Acute chest pain and esophageal mucosal injury following an extreme yoga position Case report

A young lady complained of the sudden onset of intense chest pain, in consequence of an extreme hyperextension of the back in a yoga position. At endoscopy a large lesion of the esophageal epithelium was detected, involving the middle third of the anterior wall of the esophagus. Other symptoms reported by the patient were dysphagia and odynophagia, depicting the typical features of intramural hematoma, also known as intramural dissection or intramural perforation of the oesophagus. The patient was managed conservatively and symptoms disappeared within a week. A barium swallow at six months reported normal findings. Different types of accidents occurring during yoga practice are reported in the literature, mainly involving musculoskeletal or nervous systems. Visceral lesions are exceptional and no similar cases have been reported in the literature. KEYWORDS: Acute chest pain, Esophageal lesion, Intramural hematoma, Management of esophageal lesion.

Effect of an exercise-based cardiac rehabilitation program "Baduanjin Eight-Silken-Movements with self-efficacy building" for heart failure (BESMILE-HF study): study protocol for a randomized controlled trial

BACKGROUND

Exercise-based cardiac rehabilitation is a beneficial therapy for patients with chronic heart failure. The delivery of exercise-based cardiac rehabilitation should adopt an evidence-based approach, as well as be culturally appropriate and sensitive to individual needs and preferences. The Baduanjin Eight-Silken-Movements with Self-efficacy Building for Heart Failure (BESMILE-HF) program is the first to apply a traditional Chinese exercise, Baduanjin, as the core component in an exercise-based cardiac rehabilitation program. This trial aims to assess the efficacy, safety, and acceptability of the addition of the BESMILE-HF program to usual medications for patients with chronic heart failure.

METHODS/DESIGN

The BESMILE-HF study is a mixed-design study. It includes a two-group, parallel, randomized controlled trial with 200 chronic heart failure patients, as well as a qualitative component. Patients will be randomized into either an intervention group receiving the 12-week BESMILE-HF program plus usual medications, or a control group receiving only usual medications. The primary outcomes are peak oxygen consumption assessed using a cardiopulmonary exercise test, and disease-specific quality of life using the Minnesota Living with Heart Failure Questionnaire. The secondary outcomes are: exercise performance, exercise self-efficacy, general quality of life, dyspnea and fatigue, depression, cardiac function, prognostic and inflammatory indicator levels, hospitalization, use of medications, and major adverse cardiac events. Assessments will be carried out at baseline, and at the 4th week, 8th week, and 12th week. The qualitative component will include a semi-structure interview describing patients' experiences with the intervention.

DISCUSSION

This study can provide evidence for how to deliver a contextually adapted exercise-based cardiac rehabilitation program with the potential to be scaled up throughout China.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03180320 . Registered on 2 June 2017.

Pilates for low back pain

BACKGROUND

Non-specific low back pain is a major health problem worldwide. Interventions based on exercises have been the most commonly used treatments for patients with this condition. Over the past few years, the Pilates method has been one of the most popular exercise programmes used in clinical practice.

OBJECTIVES

To determine the effects of the Pilates method for patients with non-specific acute, subacute or chronic low back pain.

SEARCH METHODS

We conducted the searches in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro and SPORTDiscus from the date of their inception to March 2014. We updated the search in June 2015 but these results have not yet been incorporated. We also searched the reference lists of eligible papers as well as six trial registry websites. We placed no limitations on language or date of publication.

SELECTION CRITERIA

We only included randomised controlled trials that examined the effectiveness of Pilates intervention in adults with acute, subacute or chronic non-specific low back pain. The primary outcomes considered were pain, disability, global impression of recovery and quality of life.

DATA COLLECTION AND ANALYSIS

Two independent raters performed the assessment of risk of bias in the included studies using the 'Risk of bias' assessment tool recommended by The Cochrane Collaboration. We also assessed clinical relevance by scoring five questions related to this domain as 'yes', 'no' or 'unclear'. We evaluated the overall quality of evidence using the GRADE approach and for effect sizes we used three levels: small (mean difference (MD) < 10% of the scale), medium (MD 10% to 20% of the scale) or large (MD > 20% of the scale). We converted outcome measures to a common 0 to 100 scale when different scales were used.

MAIN RESULTS

The search retrieved 126 trials; 10 fulfilled the inclusion criteria and we included them in the review (a total sample of 510 participants). Seven studies were considered to have low risk of bias, and three were considered as high risk of bias.A total of six trials compared Pilates to minimal intervention. There is low quality evidence that Pilates reduces pain compared with minimal intervention, with a medium effect size at short-term follow-up (less than three months after randomisation) (MD -14.05, 95% confidence interval (CI) -18.91 to -9.19). For intermediate-term follow-up (at least three months but less than 12 months after randomisation), two trials provided moderate quality evidence that Pilates reduces pain compared to minimal intervention, with a medium effect size (MD -10.54, 95% CI -18.46 to -2.62). Based on five trials, there is low quality evidence that Pilates improves disability compared with minimal intervention, with a small effect size at short-term follow-up (MD -7.95, 95% CI -13.23 to -2.67), and moderate quality evidence for an intermediate-term effect with a medium effect size (MD -11.17, 95% CI -18.41 to -3.92). Based on one trial and low quality evidence, a significant short-term effect with a small effect size was reported for function (MD 1.10, 95% CI 0.23 to 1.97) and global impression of recovery (MD 1.50, 95% CI 0.70 to 2.30), but not at intermediate-term follow-up for either outcome.Four trials compared Pilates to other exercises. For the outcome pain, we presented the results as a narrative synthesis due to the high level of heterogeneity. At short-term follow-up, based on low quality evidence, two trials demonstrated a significant effect in favour of Pilates and one trial did not find a significant difference. At intermediate-term follow-up, based on low quality evidence, one trial reported a significant effect in favour of Pilates, and one trial reported a non-significant difference for this comparison. For disability, there is moderate quality evidence that there is no significant difference between Pilates and other exercise either in the short term (MD -3.29, 95% CI -6.82 to 0.24) or in the intermediate term (MD -0.91, 95% CI -5.02 to 3.20) based on two studies for each comparison. Based on low quality evidence and one trial, there was no significant difference in function between Pilates and other exercises at short-term follow-up (MD 0.10, 95% CI -2.44 to 2.64), but there was a significant effect in favour of other exercises for intermediate-term function, with a small effect size (MD -3.60, 95% CI -7.00 to -0.20). Global impression of recovery was not assessed in this comparison and none of the trials included quality of life outcomes. Two trials assessed adverse events in this review, one did not find any adverse events, and another reported minor events.

AUTHORS' CONCLUSIONS

We did not find any high quality evidence for any of the treatment comparisons, outcomes or follow-up periods investigated. However, there is low to moderate quality evidence that Pilates is more effective than minimal intervention for pain and disability. When Pilates was compared with other exercises we found a small effect for function at intermediate-term follow-up. Thus, while there is some evidence for the effectiveness of Pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercises. The decision to use Pilates for low back pain may be based on the patient's or care provider's preferences, and costs.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.

OBJECTIVES

To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.

SELECTION CRITERIA

Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.

AUTHORS' CONCLUSIONS

There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

Eurythmy therapy in chronic disease: a four-year prospective cohort study

BACKGROUND

Many patients with chronic diseases use complementary therapies, often provided by their physicians. In Germany, several physician-provided complementary therapies have been reimbursed by health insurance companies as part of health benefit programs. In most of these therapies, the patient has a predominantly passive role. In eurythmy therapy, however, patients actively exercise specific movements with the hands, the feet or the whole body. The purpose of this study was to describe clinical outcomes in patients practising eurythmy therapy exercises for chronic diseases.

METHODS

In conjunction with a health benefit program, 419 outpatients from 94 medical practices in Germany, referred to 118 eurythmy therapists, participated in a prospective cohort study. Main outcomes were disease severity (Disease and Symptom Scores, physicians' and patients' assessment on numerical rating scales 0-10) and quality of life (adults: SF-36, children aged 8-16: KINDL, children 1-7: KITA). Disease Score was documented after 0, 6 and 12 months, other outcomes after 0, 3, 6, 12, 18, 24, and (SF-36 and Symptom Score) 48 months.

RESULTS

Most common indications were mental disorders (31.7% of patients; primarily depression, fatigue, and childhood emotional disorder) and musculoskeletal diseases (23.4%). Median disease duration at baseline was 3.0 years (interquartile range 1.0-8.5). Median number of eurythmy therapy sessions was 12 (interquartile range 10-19), median therapy duration was 119 days (84-188). All outcomes improved significantly between baseline and all subsequent follow-ups (exceptions: KITA Psychosoma in first three months and KINDL). Improvements from baseline to 12 months were: Disease Score from mean (standard deviation) 6.65 (1.81) to 3.19 (2.27) (p < 0.001), Symptom Score from 5.95 (1.75) to 3.49 (2.12) (p < 0.001), SF-36 Physical Component Summary from 43.13 (10.25) to 47.10 (9.78) (p < 0.001), SF-36 Mental Component Summary from 38.31 (11.67) to 45.01 (11.76) (p < 0.001), KITA Psychosoma from 69.53 (15.45) to 77.21 (13.60) (p = 0.001), and KITA Daily Life from 59.23 (21.78) to 68.14 (18.52) (p = 0.001). All these improvements were maintained until the last follow-up. Improvements were similar in patients not using diagnosis-related adjunctive therapies within the first six study months. Adverse reactions to eurythmy therapy occurred in 3.1% (13/419) of patients. No patient stopped eurythmy therapy due to adverse reactions.

CONCLUSION

Patients practising eurythmy therapy exercises had long-term improvement of chronic disease symptoms and quality of life. Although the pre-post design of the present study does not allow for conclusions about comparative effectiveness, study findings suggest that eurythmy therapy can be useful for patients motivated for this therapy.

Comparison of the symptoms of exercise-induced muscle damage after an initial and repeated bout of plyometric exercise in men and boys

The purpose of this study was to compare symptoms of exercise-induced muscle damage after an initial and repeated bout of plyometric exercise in men and boys. Ten boys (9–10 yr) and 10 men (20–29 yr) completed two bouts of eight sets of 10 plyometric jumps, 2 wk apart. Perceived soreness (0–10, visual analog scale), isometric strength of the quadriceps at six knee flexion angles, and countermovement jump and squat jump height were assessed before and at 30 min, 24 h, 48 h, and 72 h after each bout. All variables followed the expected patterns of change in men, with soreness peaking at 24–48 h (5.8 ± 1.7) and decrements in muscle function peaking at 30 min after the first bout (73–85% of baseline scores). Symptoms remained for 72 h after the first bout in men. In boys, symptoms were much less severe and peaked at 30 min (visual analog scale = 2.1 ± 1.8, functional decrements 87–92% of baseline) and, with the exception of soreness, returned to baseline after 24 h. After the second bout of plyometric exercise, the level of soreness and decrements in countermovement jump, squat jump, and isometric strength were lower, although the effect was stronger in men, in all cases. The results of this study suggest that although children may experience symptoms of muscle damage after intensive plyometric exercise, they are much less severe. A prior bout of plyometric exercise also appears to provide children with some protection from soreness after a subsequent bout of plyometric exercise. Explanations for milder symptoms of exercise-induced muscle damage in children include greater flexibility leading to less overextension of sarcomeres during eccentric exercise, fewer fast-twitch muscle fibers, and greater and perhaps more varied habitual physical activity patterns.

Effect of hyperoxia on maximal O2 uptake in exercise-induced arterial hypoxaemic subjects

This study focuses on the effect of hyperoxia on maximal oxygen uptake VO2max and maximal power (Pmax) in subjects exhibiting exercise-induced arterial hypoxemia (EIH) at sea level. Sixteen competing male cyclists VO2max > 60 ml.min(-1).kg(-1)) performed exhaustive ramp exercise (cycle-ergometer) under normoxia and moderate hyperoxia (FIO2 = 30%). After the normoxic trial, the subjects were divided into those demonstrating EIH during exercise [arterial O2 desaturation (delta SaO2) >5%; n = 9] and those who did not (n = 7). Under hyperoxia, SaO2 raised and the increase was greater for the EIH than for the non-EIH group (P<0.001). VO2max improved for both groups and to a greater extent for EIH (12.8 +/- 5.7% vs. 4.2 +/- 4.6%, P<0.01; mean+/-SD) and the increase was correlated to the gain in SaO2 for all subjects (r = 0.71, P<0.01). Pmax improved by 3.3 +/- 3.3% (P<0.01) regardless of the group. These data suggest that pulmonary gas exchange contributes to a limitation in VO2max and power for especially EIH subjects.

Reliability of maximal muscle force and voluntary activation as markers of exercise-induced muscle damage

The loss of the ability of skeletal muscle to generate force is one of the most appropriate and valid means to quantify muscle damage. Routine measurements of maximal muscle force, however, include many potential sources of error, the most important of which may be a possible lack of central drive to the muscles. The aim of the present study was to determine the reliability of maximal isometric quadriceps muscle force and voluntary activation over a time scale that is typically employed to examine the aetiology of exercise-induced muscle damage. We also attempted to characterise the reliability of several twitch interpolation variables including the size of the interpolated twitch and the state (i.e. un-potentiated vs potentiated) and size of the resting twitch. Over a 7-day period, eight healthy active males performed repeated maximal voluntary isometric contractions (MVC) of the quadriceps (baseline and 2 h, 6 h, 24 h, 48 h, 72 h and 7 days post). Systematic variations in maximal muscle force, voluntary activation, interpolated twitch, un-potentiated twitch and potentiated twitch were not statistically significant (P>0.05) and 95% repeatability coefficients of +/-76.03 N, +/-4.42%, +/- 8.44 N, +/-25.92 N and +/-43.58 N were observed, respectively. These data indicate that young healthy well-familiarized male subjects can reproduce their perceived maximal efforts both within and between days where activation levels of >90% are routinely achieved. Providing activation remains within these limits in the 7 days following an acute bout of exercise, the researcher would be 95% certain that exercise-induced muscle damage is present in individual subjects (taken from similar subject populations) if MVC force falls outside these limits.

