.
Ankle weights strengthen and tone muscles in the lower body. Wearable ankle weights should not be worn during high-impact aerobics or jumping.
Hand grips strengthen arms and are good for relieving tension.
A pull-up bar can be mounted in a doorway for chin-ups and pull-ups.

More elaborate and expensive home equipment for working body muscles is also available, costing from $100 to over $1,000. No one should purchase or use strength-training equipment without instruction from a professional.

Benefits of Flexibility Training. Flexibility training uses stretching exercises. Many stretching exercises are particularly beneficial for the back. In general, flexibility training provides the following benefits:

Prevents cramps, stiffness, and injuries
Improves joint and muscle movement (improved range of motion)

Certain flexibility practices, such as yoga and tai chi, also involve meditation and breathing techniques that reduce stress. Such practices appear to have many health and mental benefits. They may be very suitable and highly beneficial for older people, and for patients with certain chronic diseases.

Click the icon to see an image of flexibility exercise.

Flexibility Training Regiments. Doctors recommend performing stretching exercises for 10 to 12 minutes at least three times a week. The following are some general guidelines:

When stretching, exhale and extend the muscles to the point of tension, not pain, and hold for 20 - 60 seconds. (Beginners may need to start with a 5- to 10-second stretch.)
Breathe evenly and constantly while holding the stretch.
Inhale when returning to a relaxed position. Holding your breath defeats the purpose; it causes muscle contraction and raises blood pressure.
When doing stretches that involve the back, relax the spine to keep the lower back flush with the mat, and to work only the muscles required for changing position (often these are only the abdominal muscles).

Studies continue to show that it is never too late to start exercising. A report published in the February 2006 Journal of Aging and Health found that elderly adults who exercised twice a week for four months significantly increased their body strength, flexibility, balance, and agility. The exercise program included walking and lifting weights. The average age of the study participants was 83.5. The study adds further evidence that even small improvements in physical fitness and activity can prolong life and independent living.

Still, about half of Americans over 60 describe themselves as sedentary (inactive). According to a 2004 report by the Centers for Disease Control and Prevention, approximately 12% of people aged 65 - 75 years and 10% of people aged 75 years or older meet current recommendations for strength training.

The following tips for exercising may be helpful:

Any older person should have a complete physical and medical examination, as well as professional instruction, before starting an exercise program.
Start low and go slow. For sedentary, older people, one or more of the following programs may be helpful and safe: Low-impact aerobics, gait (step) training, balance exercises, tai chi, self-paced walking, and lower legs resistance training, using elastic tubing or ankle weights. Even in the nursing home, programs aimed at improving strength, balance, gait, and flexibility have significant benefits.
Strength training assumes even more importance as one ages, because after age 30 everyone undergoes a slow process of muscular erosion. The effect can be reduced or even reversed by adding resistance training to an exercise program. As little as one day a week of resistance training improves overall strength and agility. Strength training also improves heart and blood vessel health.
Power training, which aims for the fastest rate at which a muscle or muscle group can perform work, may be particularly helpful for older women in strengthening muscles and preventing falls.
Flexibility exercises promote healthy muscle growth and help reduce the stiffness and loss of balance that accompanies aging.
Chair exercises may be performed by people who are unable to walk.
Older women are at risk for incontinence accidents during exercise. This can be reduced or prevented by performing Kegel exercises, limiting fluids (without risking dehydration), going to the bathroom frequently, and using leakage prevention pads or insertable devices.

Exercise's Effects on the Heart

Inactivity is one of the major risk factors for heart disease. However, exercise helps improve heart health, and can even reverse some heart disease risk factors.

Like all muscles, the heart becomes stronger as a result of exercise, so it can pump more blood through the body with every beat and continue working at maximum level, if need be, with less strain. The resting heart rate of those who exercise is also slower, because less effort is needed to pump blood.

A person who exercises often and vigorously has the lowest risk for heart disease, but any amount of exercise is beneficial. Studies consistently find that light-to-moderate exercise is even beneficial in people with existing heart disease. Note, however, that anyone with heart disease should seek medical advice before beginning a workout program.

The heart is a large muscular organ that pumps blood throughout the body. Valves inside the heart open and close. This controls how much blood enters or leaves the heart.

Exercise has a number of effects that benefit the heart and circulation (blood flow throughout the body). These benefits include improving cholesterol and fat levels, reducing inflammation in the arteries, assisting weight loss programs, and helping to keep blood vessels flexible and open. Studies continue to show that physical activity and avoiding high-fat foods are the two most successful means of reaching and maintaining heart-healthy levels of fitness and weight.

The American Heart Association recommends that individuals perform moderately-intense exercise for at least 30 minutes on most days of the week. This recommendation supports similar exercise guidelines issued by the Centers for Disease Control and Prevention, and the American College of Sports Medicine.

Coronary Artery Disease. People who maintain an active lifestyle have a 45% lower risk of developing heart disease than do sedentary people. Experts have been attempting to define how much exercise is needed to produce heart benefits. In 2002, a well-conducted study on overweight adults confirmed previous research that reported beneficial changes in cholesterol and lipid levels, including lower LDL levels (bad cholesterol), even when people performed low amounts of moderate- or high-intensity exercise such as walking or jogging 12 miles a week. However, more intense exercise is required to significantly change cholesterol levels, notably increasing HDL (good cholesterol). An example of this kind of program would be jogging about 20 miles a week. Such benefits in the study occurred even with very modest weight loss, suggesting that overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising.

Some studies suggest that for the greatest heart protection, it is not the duration of a single exercise session that counts but the total daily amount of energy expended. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people.

Resistance (weight) training has also been associated with heart protection. It may offer a complementary benefit to aerobics by reducing LDL levels. Exercises that train and strengthen the chest muscles may prove to be very important for patients with angina.

Effects of Exercise on Blood Pressure. Regular exercise helps keep arteries elastic (flexible), even in older people. This, in turn, ensures good blood flow and normal blood pressure. Sedentary people have a 35% greater risk of developing high blood pressure than athletes do.

Click the icon to see the risks associated with untreated hypertension.

It should be noted that high-intensity exercise may not lower blood pressure as effectively as moderate-intensity exercise. In one study, moderate exercise (jogging 2 miles a day) controlled high blood pressure so well that more than half the patients who had been taking drugs for the condition were able to discontinue their medication. However, a small study published in 2005 suggests that moderate exercise does not have a significant impact on systolic blood pressure (the top number) in older adults. While those who exercised did have notable drops in both the top and lower (diastolic) blood pressure levels, the only statistically significant change was the decrease in the lower number.

Experts recommend at least 30 minutes of exercise on most -- if not all -- days. Studies show that yoga and tai chi, an ancient Chinese exercise involving slow, relaxing movements, may lower blood pressure almost as well as moderate-intensity aerobic exercises.

Click the icon to see an image of someone practicing yoga.

Anyone with existing high blood pressure should discuss an exercise program with their doctor. Before starting to exercise, people with moderate-to-severe high blood pressure should lower their pressure, and be able to control it with medications. Everyone, and especially people with high blood pressure, should breathe as normally as possible through each exercise. Holding the breath increases blood pressure.

Effects of Exercise on Heart Failure. Traditionally, heart failure patients have been discouraged from exercising. Now, exercise performed under medical supervision is proving to be helpful for select patients with stable heart failure.

Studies continue to report benefits from exercise training. In one study, heart failure patients as old as 91 years old increased their oxygen use significantly, after 6 months of supervised treadmill and stationary bicycle exercises.
Progressive resistance training may be particularly useful for heart failure patients, since it strengthens muscles, which commonly weaken in this disorder. Even simply performing daily handgrip exercises can improve blood flow through the arteries.

Experts warn, however, that exercise is not appropriate for all heart failure patients.

All stroke survivors should have a pre-exercise evaluation done by their doctor before starting an exercise program.

The effects of exercise on stroke are less established than those on heart disease, but most studies show benefits. The following are some examples:

According to one major analysis, men cut their risk for stroke in half if their exercise program was roughly equivalent to about an hour of brisk daily walking 5 days a week. In the same study, exercise that involved recreation was more protective against stroke than exercise routines consisting simply of walking or climbing.
A 2000 study of women also found substantial protection from stroke in brisk walking or striding (rather than casual walking).

Anyone with heart disease or risk factors for developing heart disease or stroke should seek medical advice before beginning a workout program. Patients with heart disease can nearly always exercise safely as long as they work out under medical supervision. Still, it is often difficult for a doctor to predict health problems that might arise as the result of an exercise program. At-risk individuals should be very aware of any symptoms warning of harmful complications while they exercise.

Some experts believe that anyone over 40 years old, whether or not they are at risk for heart disease, should have a complete physical examination before starting or intensifying an exercise program. Some doctors use a questionnaire for people over 40 to help determine whether they require such an examination. The questions they use are as follows:

Has any doctor previously recommended medically supervised activity because of a heart condition?
Is chest pain brought on by physical activity?
Has chest pain occurred during the previous month?
Does the person faint or fall over from dizziness?
Is bone or joint pain intensified by exercise?
Has medication been prescribed for hypertension (high blood pressure) or heart problems?
Is the person aware of or has a doctor suggested any physical reason for not exercising without medical supervision?

Those who answer "yes" to any of the above questions should have a complete medical examination before developing an exercise program.

Stress Test. A stress test helps determine the risk for a heart problem resulting from exercise. Anyone with a heart condition or history of heart disease should have a stress test before starting an exercise program. Experts currently also recommend this test before a vigorous exercise program for older persons who are sedentary, even in the absence of known or suspected heart disease. The test is expensive, however, and some experts believe that it may not be necessary for many older people with no evident health problems or risk factors.

A small percentage of heart attacks occur after heavy physical work.

High-Risk Individuals. In general, the following people should avoid intense exercise or start it only with careful monitoring:

People who have certain medical conditions: These conditions include uncontrolled diabetes, uncontrolled seizures, uncontrolled high blood pressure, a heart attack within the previous 6 months, heart failure, unstable angina, significant aortic valve disease, or aortic aneurysm.
People with moderate-to-severe hypertension: Experts generally recommend that moderate or severe high blood pressure (systolic blood pressure over 160 mm Hg or diastolic (bottom number) pressure over 100 mm Hg) should be brought to lower levels before a person starts a vigorous exercise program.
Sedentary people should be cautious. One major study found that sedentary people who throw themselves into a grueling workout significantly increase their risk of heart attack.
Episodes of exercise-related sudden death in young people are rare but of great concern. Some are preceded by fainting, which is due to a sudden and severe drop in blood pressure. It should be noted that fainting is relatively common in athletes, and is dangerous only in people with existing heart conditions. Young people with genetic or congenital (present at birth) heart disorders should avoid intensive competitive sports.
Anabolic steroids or products containing ephedra have been associated with cases of stroke, heart attack, and even death.

The risk for heart attack from exercise should be kept in perspective, however. Some form of exercise, carefully personalized, has benefits for most of the individuals mentioned above. In many cases, particularly when the only risk factors are a sedentary lifestyle and older age, exercise can often be increased over time until it is intense.

Hazardous Activities for High-Risk Individuals. The following activities may pose particular dangers for high-risk individuals:

Intense workouts (snow shoveling, slow jogging, speed walking, tennis, heavy lifting, heavy gardening) may be particularly hazardous for people with risk factors for heart disease, especially older people. They tend to stress the heart, raise blood pressure for a brief period, and may cause spasms in the arteries leading to the heart. (See image: Coronary Artery Spasm)
Some studies suggest that competitive sports, which couple intense activity with aggressive emotions, are more likely to trigger a heart attack than other forms of exercise.

Listening for Warning Signs. It should be noted that according to one study, at least 40% of young men who die suddenly during a workout have previously experienced, and ignored, warning signs of heart disease. In addition to avoiding risky activities, the best preventive tactic is simply to listen to the body and seek medical help at the first sign of symptoms during or following exercise. These symptoms include the following:

Irregular heartbeat
Shortness of breath
Chest pain

Click the icon to see an image of a coronary artery spasm.

Click the icon to see an image of stable angina.

Exercise's Effects on Diabetes

Moderate aerobic exercise can lower your risk for type 2 diabetes. An important study found that adults who worked out 2 and 1/2 hours a week cut their risk by 58%.

Exercise has positive benefits for those who have diabetes. It can lower blood sugar, improve insulin sensitivity, and strengthen the heart. Strength training, which increases muscle and reduces fat, may be particularly helpful for people with diabetes, but more evidence is needed to confirm this theory. One study reported that yoga helped patients with type 2 diabetes reduce their need for oral medications.

In 2005, researchers found that people with type 2 diabetes who walked a minimum of 3 miles every day were in better health, and had lower medical expenses, after 2 years of such exercise. Those who remained sedentary for that time period experienced a decline in their overall health and higher health care-related expenses. Study participants who worked out for an average of 38 minutes per day lowered their blood pressure, cholesterol ,and A1C levels (glucose concentration over time). These participants also had lower heart disease risk, even if they didn't lose weight. The increase in the study participants' activity equaled about 2,200 extra steps a day. The findings were reported in the journal Diabetes Care.

An earlier study found that healthy lifestyle changes may work better than the prescription medication metformin (Glucophage), when it comes to preventing metabolic syndrome. Metabolic syndrome is a combination of risk factors including abdominal obesity, insulin resistance, high triglycerides, and hypertension.

The following are precautions for all people with diabetes, whether type 1 or 2:

Because people with diabetes are at higher than average risk for heart disease, they should always check with their doctors before starting a demanding exercise program. For best and fastest results, frequent high-intensity (not high-impact) exercises are best for people who are cleared by their doctor. For people who have been sedentary, or have other medical problems, lower-intensity exercises are recommended, using programs the patients designed with their doctors.
Strenuous strength training or high-impact exercise is not recommended for people with uncontrolled diabetes. Such exercises can strain weakened blood vessels in the eyes of patients with retinopathy (a common diabetic complication). High-impact exercise may also injure blood vessels in the feet.

Patients who are taking medications that lower blood glucose, particularly insulin, should take special precautions before starting a workout program.

Glucose levels swing dramatically during exercise. People with diabetes should monitor their levels carefully before, during, and after workouts.
Patients should probably avoid exercise if glucose levels are above 300 mg/dL or under 100 mg/dL.
To avoid hypoglycemia (low blood sugar), people with diabetes should inject insulin in sites away from the muscles they use the most during exercise.
People with diabetes should drink plenty of fluids. Before exercising, they should avoid alcohol, which increases the risk of hypoglycemia.
Insulin-dependent athletes may need to decrease insulin doses, or take in more carbohydrates, prior to exercise. However, they may need to take an extra dose of insulin after exercise. Stress hormones released during exercise may increase blood glucose level (in people without diabetes, insulin is released to control this increase). People with diabetes must regularly test their blood sugar, and take any medications as instructed by their doctor.

A person with diabetes must regularly check their blood sugar (glucose) level.

Exercise's Effects on Bones and Muscles

Exercise is critical for strong muscles and bones. Muscle strength declines as people age, but studies report that when people exercise they are stronger and leaner than others in their age group.

Exercise helps kids lower their risk of chronic pain in the future. Research has shown that it helps them prevent back and neck pain. The more flexible men are as teenagers, the lower their risk of neck tension in the future, according to a study published in the February 2006 British Journal of Sports Medicine. The same report found that women who had the greatest endurance strength as teenagers had a lower risk of tension neck than those with lower teenager endurance strength. However, men with the greatest endurance strength had higher rates of knee injuries later on.

Joints are complex structures. They are designed to bear weight and move the body. Above the knee is the femur (thigh bone). Below the knee is the tibia (shin bone) and fibula. The kneecap is also called the patella. It rides on top of the lower portion of the femur and the top portion of the tibia. The muscles and ligaments connect these bones and the space between them is cushioned by fluid-filled capsules (synovia) and cartilage. When you exercise, the muscles pull on the bones, strengthening them. The range of motion of a joint represents how far it can be flexed (bent) and extended (stretched).

Joints require motion to stay healthy. Long periods of inactivity cause the arthritic joint to stiffen and the adjoining tissue to weaken. A moderate exercise program that includes low-impact aerobics, power, and strength training has benefits for osteoarthritic patients, even if exercise does not slow down the disease progression. Many patients who start an exercise program report less disability and pain. They are also better able to perform daily chores, and remain independent longer than their inactive peers. Older patients and those with medical problems should always check with their doctor before starting an exercise program.

Click the icon to see an image of osteoporosis.

The following are useful exercises for osteoarthritis patients:

Strengthening exercises builds muscle strength. Some experts encourage patients to emphasize strengthening leg muscles as a first treatment step, even before using pain relievers. They fear that patients who rely on painkilling drugs may overuse knees, which do not have strong enough muscle tissue to protect the joints from further damage. Strengthening the thigh muscles is certainly protective for those who have not developed osteoarthritis.
Range-of-motion exercises increase the amount of movement in a joint and muscle. The best examples are yoga and tai chi, which focus on flexibility, balance, and proper breathing. In one 2001 study, older adults who practiced the gentle movement, breathing, and meditation exercises of tai chi for 10 weeks reported less pain than their peers who did not learn the technique.
Low-impact aerobic workouts help stabilize and support the joints. Cycling and walking are beneficial, and swimming or exercising in water is highly recommended for people with arthritis. Patients with arthritis should avoid high-impact sports, such as jogging, tennis, and racquetball.
Some researchers are now focusing on "power" training, which involves improving the muscle's ability to move more rapidly against resisting forces, such as gravity. For example, such training helps people stand up or climb stairs more quickly. Muscle power declines more rapidly than muscle strength, and may be particularly important in older people.

Exercise is very important for slowing the progression of osteoporosis, and extremely important for reducing the risk of falling, which causes fractures. Falls are one of the leading causes of death in people over the age of 65. Exercise helps build balance and flexibility, which reduces the risk of falling.

Specific exercises may be especially helpful for reducing the risk of fractures:

Weight-bearing exercise is very beneficial for bones in people of all ages, even older people. This approach applies tension to muscle and bone, and the body responds to this stress by increasing bone density, in young adults by as much as 2 - 8% a year. Careful weight training can also be very beneficial for elderly people, particularly women. In addition to improving bone density, weight-bearing exercise reduces the risk of fractures by improving muscle strength and balance, thus helping to prevent falls.
Regular brisk long walks improve bone density and mobility. In one 2002 study, for example, older women reduced their risk of hip fracture by over 40% by working out just four hours a week.
Exercises specifically targeted to strengthen the back can be beneficial in improving posture, and may even reduce kyphosis (hunchback) in people with osteoporosis.
Low-impact exercises, particularly yoga and tai chi, which improve balance and strength, have been found to decrease the risk of falling. In one study, tai chi reduced this risk by almost half.

Click the icon to see an image of the bone-building exercise.

Note on Female Athlete Triad. Some young female athletes who exercise very intensely, and are subject to intense pressure to remain thin, are at risk for the female athlete triad. This syndrome is a combination of three disorders -- an eating disorder, loss of menstrual periods, and osteoporosis.

People who do not exercise regularly face an increased risk for low back pain, especially during times when they suddenly have to perform stressful, unfamiliar activities. These activities may include shoveling, digging, or moving heavy items. Although no definitive studies have been done to prove the relationship between lack of exercise and low back pain, sedentary living is probably a primary nonmedical cause contributing to this condition.

Lack of exercise leads to the following conditions that may threaten the back:

Muscle inflexibility can restrict the back's ability to move, rotate, and bend.
Weak stomach muscles can increase the strain on the back and can cause an abnormal tilt of the pelvis (hip bones).
Weak back muscles may increase the load on the spine and the risk of disk compression.
Obesity puts more weight on the spine and increases pressure on the vertebrae and disks. Studies report only a weak association between obesity and low back pain, however.

Benefits for Chronic Back Pain. People in with sudden and severe back pain should not exercise. Exercise plays a very beneficial role in relieving chronic back pain, however. In one study, patients with back pain lasting for an average of 18 months were assigned eight 1-hour exercise sessions over 4 weeks. They showed greater improvement in nearly every area, including reduced pain, compared to patients who did not exercise.

Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but they also alter and improve the patients' attitudes toward their disability and pain.

Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support the spine. Some exercise programs used for prevention or treatment of chronic low back pain include the following:

Low-impact Aerobic Exercises: Low-impact aerobic exercises, such as swimming, bicycling, and walking, can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. In one study, for example, pregnant women who engaged in a water gymnastics program had less back pain, and were able to continue working longer.
Lumbar Extension Strength Training: Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, and improve lower back mobility, strength, and endurance. They also enhance flexibility in the hip and hamstring muscles, and in the tendons at the back of the thigh.
Yoga, Tai Chi, and Chi Kung: These exercises combine low-impact physical movements and meditation. They are based on principles of disciplining the mind to achieve a physical and mental balance, and can be very helpful in preventing recurrences of low back pain. In one study of Pilates, an exercise practice that uses yoga principles, the exercises were helpful in a woman with progressive and disabling severe low back pain resulting from early scoliosis. This approach deserves further research.
Flexibility Exercises: Whether flexibility exercises alone offer any significant benefit for chronic back pain is uncertain. One study suggested that any benefits derived from flexibility exercises are lost unless the exercise programs are sustained.
Retraining Deep Muscles: Studies are finding a link between low back pain and poor motor control of deep muscles in the back and trunk. According to these studies, contraction exercises specifically designed to retrain these muscles may be effective for patients with both acute and chronic pain.

It is important for any person who has low back pain to have an exercise program guided by professionals who understand the limitations and special needs of back pain and who can address individual health conditions. One study indicated that patients who planned their own exercise did worse than those in physical therapy or doctor-directed programs.

Hazardous Effects on the Back. Improper or excessive exercise can also cause back pain.

Exercise's Effects on the Lungs

Patients with chronic lung problems have difficulty exercising. Shortness of breath is a major limitation in most patients, but in about a third, muscle fatigue is an even greater problem. Although exercise does not improve lung function, training helps many patients with chronic lung disease by strengthening their limb muscles, thus improving endurance and reducing breathlessness.

In people who already have colds, exercise has no effect on the illness' severity or duration. People should avoid strenuous physical activity when they have fevers, muscle aches, or other symptoms of a widespread viral illnesses.

Long-term exercise may help control asthma and reduce hospitalization. One 2000 study found that aerobic exercise improves breathing capacity and function in patients with mild asthma. People with asthma who enjoy running should probably choose an indoor track, to avoid pollutants. Swimming is particularly excellent for people with asthma. Yoga practice, which uses both stretching, breathing, chest expansion, and meditation techniques may have specific benefits that include stress reduction as well as airway opening. One study reported that two thirds of patients who practiced yoga regularly were able to reduce or eliminate their asthma medications.

Exercise-Induced Asthma. About 40 - 90% of asthma cases are exercise-induced asthma (EIA), in which exercise triggers coughing, wheezing, or shortness of breath. It occurs most often in children and young adults and during intense exercise in cold dry air. EIA is triggered only by exercise. Unlike allergic asthma, there is no long-term increase in airway activity. People who only have EIA do not require long-term maintenance therapy. The warm-up and cool-down periods, which are important for any exercise regimen, may help reduce EIA events. A study of military recruits found that exercise-induced asthma attacks did not hinder their ability to perform or train, suggesting that EIA is not a reason to exclude people from physically demanding occupations.

Exercise-induced asthma is distinct from allergic asthma in that it does not produce long-term increase in airway activity. People who only experience asthma when they exercise may be able to control their symptoms with preventive measures such as warm-up and cool-down exercises.

Walking is the best exercise for people with emphysema. Patients should try to walk three to four times daily for 5 - 15 minutes each time. Devices that assist ventilation may reduce breathlessness that occurs during exercise.

Inspiratory muscle training involves exercises and devices that make inhaling (breathing in) more difficult, in order to strengthen breathing muscles. In a 2001 study, patients who took part in an inspiratory muscle training group improved their breathing, walking capacity, and quality of life. Yoga or martial arts exercises, such as tai chi, which emphasize breathing techniques and balanced movements, may be particularly beneficial for patients with emphysema.

Exercise's Effects on Weight

Exercising helps people reduce their weight, maintain weight loss, and fight obesity. Research has shown that women who regularly exercise but do not change their diet can lose significantly more weight than less active women.

Thirty minutes of moderate-intensity exercise may be adequate to maintain cardiovascular health, but it might not prevent weight gain. Recommendations published in 2003 and 2004 suggest that 45 - 60 minutes of exercise per day is necessary to promote weight loss. Children may need more activity.

Losing significant weight requires both exercise and calorie restriction. In addition, if a person exercises without dieting, any actual weight loss may be minimal because dense and heavier muscle mass replaces fat. Nonetheless, regardless of weight loss, a fit body will look more toned and be healthier.

People who exercise are more apt to stay on a diet plan. Exercise improves psychological well-being and replaces sedentary habits that usually lead to snacking. Exercise may even act as a mild appetite suppressant.

Exercising without dieting still adds health benefits. One study found that overweight but fit people have half the death rate of overweight, unfit people. Research suggests that people who have trained for a long time develop more efficient mechanisms for burning fat and are able to stay leaner.

Lifting weights builds muscle, which burns calories more efficiently than other body tissues.

The following are some suggestions and observations on exercise and weight loss:

The treadmill burns the most calories of standard aerobic machines. It may be particularly effective when used in short multiple bouts during the day. Exercise sessions as short as 10 minutes, which are done frequently (about four times a day), may be the most successful program for obese people.
The more strenuous the exercise, the longer the body continues to burn calories before returning to its resting level. This state of fast calorie burning can last for as little as a few minutes after light exercise, to as long as several hours after prolonged or heavy exercise.
Resistance (strength) training is excellent for replacing fat with muscles. It should be performed two or three times a week.
Fidgeting may be very helpful in keeping pounds off. Regular exercise is certainly the best course, but for people who must sit for hours at work, frequently shifting positions while sitting may have some benefit.
It is important to realize that as people slim down, they burn fewer calories per mile of walking or jogging. The rate of weight loss slows down, sometimes discouragingly so, after an initial dramatic head start using diet and exercise combinations. People should be aware of this trend and keep adding to their daily exercise routine.
Changes in fat and muscle distribution may differ between men and women as they exercise. Men tend to lose abdominal fat (which lowers their risk for heart disease faster than reducing general body fat). Exercise, however, does not appear to have the same effect on weight distribution in women. A study of women who practiced aerobic and strength training showed the training resulted in fat loss in the women's arms and trunk. However, they did not gain muscle tissue in those areas.

Because obesity is one of the risk factors for heart disease, anyone who is overweight must discuss their exercise program with a physician before starting.

Exercise's Effects on Other Conditions

Physical activity makes you healthier. It lowers your risk for cardiovascular disease and reduces bone loss. Physical activity also helps the body use calories more efficiently, which helps you eliminate body fat and lose weight. It also helps you maintain weight loss by increasing your metabolism and reducing your appetite.

A number of studies have indicated that regular exercise may reduce the risk of breast, colon, and possibly prostate cancers.

Studies confirm that exercise significantly reduces the risk of both colon cancer (by up to 50%) and breast cancer (by up to 30%).

A 2006 study found that, though protection from breast cancer may vary among the types of tumor, exercise offered the most marked protection from the more aggressive tumors. A second study, also done in 2006, supported this finding. Several studies also suggested that more intense exercise is more protective against breast cancer. Exercising consistently throughout life gives the best protection. Exercise not only lowers a woman's chance of getting breast cancer, it can help those who have received chemotherapy for the disease fight off fatigue.

While endurance athletes may suffer from stomach problems, low intensity exercise has a marked protective effect against colon cancer, according to studies, including the Nurses Health Study and the American Cancer Society's Cancer Prevention Study II. Furthermore, a 2006 study found that people with colon cancer who exercise reduce their risk of a recurrence.

Exercise also has a beneficial effect on people receiving treatment for prostate cancer. A new study found that aerobic and resistance training significantly reduced fatigue in men undergoing radiation treatments for prostate cancer. Fatigue is a common side effect of such treatments. In this study, 122 patients received supervised aerobic training, resistance training, or neither. At the end of 24 weeks, participants in both exercise groups noted significant improvement in their fatigue symptoms, compared to the control group. Participants in the resistance training group also lost a significant percentage of their body fat.

Endurance athletes often report stomach problems, such as bloating, diarrhea, and gas, even at rest. Experts suggest that moderate regular exercise might reduce the risk for some intestinal disorders. These disorders include ulcers, irritable bowel syndrome, indigestion, and diverticulosis. Older people who exercise moderately may have a lower risk for severe gastrointestinal bleeding.

Patients with end-stage kidney disease who exercise four to five times per week have better survival rates than those who are less active, according to researchers involved in the Dialysis Morbidity and Mortality Wave 2 study. However, the majority of study participants said that severe physical limitations prevented them from exercising so often.

Studies have shown that regular exercise, particularly walking, helps reduce one's risk for memory loss. A 2005 study found that older men who walked less than a mile daily had a 71% higher risk of dementia than those who walked more than two miles a day. A 2006 study found that people older than 65 who exercise regularly had lower risk of developing dementia, particularly Alzheimer's disease. An earlier study found that walking regularly protects women from mental decline. To date, there are no clear explanations for this apparent benefit. A preliminary study in mice suggests that physical activity changes the way brain-damaging proteins are processed in the brain, thus slowing the development of Alzheimer's disease. Aerobic exercise has been linked with improved reaction time, perception, and math skills in people of all ages.

Doctors found that exercise improves the physical and emotional well-being of patients who already have Alzheimer's disease. The patients exercised moderately for as little as 60 minutes each week. Doctors noted patients who exercised were less depressed, wandered away less, suffered fewer falls, and were placed in nursing homes later, compared to patients who did not exercise.

People with existing neurological diseases, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, should be encouraged to exercise. Specialized exercise programs that improve mobility are particularly valuable for patients with Parkinson's disease. Patients with neurological disorders who exercise experience less stiffness, as well as reduction in, and even reversal of, muscle wasting. In addition, the psychological benefits of exercise are extremely important in managing these disorders. Exercise machines, aquatic exercises, and walking are particularly useful.

Some research has suggested that exercise may have antidepressant effects. Although there is little strong evidence that exercise can help manage depression, a number of studies have suggested benefits. Research findings include:

Just 30 minutes of brisk exercise three times a week was as effective as medication in relieving symptoms, and reducing relapse, in many patients with mild-to-moderate depression.
Over half of older women with depression that did not respond to medication improved with 10 weeks of exercise. (About a third of women who did not exercise also improved during that time.)
Studies on elderly, depressed patients report modest benefits from exercise, even in those who do not response to antidepressants. Simply participating in a group activity may help improve mood.
Teenagers who are active in sports have a greater sense of well-being than their sedentary peers. The more vigorously they exercise, the better their emotional health.
Physical inactivity is strongly linked to depression in children 8 - 12 years of age.

Specific exercises may be particularly beneficial:

Aerobics. Either brief periods of intense training or prolonged aerobic workouts can raise levels of certain chemicals in the brain. These chemicals -- which include endorphins, adrenaline, serotonin, and dopamine -- produce the so-called runner's high. Weight loss and increased muscle tone can boost self-esteem.

Yoga. Yoga practice, which involves rhythmic stretching movements and breathing, has been found to positively affect mood. It may have clinical potential as a technique for improving and stabilizing mood. A study comparing yoga to aerobic exercise found that men have significantly lower levels of tension, fatigue, and anger after yoga, compared with levels after swimming. Yoga and swimming tended to produce equal benefits in women.

Click the icon to see an image of the benefits of yoga.

Moderate exercise in healthy pregnant women does not increase the risk for miscarriage, preterm labor, or rupture of the membrane. Not exercising increases the risk for complications, including low-birth weight babies. Exercising increases the fetal heart rate, which in turn protects the baby.

Healthy women with normal pregnancies should exercise at least three times a week, being careful to warm up, cool down, and drink plenty of liquids. Many prenatal calisthenics programs are available.

The following are specific exercises that may benefit the pregnant woman:

Swimming and water aerobics may be the best option for most pregnant women. Swimming has special benefits for those with fluid buildup. Water exercises involve no impact, overheating is unlikely, and swimming face down promotes optimum blood flow to the uterus.
Performing yoga exercises under the guidance of informed instructors can be very helpful.
Walking is also beneficial.

To strengthen pelvic muscles, women should perform Kegel exercises at least six times a day. This involves contracting the muscles around the vagina and urethra for three seconds 12 - 15 times in a row.

Experts generally recommend the following precautions for pregnant women who exercise:

Fit women who have exercised regularly before pregnancy may work out intensely as long as the doctor approves and no discomfort occurs.
As a rule for previously sedentary, low-risk expectant mothers, the pulse rate should not exceed 70 - 75% of the maximum heart rate, or more than 150 beats per minute. Any sedentary expectant mother should check with her doctor before starting an exercise program.
According to one study, vigorous exercise may improve the chances for a timely delivery. All pregnant women, however, should avoid high-impact, jerky, and jarring exercises, such as aerobic dancing, which can weaken the pelvic floor muscles that support the uterus.
During exercise, women should monitor their temperature to avoid overheating, a side effect that can damage the fetus. (Pregnant women should also not use hot tubs or steam baths, which can cause fetal damage and miscarriage.)

Note: Strenuous exercise may affect the flavor of breast milk for a short time afterward. Nursing mothers who engage in such activity might want to wait about an hour after exercising before they feed their infant.

Complications

Exercise may lead to injury if not done properly. Always exercise with care.

Competitive running or high-impact aerobics pose a high risk of a number of injuries to the bones and muscle. The effect of high-impact exercise on the back is not entirely clear. Some research suggests that over time, high-impact exercise may increase the risk for degenerative disk disease. A survey of people who played tennis, however, found no increased risk for low back pain or sciatica.

High-impact exercise can also cause dizziness, ringing in the ear, motion sickness, or loss of high-frequency hearing.

Some research further suggests that in people unused to exercise, intense activity increases production of harmful particles in the body called free radicals. These unstable oxygen particles injure muscle tissue. Muscle pain in this case does not occur until 24 - 48 hours after exercise.

Some people have a higher than average risk for injury:

About half of people at any age who participate in competitive running or high-impact aerobics experience minor injuries at least once a year. Young, intensely competitive athletes may be at risk for permanent injury. Studies are mixed over whether intensive high-impact sports in younger people cause long-term degenerative joint disease.
As the number of older people who start exercising increases, there has also been an increase in injuries for this age group. Between 1990 and 1996, injuries from active sports increased by 54% in people age 65 and older.
Women are far more likely than men to suffer knee injuries.
Urinary incontinence affects many female athletes who engage in high-impact exercise.
Tennis players are at high risk for injuries from repetitive force on the shoulder joint.

Preventing High-Impact Injuries. The following may be helpful for preventing injury:

Wear shock-absorbing footwear with weight-dampening inserts.
Combine weight lifting with jumping exercises. This may prevent injury by strengthening hamstrings and improving coordination.
Vary training and alternate easy and harder workouts.
Be careful to warm up, cool down, and stretch. Flexibility is the key to preventing many muscle strains.
Take days off now and then. The risk of injury increases when athletes train more than five times a week.

Because of the association between high-impact exercises and oxidation, some experts suggest eating foods rich in antioxidants, such as vitamins A, C, and E. Such foods, which may protect against damage from free radicals, include many fresh fruits and vegetables.

Treating Minor Injuries. Most mild or moderate injuries respond well to a simple, four-step treatment: rest, ice, compression, and elevation (RICE). This combination works well for both spot injuries and chronic problems. Ice packs, which reduce inflammation and pain, can help new injuries, and can be useful for the first few hours after a chronically injured area is exercised. How much or how long to compress the injury is unclear.

Evidence suggests that early movement is helpful, although taping or bracing in people with a recurrent ankle sprain is known to be protective. It may not be helpful in those without a previous ankle injury.

Minor injuries like sprains may be treated at home if broken bones are not suspected. The acronym RICE can help you remember how to treat minor injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is for elevation. Pain and swelling should decrease within 48 hours. Gentle movement may help, but pressure should not be put on a sprained joint until pain is completely gone. This can take up to a few weeks.

Heat, ultrasound, whirlpool, and massage may speed healing if applied a day or two after the initial injury or for warm-up before another workout session.

Some young female athletes who exercise very intensely, and are subject to intense pressure to remain thin, are at risk for a syndrome known as the female athlete triad. This combination of symptoms includes loss of menstruation, eating disorders, and osteoporosis. Eating disorders among young female athletes are estimated at 15 - 62%. Women at higher risk include ballet dancers, gymnasts, and divers. Continued intense exercise causes a stress response in which estrogen (the primary female hormone) is lost. Estrogen loss can lead to infertility and osteoporosis. Iron loss and anemia may also be a problem in women who exercise frequently, even at moderate intensity. A doctor should be consulted for any of these concerns.

Incorrect movements can literally cause mechanical problems in the muscles. These problems are usually the result of improper exercise instruction, and lack of attention. A single jerky golf swing, or the incorrect use of exercise equipment (especially free weights, nautilus, and rowing machines), can cause serious back injuries.

Between 30 - 70% of cyclists experience low back pain. Pain may be improved by adjusting the angle of the bicycle seat.

Everyone should drink lots of fluid during intense exercise. Thirst is often a poor indicator of dehydration in people who exercise, particularly older people. During a tough workout in a hot environment, the body can lose two liters of fluid per hour through sweat.

Anyone who exercises intensely should take the following precautions:

Drink 6 - 8 ounces of fluid about 15 minutes before a workout, and then pause regularly during exercise to drink more.
Water is the best choice for replenishing body fluids. Glucose-sodium-potassium solutions, the so-called "sports drinks," which promise instant energy, appear to be no better than water at improving endurance during prolonged intense running.
Caffeinated beverages like coffee and soft drinks give short bursts of energy, but can actually cause fluid loss. Caffeine before a workout has been shown to temporarily raise blood pressure, and reduces blood flow to inactive limbs.

Contrary to popular belief, drinking fluids will not cause cramps. Drinking enough, in fact, helps prevent the painful involuntary muscle spasms that sometimes occur during exercise.

Overheating, or hyperthermia, can be a problem with hard exercise, or when working out in hot weather. Overheating can cause mild to life-threatening conditions. Heat exhaustion, a moderate form of hyperthermia, is characterized by the following symptoms:

Lightheadedness, nausea, headache, hyperventilation, fatigue, and loss of concentration
A high temperature (above 103° F), possibly accompanied by complaints of chills and clammy skin

Individuals should rest in a cool, dry place, drink plenty of fluids, and bring down their body temperature with ice packs pressed against the skin.

Heatstroke. Heatstroke is the most dangerous complication of hyperthermia. The victim may suddenly stop sweating, after which symptoms such as altered consciousness, seizures, and even coma may quickly follow. Heat stroke is a medical emergency and requires immediate cooling of the victim in an ice-water bath or with ice packs. One study suggests that risk for serious complications from exercising in high temperatures may persist as late as the following day, even if the weather has cooled down.

Click the icon to see an image of the dangers of heatstroke.

Precautions are also necessary in cold weather. When exercising in winter dress in layers, including gloves and socks, which create insulated air pockets that trap heat. In cold weather, wear shoes with less ventilation than those worn in the summer. Fingers, toes, ears, and nose are most susceptible to frostbite. Frostbite progresses from stinging or aching to numbness. Fingers and toes may become white. Soaking the hands and feet in warm water can help, but only once there is no risk of refreezing, since a second bout of frostbite after thawing can quicken tissue damage.

Hypothermia can be life-threatening and can occur even after long exposure to temperatures that are above freezing. The condition is characterized by extreme fatigue, mental confusion, apathy, and a lack of coordination. The victim should be warmed as soon as possible with blankets, body heat, and warm fluids.

Motivation

Motivation, or a lack thereof, is one reason many people stop exercising. Here are some tips for avoiding burnout:

Think of exercise as a menu rather than a diet. Choose a number of different physical activities that are personally enjoyable such as sports, dancing, or biking. Although experts say you should get 30 minutes of aerobic exercises at least five times a week, those times can be divided into shorter periods -- such as 10 minute sessions. In addition, people can achieve health benefits from other exercise programs, including weight training, yoga, or tai chi.
Stick to a prepared schedule and record progress.
Develop an interest or hobby that requires physical activity.
Adopt simple routines such as climbing the stairs instead of taking the elevator, walking instead of driving to the local newsstand, or canoeing instead of zooming along in a powerboat.
Try cross training (regularly switching from one type of exercise to another). Studies suggest it is more beneficial than focusing only on one form of exercise.
Exercise with friends.
Join a gym or take classes. Many affordable programs are available.
For those who can afford them, personal trainers can be very helpful and are available in many gyms and exercise clubs. Personal trainers without any connection to a well-reputed gym or fitness club should be certified by a major fitness organization, such as the Aerobics and Fitness Association of America (AFAA) or the American Council on Exercise.
Exercise videos may also be helpful, but people should be sure they are suited to their individual age and health needs, and bear the seal of the AFAA.
Consider getting a dog. A study in the February 2006 American Journal of Preventive Medicine found that dog owners in Canada walk almost twice as much as those who don’t own a dog. Regular walking is a good way to improve health.

Differences in Motivation Between Men and Women. Motivation factors may differ by gender, and women appear to have a harder time. In one study, weight loss was the greatest motivator to exercise for women, and muscle tone was the primary motivator for men. Unfortunately, effects on appearances may take a long time to show, discouraging people from continuing an exercise program even though their health is improving.

