Stability and mobility:
In the treatment of abnormal condition of joints and muscles, one must determine the over all objectives of treatment based on whether stability and mobility desired out come for optimal function. Joint structure are so designed that along with greater mobility there is less stability, and long ith greater stability there is les mobility.
It's quite generally accepted that along with growth from childhood to adulthood, there is a ''tightening up'' of the ligamentus structures, with a corresponding decrease in flexibility of muscles. This change affords greater stability and strength for adults than for children.
The individual with relaxed ligaments, often referred to as the loosely knite, does not have the stability in standing that less flexible individual has. A knee that goes into hyperextension, for example, is not mechanically as stable for weight bearing as one that is held in normal extension.
Lack of stability of the spine in the flexible individual can lead to problem when work requires prolonged sitting or standing, or the need to lift or carry heavy object. Muscles do not succeed in functioning for both movement and the support normally afforded by the ligaments. When symptoms occur, they will at first appear as fatigue, and later as pain. Often a young adult with excellent strength, but excessive spinal flexibility will require a back support to relieve painful symptoms.
Under some circumstances, function is improved and pain is alleviated by range of motion being restricted to the point of complete fixation. Such condition as marie-strumbell arthritis of spine, if fused in good alignment, and postoperative fusion of spine, hip, foot, or wrist, all exemplify this principle.
From the mechanical stand point, there are two types of faults relating to alignment and mobility:

1) Undue compression on articulating surface of bone and

2) Undue tension on bones, ligaments, or muscles.

Eventually, two types of bony changes may occur. Excessive compressions produce an eroding effect on the articulating surfaces, while traction may result in an increase in bony growth at the point of attachment.
Lack of mobility is closely associated with persistent faulty alignment as a factor in causing undue compression. When mobility is lost there is stiffness and a certain alignment remains constant. This may be due to restriction of motion by tight muscle, or due to the inability of weak muscles to move the part through arc of motion. Muscle tightness is a constant factor tending to maintain the part in faulty alignment regardless of the position of the body. Muscle weakness is a less constant factor because changing the body position can bring about a change in alignment of the part. When there is normal movement in joints, wear and tear on joint surface tends to be distributed; however, if there is limitation range, the wear will be take place only on joint surface that repressed the arc of use. If the part that is restricted by muscle tightness is protected against any movement that may cause the strain, other parts that must compensate for such restriction will suffer the strain instead.
Excessive joint mobility results in tension on the ligaments that normally limit the range of motion can results in undue compression on the margins of the articulating surfaces when the excessive range is longstanding

Stretch weakness:
Stretch weakness is defined as weakness that results from muscle remaining in an elongated condition, however slight, beyond the neutral physiological rest position, but not beyond the normal range of muscle length. The concept relates to the duration of the faulty alignment rather than to the severity of it.
Many cases of stretch weakness have responded to treatment that supported the muscle in favourable position, even though the muscle had been weak or partially paralyzed for a long time, even as long as several years after onset of initial problem.
Muscle exhibiting stretch weakness should not be treated by stretching or movement through the full range of joint motion in the direction of elongating the weak muscle. The condition has resulted from continues stretching and responds to immobilization in physiological rest position for a sufficient period of time to allow for recovery to occur.
Stretch weakness may be superimposed on normal muscles, or on muscle initially affected by the peripheral nerve, anterior horn cell, or central nervous system. Stretch weakness of less dramatic nature is seen frequently in cases of occupational and postural strain. The muscles most often affected have been one-joint muscles.
Stretch weakness, being the result of persistent tension on the muscle, must be treated by relief of tension. Realignment of the part, bringing it into a neutral position, and use supportive measures to help restore and maintain such alignment until weak muscle recover strength are important factor in treatment. Any opposing tightness that tends to hold the part out of alignment must be corrected in order to relive the tension on weak muscle. Faulty occupational positions that impose continuous tension on certain muscles must also adjusted or corrected. Care must be taken not to overwork a muscle that has been subjected to a prolonged tension stress. As the muscle improve in strength and are capable of maintaining the gain, the patient is expected to use the muscle by working to maintain proper muscle balance and good alignment.

Continue.........

PAINFUL CONDITIONS OF UPPER BACK AND NECK AND ARM

TREATMENT CONCEPT: This introdution contains brief overview of the various topic that will be covered in this page.
Mechanical causes of pain: Pain-whether its is in muscle, joint, or nerve itself -is a responce of the nerve.Regardless of where the stimulus may arise , the sensation os pain is conducted by nerve fibres.The mechanical factors that give rise to pain must, therefore,directly affect nerve fibres.There are two such factors to be considered in problems of faulty body mechanics.

Pressure on nerve root,trunk,nerve branches or nerve ending may be caused by some adjant frim structure such as bone, cartilage, fascia, scar tissue, or taut muscle.Pain resulting from an enlarged ligamentum flavum or protruded disc exemplifies nerve root pressure.The" scalenus anticus syndrome" in cases of arm pain, and the "Piriformis syndrome" in cases of sciatica are example of nerve irritation associated with tautness of the respective muscle.

Tension on structures containing nerve ending sensitive to deformation,as found in stretch or strain of muscle, tendons, or ligaments, can cause pain that is slight or excruciating,depending on the severity of the strain.

Distribution of pain along the course of the involved nerve and the areas of cutaneous sensory disturbance are aid in determining the site of the lesion.Pain may be localized below the level of direct involvement or may be widespread because of reflex or referred pain.In a root lesion, pain tends to extend from the orgin of the nerve to its periphery, and cutaneous sensory involvement is dermatone basis.A peripheral nerve involvement is often distinguished by pain below the level of the lesion.Most peripheral nerves contain both sensory and motor fibres.Symptoms of pain or tingling usually appear in the cutaneous areas supplied by the nerve before numbness or weakness is apparent.There are however. numbness muscle that are supplied by nerve that are purely motor to the muscle,and the symptoms of weakness appear without prior or concurrent symptoms of pain or tinliging .

Spasm.Muscle spasm is an involuntry contraction of muscle, or of a segments within in a muscle , that occur as a result of painful nerve stimulation.Irritation from root, plexus, or peripheral nerve branch level will tend to causes sapam of a number of muscle, while spasm due to irritation of the nerve ending within a muscle may be limited to the muscle involved, or may be wide spread due to reflex pain mechanisms.

Treatment of muscle spasm depends on the type of spasm.Relief of spasm resulting from initaial nerve irritation of the root, trunk, or peripheral branch must depend on relief of the nerve irritation causing it.Aggressive treatment of the muscle or muscles in spasm will tend to aggravate the symptoms.

Productive spasm may occur sencondary to injury of underlying structures such as ligaments or bone.This protective "splinting",such as often occurs following back injury,prevent the movement and further irritation of the injured structure.Productive spasms should be treated by the application a productive supports in order to relive the muscle of this extaraordinary function.In the low back,where protective muscle spasms frequently occurs,a brace with a lumbar pad,or a corset with posterior stays bent to conform to the contour of the low back,may be used for both immobilization and pressure.

Segmental muscle spasm an involuntary contraction of the uninjured segment of a muscle as a result of an injury to the muscle.Pain associated with tension within the muscle may be outlined by the margins of the muscle, or may be widespeard due to reflex or referred pain mechanisms.Treatment requires immobilization in a position thet relives tension on the affected muscle.A positive responce may also be obtained by gentle, localized massage to the area in spasm.

Muscle spasm associated with tendon injury differ from the above when the tension is exerted on the tendon rather than on a part of the muscle.Tendon contain many nerve ending sensitive to stretch, and pain associated with tendon injury tends to be severe.

Adaptive shortening:Adaptive shortening tightness that occurs as a result remaning in a shortened position.Unless the opposing muscle is able to pull the part back to neutral position, or some outside force exerted to lenghen the short muscle, it will remain in a shortened condition.

Tightness and shortness represents a slight to moderate decrease in muscle lengh, and result in a correspoding restriction of range of motion.It is considered to be reversible,but stretching movement must be done gradually to avoid damage to tissue structures.A period of several weeks is usually for restoration of mobility in muscle excibiting moderate tightness.

Back Pain and Aging

Back pain is extremely common in our society. In fact, almost 80% of adults in the United States will encounter some form of back pain in their lifetimes. There are many reasons why so many people experience back pain, including poor posture, poor body mechanics, overweight, excessive strain on the spine, smoking, poor diet, as well as spinal diseases and other health conditions, but the most common cause of back pain in our country is simply aging. Read on to find out why aging can be a real pain.

The Spine

The spine is made up of individual bones called vertebrae, which provide support for the body. In between each vertebra is a disc that gives the spine flexibility and serves as a shock absorber for the body. Discs are made up of a tire-like outer band (called the annulus fibrosus) and a gel-like inner substance (called the nucleus pulposus). Together, the vertebrae and the discs provide a protective tunnel (called the spinal canal) through which the spinal cord and spinal nerves pass through.

What happens when we age?

For many of us, several things begin to happen to our spines as we age. Our vertebrae begin to thicken and our discs start to loose moisture and shape. As a result, the spinal canal becomes narrower putting pressure on the spinal cord and nerve endings and causing pain, numbness, or weakness in the body. This condition is called spinal stenosis. While stenosis can affect people in their 20s and 30s, it is most commonly seen in older patients. Spinal stenosis is a degenerative condition, meaning the symptoms tend to be progressive, increasing in severity as the patient ages.

Symptoms of Spinal Stenosis

Spinal stenosis can occur in all areas of the spine, but occurs most often in the lumbar (lower back) and cervical (neck) areas. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. Symptoms often increase when walking short distances and decrease when sitting, bending forward, or lying down. Cervical spinal stenosis has similar symptoms in the shoulders, arms, and legs, and may also include hand clumsiness and gait and balance disturbances.

Treatment Options for Spinal Stenosis

The good news is that nearly 90 percent of spinal stenosis cases are successfully treated without surgery. Non-surgical treatment options most commonly used for patients with stenosis include the following:

• Rest or restricted activity (this may vary depending on extent of nerve involvement).

• Physical therapy and stretching and strengthening exercise to help stabilize the spine, restore mobility, and increase flexibility.

Don't Ignore Back Pain

With all of the treatment options available today, it's no longer necessary to accept back pain as a normal part of the aging process. Back pain, especially if it continues to get worse, includes bowel and bladder difficulties, or prevents you from participating in your everyday activities, should not be ignored. Talk to your physician or see a spine specialist. They will help you find a treatment plan that can return you to your pain-free life once more.

CORE STABILITY AND LOWER BACK PAIN

Training obviously focuses on visible muscle groups mainly in the arms and legs. While these muscles are required for activities like walking up stairs, running, jumping and lifting, what is often overlooked is an understanding that these muscles need a solid base to pull from for them to be effective. This solid base is the body core and the training of core stability develops this.

The ability of your trunk to support your everyday functional activities enables your muscles and joints to perform at their safest and most effective position. Core stability is now used widely in sport for prevention of injury; improve balance, coordination, and increase speed /power.

Your core is your back, pelvis and shoulder girdle. The pelvic girdle functions, using your abdomen and gluteals (bottom) muscles working to maintain this position relative to the spine. If the wrong muscles are used to transfer the forces through this core area of your body or the appropriate muscles work but are weak the body will try to compensate. It is when the body tries to compensate that it loses efficiency that leads to a loss of posture and strength.

This loss of core strength and poor posture predisposes the individual to injuries
especially lower back pain.The muscles that are responsible for the transfer of the force between your limbs that stabilize your central body (core) are essential for optimal body function and back care. It doesn’t matter how much weight training you do on your arms, legs you can only be as strong as your weakest link and if your core is weak you are predisposing yourself to injuries and long term back pain.

Core stability not only decreases the risk of sustaining back injuries but also improves balance, muscular coordination, the ability to develop power this is all very important and is required especially when lifting objects or bending forwards. This is when so many back injuries occur. Therefore by adding core stability exercises into your weekly schedule you can not only prevent possible back problems but also improve your overall physical performance.

There is a misconception regarding your abdominal muscles, although the abdominals are one of the key stabilisers in the trunk they are often trained by doing sit ups and crunches. Doing sit-ups trains the abdominals as mobilisers, which creates motion as opposed to training the abdominals as stabilisers which would support and hold your trunk and help transfer forces through moving limbs.

Exercising on an unstable base like an exercise ball helps to stimulate the core stabilisers and wake them up. Through inactivity, sedentary life style or previous back injuries the core stabilisers become weak and often are not easily recruited. With regular stimulation and mental focus your core stability will improve and those muscles that have been inactive will a period of time start to activate automatically.

Identifying Exercise-Induced Bronchospasm

In Brief: Exercise-induced bronchospasm (EIB) is an often-undiagnosed but common problem affecting both recreational and elite athletes. Although exercise can trigger exacerbation of chronic asthma, EIB should not be confused with the chronic inflammatory disease. In this article, Drs Hermansen and Kirchner review the incidence, diagnosis, and treatment of EIB and explain how to distinguish EIB from chronic asthma.

EIB is defined as the transient constriction of the airways as a consequence of vigorous exertion. It occurs in about 12% to 15% of the US general population. Of patients with chronic asthma, 70% to 90% have an exercise component to their disease. As many as 40% of patients with allergic rhinitis also have EIB. However, between 5% and 10% of patients with EIB have no concomitant respiratory or allergic disease.

Olympians have been studied to quantify the incidence of EIB among elite athletes. About 11% of US Olympians who participated in the 1984 Olympic Summer Games met the criteria for EIB.These athletes won 41 medals, a testament to EIB's prevalent but controllable nature. Of the US Olympians who participated in the 1998 Olympic Winter Games, 17% admitted the need for medication for their exercise-induced symptoms.The incidence of EIB in a recent study involving US Army recruits6 was about 7%, but it had no effect on physical performance during basic training.

Pathophysiologic Factors
The etiology of EIB remains controversial. Two theories, the osmotic hypothesis and the thermal hypothesis, represent the current thinking about the cause of EIB.

The osmotic hypothesis is predicated on the theory that dehydration of the airways causes bronchospasm. Inspired air is humidified during the act of respiration, which results in water loss in the bronchial tree. Thus, the airway surface liquid evaporates, causing some degree of hyperosmolarity. By mechanisms not fully understood, this state of dehydration and hyperosmolarity triggers the release of cytokines and the degranulation of mast cells. These changes cause bronchospasm and shortness of breath in susceptible patients.

The thermal hypothesis of EIB involves a combination of temperature and vascular changes that cause bronchospasm.The inspired air is cool relative to the temperature in the bronchial tree. As the respiration rate increases during exercise, airway temperature gradually decreases. Exercise also causes increased blood flow to the pulmonary vascular beds for adequate oxygen exchange. The influx of warm blood translates to a reactive hyperemia and hyperthermia. The increased blood flow causes airway edema, leading to narrowed airway spaces and resultant pulmonary symptoms.

The pathophysiologic features of chronic asthma are bronchoconstriction, mucus secretion, and inflammation. Abnormal interaction between TH2 lymphocytes seems to instigate the inflammatory pathway in chronic asthma.8 Similar effects have not been specifically demonstrated in EIB. Unfortunately, most studies designed to detect markers of inflammation in EIB have evaluated patients with mild asthma and have had few patients enrolled. Jarjour and Calhoun9 demonstrated an absence of mast cell activation and inflammation in patients with mild stable asthma. After exercise challenge, there was no increase in histamine level or white blood cell count on bronchoalveolar lavage. Karjalainen and coinvestigators10 studied elite cross-country skiers and found that 33% had bronchospasm in response to methacholine chloride. However, no correlation between bronchial responsiveness and inflammation seen on bronchoalveolar lavage was noted. Clearly, the mechanism of EIB and its physiologic distinction from chronic asthma have not been adequately elucidated.

The Exercise Component
Certain activities have a higher propensity to trigger bronchospasm, which is referred to as the asthmogenic potential. Marathon running, basketball, soccer, and ice hockey require significant aerobic exercise that can induce respiratory symptoms. Therefore, these sports have a high asthmogenic potential. Conversely, golf, weight lifting, and the martial arts have a low asthmogenic potential. Water sports have an intermediate effect; in some patients, the warm, wet environment does not cause symptoms, but the chlorine in the water produces irritation leading to bronchospasm.11 Realistically, any activity can lead to symptoms, and susceptible patients must be educated about this possibility.

Varied exercise regimens do not change the likelihood of recurrent bronchospastic exacerbation. A Cochrane review12 revealed no significant improvement in peak flow measurement, spirometry readings, or the number of episodes of wheeze in patients with EIB who engaged in various aerobic training regimens. Matsumoto and associates13 showed that a swimming regimen improved aerobic capacity in patients with EIB but did not change histamine responsiveness, indicating a continued likelihood of EIB exacerbation. However, exercise is still recommended because of its cardiovascular benefits.14

Stages of EIB
EIB occurs in three distinct phases that have clinical and therapeutic ramifications. The first phase consists of the most severe bronchospasm. Symptoms peak 5 to 10 minutes after exercise begins and last for 30 to 60 minutes. If symptoms are not severe enough to treat, this phase spontaneously resolves after adequate rest.

The second phase, the refractory period, refers to the interval in which little or no bronchospasm occurs. It begins 30 minutes to 4 hours after exercise is initiated and is due to the release of adrenaline and norepinephrine, which act locally as bronchodilators. Concurrently, the depletion of mast cell contents results in diminished bronchoconstriction. About 50% of patients with EIB experience a refractory period and can capitalize on it to allow continued physical activity.

The final phase of EIB involves symptoms similar to those experienced in the first phase, but they are less severe. Symptoms recur 12 to 16 hours after exercise is finished and usually remit within 24 hours.

Clinical Symptoms
EIB presents in various ways, and patients report both obvious and vague complaints (table 1). Symptom onset usually occurs 5 to 10 minutes after the start of exercise but may take longer in a conditioned athlete. Chest pain rarely indicates cardiac disease in children. In a study by Wiens and colleagues,16 up to 72% of children with chest pain met the criteria for EIB. Adults present with wheezing and dyspnea more often than do children. Determination of functional limitations from symptoms is important for diagnosis and for treatment efficacy. A patient's inability to keep up with his or her peers is an important detail in history taking in pediatric and adolescent athletes.

TABLE 1. Characteristics Related to Exercise-Induced Bronchospasm


Typical
Chest tightness or pain
Cough
Shortness of breath
Wheeze
Atypical or Vague
Avoidance of activity
Conditioned athlete feels out of shape
Easy fatigability
Inability to keep up with peers
Problems with various environments or seasons
Stomachache
Suboptimal athletic performance



EIB has multiple triggers that can lead to poor symptom control or frank bronchospastic exacerbation. Cold, dry air classically induces symptoms. Patients may note worsening bronchospasm during viral illness. Because allergic rhinitis and EIB are associated, inhaled seasonal allergens also play a role.Other irritants include dust, automobile exhaust, and chlorine. The most problematic irritant is tobacco smoke; all patients with EIB should be strongly encouraged not to smoke.

Diagnosis
An old adage states, "All that wheezes is not asthma." Krieger17 provides a review of reasons for wheezing other than asthma. Similarly, symptoms seemingly related to exercise may not be due to EIB. Other diagnostic considerations include vocal cord dysfunction, gastroesophageal reflux disease (GERD), and panic disorder.Vocal cord dysfunction can mimic asthma with such complaints as "difficulty getting in air," dysphonia, and an uncomfortable throat tightness. Patients with GERD may have shortness of breath as a result of micro-aspiration of stomach contents into the respiratory tree. These patients also experience frequent belching, dyspepsia, and a metallic or foul taste in the mouth. Panic attacks and frequent anxiety before athletic events are characteristic of panic disorder.

As with any diagnosis, detailed history taking and physical examination are crucial. Determination of which activities trigger which symptoms is necessary for the initial consideration of EIB. Physical examination may reveal signs of allergic rhinitis, such as postnasal drip, turbinate discoloration, and infraorbital ecchymosis. Wheezing found on lung examination at rest may indicate chronic asthma.

If EIB is suspected, the diagnosis can be confirmed by measurement of peak expiratory flow or with spirometry.In the physician's office, patients can undergo an exercise challenge on a treadmill, attaining 85% to 95% of maximum heart rate. Peak flow and spirometry values are recorded before and after physical activity. (Patients should not take an antihistamine or bronchodilator for 48 hours before testing.) A documented reduction in peak flow of 15% or more is diagnostic of EIB.A reversal of peak flow reduction after bronchodilator use can confirm the diagnosis.

Other methods of documenting potential for bronchospasm include a respiratory challenge with methacholine, histamine, or cold air. These methods often are restricted to a hospital or advanced outpatient setting. An easier but less exact method is to have patients record their peak flows at home with a peak flow meter before and after vigorous exercise. Empirical treatment with a fast-acting bronchodilator that induces subsequent improvement of symptoms also can aid in cost-effective diagnosis.

EIB Versus Chronic Asthma
Controversy remains as to whether patients with EIB actually have chronic asthma with strictly an exercise component. The current literature on EIB and chronic asthma adds to the confusion. Many authors still use the term exercise-induced asthma, although this usage is discouraged. By definition, asthma has broncho-spastic and inflammatory components, yet patients with EIB alone do not have the inflammatory element. Furthermore, many studies on the treatment of EIB have included patients with chronic asthma whose symptoms worsen with exercise. This inclusion makes it difficult to determine whether certain therapies are efficacious in patients without true asthma.

Specific differences between EIB and chronic asthma exist.Patients with EIB usually have normal lung examinations at rest. Peak flow and spirometry values also are normal at rest. Patients with EIB experience symptoms at a particular level of exertion and need medication only before exercise, which also suggests a lack of inflammation and only transient bronchoconstriction. Patients with chronic uncontrolled asthma typically wheeze while at rest and have abnormal peak flow and spirometry values at rest. These patients generally require long-term therapy plus additional medication before exercise. It is important to note that there is no evidence that patients with EIB eventually have chronic asthma.

Treatment
There are various pharmacologic and nonpharmacologic treatment options for EIB (table 2). A general principle in pharmacologic therapy is to use the shortest-acting drug and to introduce longer-acting therapies when it does not control symptoms.

TABLE 2. Treatment Options in Exercise-Induced Bronchospasm


Nonpharmacologic
Avoidance of viral infection
Exposure to humidified air
Induction of refractory period
Nasal breathing
Treatment of underlying allergy
Use of face mask during activity
Pharmacologic
Short-acting bronchodilator (albuterol)
Mast cell stabilizer (cromolyn sodium [Intal])
Long-acting bronchodilator (salmeterol [Serevent])
Leukotriene inhibitor (montelukast sodium [Singulair], zafirlukast [Accolate])
Antihistamine (cetirizine HCl [Zyrtec], loratadine [Claritin], fexofenadine HCl [Allegra])



The hallmark of pharmacologic treatment for EIB is short-acting bronchodilators such as beta-agonists.Many patients prefer these medications, such as albuterol, because they require administration only before exercise to control symptoms. Two to four puffs taken 15 minutes before exercise provide about 4 hours of relief. Side effects of beta-agonists include palpitations, tachycardia, and tremors, but these usually are mild. Tolerance to beta-agonists can develop if they are used often and in the long term.

Mast cell stabilizers are sometimes used as second-line therapy for EIB. These agents work by preventing leukocyte degranulation and resultant histamine release. Examples of such drugs include cromolyn sodium (Intal) and nedocromil sodium (Tilade). Patients take the medication 15 to 60 minutes before exercise, and its benefits last about 4 hours. A recent Cochrane review of nedocromil sodium use to prevent EIB19 showed it improved forced expiratory volume in 1 second (FEV1) by an average of 16% and shortened the duration of EIB symptoms to less than 10 minutes.

Longer-acting beta-agonists are another option for patients with EIB. Salmeterol (Serevent) has been shown to significantly improve FEV1.20,21 When these medications are taken 30 minutes before activity, they can provide relief for up to 12 hours, making them good treatment options for athletes whose exertion is prolonged.19 However, long-term use seems to shorten the duration of action.

Other adjunctive medicines, such as antihistamines, can help treat EIB by assisting with the allergic component of the disease. Cetirizine hydrochloride (Zyrtec) may be particularly helpful, because recent studies have shown it decreases airway resistance over time and improves lung ventilatory function.

If symptoms refractory to the previously mentioned medications persist, underlying inflammation from chronic asthma should be considered. A number of anti-inflammatory asthma medications have been studied in the setting of exercise. Regular use of an inhaled corticosteroid can reduce exercise-induced symptoms by as much as 50%.24 Leukotriene inhibitors also have been shown to be beneficial during exercise. Montelukast sodium (Singulair) and zafirlukast (Accolate) improve FEV1 by about 10%, and the effects can last for 24 hours.

In the Field
Physicians should have a plan for managing athletes with EIB during competitive events. These athletes should have a fast-acting bronchodilator with them at all times and can use a beta-agonist inhaler before activity. Also, they can perform warm-up exercises, such as wind sprints, at submaximal intensity in an effort to induce an early phase of EIB.After EIB enters the refractory period, participation can begin.

A fast-acting inhaler may be used for rescue therapy if symptoms recur or worsen. In addition to the two inhaled puffs taken before exercise, another dose of two puffs can be used. If an athlete's symptoms persist and further treatment is needed, the inhaler can be used again, but activity should be stopped. The physician should closely monitor the athlete's respiratory status. Despite providing optimal care, the physician may be in the unenviable position of removing the athlete from competition.

Conclusion
Controversy continues about the terminology, causes, and treatment of respiratory symptoms related to exercise. Despite this controversy, EIB is a common disease that can be easily diagnosed and treated by the primary care physician. Patient education is a crucial part of the treatment regimen.

Exercise may not alter the likelihood of future exacerbations, but it should be encouraged nonetheless. As demonstrated by the success of Olympic competitors with EIB, any athlete—from the recreational to the elite—can fully participate in exercise when his or her condition is properly recognized and treated.

The treatment and prevention of gait disturbances depends on the cause. Once the cause is treated, the disturbance will often go away. Recurrence of the disturbance can usually be prevented by preventing the injury or illness that caused the disturbance.

One of the most common causes of gait disturbances is pain. When a disturbance is caused by pain, it may be eased by rest, ice therapy, and elevation. Analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) may also be used. Typically, if the cause of the pain is removed, the resulting gait disturbance will vanish as well. Some causes of gait disturbances may require hospitalization, antibiotics or even surgery, such as arthroscopy,leg surgery or spine surgery.

Devices such as splints, casts, canes or braces may improve mobility and function. These tools may be of particular assistance when gait disturbances seriously interfere in the patient’s daily activities.

There are many treatment methods that can help correct or decrease gait disturbances. These methods may focus on treating the underlying cause of the problem as well as the actual gait disturbance. These methods include:

Physical therapy (PT). Physical therapy is commonly used to improve muscle tone, strength and balance and to teach correction techniques. PT can help determine the cause of the gait disturbance and it is often prescribed by a physician after a structural injury or surgery. PT may be particularly useful when a gait disturbance has existed for a long time and has become habitual.

Occupational therapy (OT). Occupational therapy may be used to teach a patient how to maximize independence in daily activities, such as bathing and housekeeping, that may be affected by a gait disturbance. An occupational therapist may visit a patient’s home to make recommendations for assistive devices, such as grab bars in the shower or elevated toilets.

Manipulation therapy. A chiropractor may help with gait disturbances with treatment for spinal problems (misalignment) or posture difficulties. Chiropractic treatment may be successful in treating the cause as well as reducing pain from gait problems.

Complementary and alternative medicine (CAM). Therapies such as acupuncture or biofeedback may help treat the cause and reduce pain or problems from gait disturbances.

There is no sure way to avoid gait disturbances, but it helps to practice general good health measures. For example, getting regular exercise, eating nutritious food, controlling weight,having routine medical care, limiting alcohol and abstaining from tobacco may reduce the risk of conditions ranging from osteoarthritis to neuropathy. Safety measures such as driving defensively and using seatbelts and protective sports equipment reduce the risk of trauma that could impair walking.