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Rome Presentation 2005

Stress, Exercise and the Immune Conversation

Power Point slides from a presentation at the inaugural New Masters Rome conference 7-9 October 2005. Invited by my ex-student Alfio Albasini

by Martin Krause
Bachelor of Applied Science (Physiotherapy)
Masters of applied Science (Manipulative Physiotherapy)
Graduate Diploma Health Science (Exercise and Sports Science)
Certificate IV Workplace Assessment and Training
Graduate Certificate Health Science Education

Exercise for musculoskeletal disability has been advocated for both acute and chronic musculoskeletal conditions, yet it involves the paradox of the balance between anabolic and catabolic stressor states which can have profound effects on our immune systems. Over-reaching in daily life and over-training to balance cognitive stressors may be creating more harm than good. It is the role of physiotherapy to enhance the community's ability to adapt to modern stressors with a broad but specific exercise prescription response to the prevention of chronic illness.

"The human organism has a huge capacity to recuperate if it is stressed but not strained" (Percy Cerutty, Why Die? 2003). "The hardest thing to attend to is that which is very close to ourselves, that which is most constant and familiar, and this closest 'something' is precisely, ourselves, our own habits and ways of doing things.... this can lead to profound improvements of mental 'posture' and thinking as a result" (Frederick Matthias Alexander - a famous Tasmanian)

Friman et al (1997); Interaction between infection and exercise with special reference to myocarditis and the increased frequency of sudden deaths among Swedish orienteers 1979-92. Scandinavian journal of Infectious Diseases Supplement, 104, 41-49

Sleep plays a critical role not only in recovery but also in the restoration of function of the immune system. Immune system can be discussed in terms of cellular (T helper cell Type I) and hormonal (T helper cell Type II) components. Each part has a counter-balancing regulating effect on the other. Th1 has an active role in fighting pathogens such as viruses and some bacteria (common in travelling teams and sports where open wounds can occur) as well as a role in fighting inflammation. Whereas, Th2 cells play a role in fighting against most bacteria as well as parasitic worms (Clow & Hucklebridge 2001 Ex Immun Review 7; 5-17, and Miyazaki et al 2005, Biol Psychol, 70, 1, 30-37). Cortisol, Prolactin, Melatonin and Growth Hormone have all been implicated in have a balancing affect on Th2 cells. During the early phases of sleep the immune system is pushed towards the Th1 profile which is associated with inflammatory processes. During the early phase (30-45minutes) of waking cortisol levels rise between 50 -150% creating a Th2 bias (Cutalo et al 2005, Autoimmunity Reviews 4, 8, 497-502) and hence a bias away from a pro-inflammatory profile. This may be why people may feel stiffer in the morning as a result of injury or over-training.

Mitochondrial electron transport in models of neuropathic and inflammatory pain. Elizabeth K. Joseph and Jon D. Levine (2006)

Department of Medicine, Division of Neuroscience and Biomedical Sciences Program, University of California at San Francisco, 521 Parnassus Ave, Box # 0440/C522, San Francisco, CA 94143-0440, USA
Department of Oral and Maxillofacial Surgery, Division of Neuroscience and Biomedical Sciences Program, University of California at San Francisco, 521 Parnassus Ave, Box # 0440/C522, San Francisco, CA 94143-0440, USA

Although peripheral nerve function is strongly dependent on energy stores, the role of the mitochondrial electron transport chain, which drives ATP synthesis, in peripheral pain mechanisms, has not been examined. In models of HIV/AIDS therapy (dideoxycytidine), cancer chemotherapy (vincristine), and diabetes (streptozotocin)-induced neuropathy, inhibitors of mitochondrial electron transport chain complexes I, II, III, IV, and V significantly attenuated neuropathic pain-related behavior in rats. While inhibitors of all five complexes also attenuated tumor necrosis factor a-induced hyperalgesia, they had no effect on hyperalgesia induced by prostaglandin E2 and epinephrine. Two competitive inhibitors of ATP-dependent mechanisms, adenosine 5'-(ß,?-imido) triphosphate and P1,P4-di(adenosine-5') tetraphosphate, attenuated dideoxycytidine, vincristine, and streptozotocin-induced hyperalgesia. Neither of these inhibitors, however, affected tumor necrosis factor a, prostaglandin E2 or epinephrine hyperalgesia. These experiments demonstrate a role of the mitochondrial electron transport chain in neuropathic and some forms of inflammatory pain. The contribution of the mitochondrial electron transport chain in neuropathic pain is ATP dependent.Keywords: ATP; Electron transport chain; Mitochondria; Neuropathy; Pain; Rat