Overweight among children and adolescents has now become an epidemic in the United States. Experts say that children should be vigorously active for at least 20 - 60 minutes 3 - 5 days a week. Parents and schools must be imaginative and rigorous in encouraging children to exercise.

Role of Parents. Parents must make conscious efforts to limit sedentary activities, and to encourage physical ones for their children. This includes monitoring the time children spend on the computer, in front of the TV, or playing video games. Parents should suggest different forms of entertainment. Even children who aren't interested in joining a Little League team may enjoy a round of catch with their parents, walking in the park, or swimming in a local lake.

Role of Schools. Early school physical education programs can make a significant difference and the earlier these routines are learned, the more likely they will be carried forth into a healthy adulthood. Schools should emphasize team cooperation or individual improvement and self-mastery. Studies have shown that people tend to give up more quickly and feel less competent if their perceptions of success are based only on comparison to their peers.

People mature at different rates, and there seems to be a genetic component to coordination, strength, speed, and one's response to resistance exercise. Nonetheless, everyone should strive to be as fit as they possibly can, given their strengths and limitations.

The decision to adopt a healthier behavior -- whether it's more exercise, weight loss, or quitting smoking -- is not as simple as just deciding to do it. Behavior change expert James Prochaska and his colleagues outlined a theory, which has been supported by numerous studies, showing that people cycle through a variety of stages before a new behavior is successfully adopted over the long term. It may help you to understand how this works. As you read the description of each stage -- specifically as it relates to exercise -- you may find yourself nodding and saying to yourself, "Yes, that's me!"

Stage 1: Pre-Contemplation. People at this stage have no plans or desire to exercise. They aren't even considering exercising. They are generally unaware of the specific benefits that exercise can bring -- exercise may seem more like a hassle than something worth doing. Or, they may simply have "failed" in the past and have given up.

There's no point in talking about how to start an exercise program if you are at this stage. Instead, it is important to think about how exercise might be good for you personally -- by helping you to lose weight, feel better, have more confidence, live longer, sleep better, or reduce your stress levels. The benefits must be identified before a person will consider exercise.

If you are at this stage, a good activity is to ask four friends or family members why they exercise. Their answers may show you some real-life benefits, and inspire enough interest to compel you to take the next step.

Stage 2: Contemplation. A person at this stage is thinking, "I think I should probably exercise, but I need help getting started." People at this stage know that exercise is good for them, but it seems like a daunting task or they don't think they can pull it off. Some may have tried and "failed" in the past, but they are still receptive to another go-round.

It's important for people at this stage to consider some of the truths and falsehoods of exercise. For example, it is helpful to know that there are many forms of physical activity to select from, and that you can do your exercising in small chunks. It is not true that exercise has to be painful, or that you either succeed or fail. There is no such thing as "failure" -- people become more or less active at different stages of their lives, and it is never too late to get moving again. And people at this stage should find assurance that an exercise plan can be very simple.

If you are at this stage, a good activity is to write down all the things that you believe make exercise difficult -- and to learn strategies for overcoming or side-stepping those hurdles. People at this stage might benefit from making a pledge, contract, or other commitment that they are going to get more active in the near future. The goal is to get un-stuck by identifying the roadblocks and the ways to overcome these roadblocks. The final goal at this stage is to make a commitment.

Stage 3: Preparation. These folks are primed and motivated. They are ready to give exercise a try. The goal of this stage is to create a specific action plan that takes all factors into account, so that the "launch" is successful. People at this stage need to know how much they should be exercising, their target heart rate, and the types of exercises. They should explore the different kinds of exercises and decide which ones to try.

At this stage, people will evaluate exercise machines and health plans, if that interests them, pick the proper clothing or accessories, and consult a doctor if necessary. They also need to think about how they are going to fit their exercise plans into their daily and weekly schedule.

If you are at this stage, you should also consider some backup plans -- what to do if it rains, or if you don't feel like exercising. That way you are prepared to overcome that hurdle when you encounter it. You should be aware of what to expect realistically at the beginning -- for example, be aware that weight loss takes time, but health benefits begin immediately.

Stage 4: Action! People at this stage have just started exercising. This stage is where the biggest behavior change occurs -- these people have started to exercise but it is not yet a long-term, ingrained habit. This stage requires significant commitment and energy.

If you are at this stage, keep talking to friends and family for inspiration. Review your backup plans. Reward yourself for small achievements. Give yourself notes and reminders to exercise. Having a friend to exercise with can be very helpful as you get through this stage. You want to build and maintain momentum, because exercising gets easier once it is a habit!

Stage 5: Maintenance. The people at this stage have been exercising for at least 6 months. At this point, exercising has started to become a habit. The goal here is to prevent relapse. If you are at this stage, identify ways that you can fine-tune your program. Continue to identify roadblocks and improve your backup plans. Think about what you have found most enjoyable about exercising.

What benefits have you gained? Keep reminding yourself of these perks. If giving yourself a challenge was part of your initial motivation, set new goals and find new challenges. If you risk getting bored with your routine, find ways to vary it. Or maybe you have found a comfortable routine that you enjoy -- if it's working, great! There is no need to change it. You might want to read or learn more about your method of exercising, and develop a deeper level of understanding about it. Soon you'll be a pro!

One point about this theory is that people do not proceed from one stage to another in a simple, step-by-step fashion. They actually cycle or spiral back and forth, so that they may move from stage 1 to 2 to 3, and then back to 2 again. They may stay in maintenance mode for years and then fall back to stage 2. Remember that this is normal -- if you tried exercising in the past and didn't stick with it, don't consider yourself a failure. Just know that it's time to try again!

Resources

http://fitness.gov -- The President's Council on Physical Fitness and Sports
www.ncppa.org --National Coalition for Promoting Physical Activity
www.acefitness.org --American Council on Exercise
www.arthritis.org --The Arthritis Foundation offers tips on exercising with arthritis
www.justmove.org -- Just Move (American Heart Association)

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Review Date:
4/30/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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