Pure eccentric exercise does not activate blood coagulation

Eccentric exercise can cause skeletal muscle damage with ultrastructural disruption, inflammation and increased proteolytic enzyme activity. It may be possible that these changes are able to trigger blood coagulation in vivo. The aim of the study was to investigate changes in blood coagulation via the measurement of aPTT, the thrombin potential (total [TTP] and endogenous [ETP], both intrinsic [in] and extrinsic [ex]) and the thrombin generation (prothrombinfragment 1 + 2 [F1 + 2] and thrombin-antithrombin complex [TAT]) after pure eccentric exercise. Seventeen healthy non-smokers (28 +/- 6 years, VO2-peak 59 +/- 7 ml/min/kg) underwent pure eccentric down jumps (9 x 28 isolated down jumps in 90 min, drop from a height of 55 cm), a cycle exercise (90% of the individual anaerobic threshold for 60-90 min) and a control experiment on different days. Blood samples were drawn after a 30-min rest, immediately, and 2 h after exercise. After the cycle exercise, a clear shortening by 12% (P<0.001) in aPTT and an increase in TTPin (13%; P<0.05) and TAT (33%; P<0.05) in comparison to the control experiment were seen, while after eccentric exercise only minimal changes in aPTT and thrombin potential (TTPin, ETPin) and no thrombin generation (F1 + 2 and TAT) were found. In contrast to concentric dynamic exercise, e.g. cycle ergometry, only insignificant changes in thrombin potential and no thrombin generation could be observed after skeletal muscle damage induced by pure eccentric exercise. It can be concluded that the mechanical impact associated with eccentric exercise does not activate blood coagulation.

The effects of exercise-induced muscle damage on maximal intensity intermittent exercise performance

Exercise-induced muscle damage (EIMD) is a common occurrence following activities with a high eccentric component. Alterations to the torque-velocity relationship following EIMD would appear to have serious implications for athletic performance, particularly as they relate to impairment of maximal intensity exercise. However, this has been studied infrequently. The purpose of this study was to assess the effects of EIMD on maximal intermittent sprint performance. Ten male participants (age 22.4 +/- 3.2 years, height 178.6 +/- 5.2 cm, mass 80.6 +/- 10.7 kg) performed 10 x 6 s cycle ergometer sprints, interspersed with 24 s recovery against a load corresponding to 0.10 kp/kg and 10 x 10 m sprints from a standing start, each with 12 s active (walking) recovery. All variables were measured immediately before and at 30 min, 24, 48 and 72 h following a plyometric exercise protocol comprising of 10 x 10 maximal counter movement jumps. Repeated measures ANOVA showed significant changes over time (all P<0.05) for perceived soreness, plasma creatine kinase activity (CK), peak power output (PPO), sprint time and rate of fatigue. Soreness was significantly higher (P<0.01) than baseline values at all time intervals (3.1, 4.9, 5.5 and 3.2 at 30 min, 24, 48 and 72 h, respectively). CK was significantly elevated (P<0.05) at 24 h (239 IU/l) and 48 h (245 IU/l) compared to baseline (151 IU/l). PPO was significantly lower (P<0.05) than baseline (1,054 W) at all time intervals (888, 946, 852 and 895 W, at 30 min, 24, 48 and 72 h, respectively). The rate of fatigue over the ten cycling sprints was reduced compared to baseline, with the greatest reduction of 48% occurring at 48 h (P<0.01). This was largely attributed to the lower PPO in the initial repetitions, resulting in a lower starting point for the rate of fatigue. Values returned to normal at 72 h. Sprint times over 10 m were higher (P<0.05) at 30 min, 24 h and 48 h compared to baseline (1.96 s) with values corresponding to 2.01, 2.02 and 2.01 at 30 min, 24 h and 48 h, respectively. Values returned to baseline by 72 h. The results provide further evidence that, following a plyometric, muscle-damaging exercise protocol, the ability of the muscle to generate power is reduced for at least 3 days. This is also manifested by a small, but statistically significant reduction in very short-term (approximately 2 s) intermittent sprint running performance. These findings have implications for appropriate training strategies in multiple sprint sports.