Volume 121, Issues 1-2 , March 2006, Pages 105-114

Stress affects the systems of motor control and thereby enhances susceptability to injury and/or prolonges the period required for recovery.

The role of allostasis for the development of enhanced exercise tolerance

Clinical reasoning, the neuro-matrix and allostasis in explaining the role of musculoskeletal physiotherapy in health and disease.

Macrophages are necessary for skeletal muscle regeneration. Pro-inflammatory macrophages stimulate myoblast proliferation, whereas anti-inflammatory macrophages stimulate their differentiation. Macrophages that invade skeletal muscle soon after injury present a specific phenotype, characterized by high expression of TNF-alpha, interleukin-1beta and secretory leukocyte protease inhibitor (SLPI). Non-phlogistic phagocytosis of the apoptotic and necrotic debris switches the phenotype of pro-inflammatory macrophages into anti-inflammatory macrophages. Consequently, there is a high expression of Transforming Growth Factor- Beta (TGF-beta), interleukin - 10 (IL-10), and peroxisome proliferator-activated receptor - gamma (PPAR-gamma) which have been shown to be associated with the resolution of inflammation and tissue repair (Chazaud et al 2009)

Chazaud B, Brigitte M, Yacoub-Youssef H, Arnold L, Gherardi R, Sonnet C, Lafuste P, Chretien F (2009). Dual and Beneficial Roles of Macrophages During Skeletal Muscle Regeneration. Exercise and Sports Science Reviews, 37, 1, 18-22

Cognitive Behavioural Therapy for exercise prescription

Exercise regimes should have 3 goals in mind


link to nutritional supplementation

The role of muscle mass and immune function

Pre and post exercise cellular immune responses to muscle trauma

click on image for enlargement

click on the image above to see an enlarged view

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Take home message

  • Muscle mass has been traditionally associated as an organ of movement, however it is an organ of survival and hence allostasis, as it represents 90% of protein in the body and is an important site of both local and systemic immune - inflammatory reactions
  • Progressive resistance training (PRT) associated with goal oriented cognitive behavioural therapy (CBT) represents a credible method of mediating the risks of developing sarcopenia and metabolic syndrome as well as improving immune responses to stress and inflammation.
  • Periodisation of training represents a credible method of stressing rather than straining the system. Additionally, specific plyometric exercise regimes have the potential to enhance the myofibrillar architecture thereby reducing the amount of trauma and inflammation occurring during weight bearing eccentric exercise regimes
  • Nutritional supplementation and adequate time for recuperation will enhance immune responses
  • Goal oriented specific task demands within given time frames and associated with appropriately timed feedback (both internal and external cues) will enhance allostasis and hence improve the immune response.

For more information please visit

Neuro-immune reponses & cognitive behavioral therapy

Motor Learning and the acquisition of expertise

Periodisation of endurance training

Muscle Mass & Sarcopenia

Exercise and nutrition

Pain & Inflammation

Millar et al (Clin Orthop Relat Research, 2008, May 6) used a running rat model induced suprapsinatus tendonopathy to demonstrate the release of heat shock proteins. Additionally, the up-regulation of HSP was further demonstrated on patients undergoing arthroscopic stabilisation sugery (n=10). They concluded that these findinggs suggest that HSP play a role in the cascade of stress-activated programmed cell death and degeneration in tendonopathy.

also read

Sims Graem (2003) Why Die? The extraordinary Percy Cerutty 'Maker of Champions' Lothian Books ISBN 0 7344 0540 5 
Percy Cerutty 1895-1975 was the greatest track and field trainer Australia ever produced. He had a profound belief in movement efficiency and mental agility in the pursuit of excellence.

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Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected