Silent Strokes

Silent Strokes Predicted by Traditional Cardiovascular Risk Factors
By Todd Neale, Staff Writer, MedPage Today
Published: June 26, 2008
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine. Earn CME/CE credit
for reading medical news




BOSTON, June 26 -- Among more than 2,000 participants in the Framingham Offspring Study, about one in every 10 have had a silent cerebral infarction, with none of the clinical signs or symptoms of a stroke.

Researchers found the lesions when 2,040 participants were screened by MRI, Sudha Seshadri, M.D., of Boston University, and colleagues reported online in Stroke: Journal of the American Heart Association. The prevalence of silent cerebral infarcts (10.7%) increased with age, from less than 8% in those 30 to 49 to greater than 15% in those 70 to 89.

An increase in the Framingham Stroke Risk Profile score -- which estimates a patient's risk of having a stroke in the next 10 years -- was associated with a 27% increased risk of silent cerebral infarct (P<0.001). Action Points
--------------------------------------------------------------------------------

Explain to interested patients that this study found that about one in 10 healthy participants in a community-based study had had a silent cerebral infarction.


Point out that traditional cardiovascular risk factors were associated with an increased risk of having a silent cerebral infarct.
Risk of silent cerebral infarct was also significantly associated with three components of the risk profile, atrial fibrillation (P=0.033), hypertension (P=0.004), and increased systolic blood pressure (P=0.005).


"The findings reinforce the need for early detection and treatment of cardiovascular risk factors in midlife," Dr. Seshadri said. "This is especially true since [silent cerebral infarcts] have been associated with an increased risk of incident stroke and cognitive impairment."


Estimates of the prevalence of silent cerebral infarcts in community-based samples have ranged from 5.8% to 17.7%, depending on age, ethnicity, comorbidities, and imaging techniques, according to the researchers.


Although risk factors for clinical stroke have been linked to silent cerebral infarct in previous studies, they said, there is less information on its association with circulating biomarkers, such as plasma homocysteine, or intermediate phenotypes, like carotid artery intima-media thickness.


So the researchers evaluated the 2,040 offspring (53% female; mean age 62) of participants of the Framingham Heart Study using the MRI to identify infarcts larger than 3 mm. All participants were free from clinical stroke.


Of the 220 (10.7%) who had had a silent cerebral infarct, 84.1% had a single lesion. The lesions were located in the basal ganglia (51.9%), other subcortical areas (34.8%), and cortical areas (11%).


The fact that most of the lesions were found in subcortical areas supports the hypothesis that silent cerebral infarcts produce subtle neurological damage "because they occur in clinically ineloquent areas of the brain," the researchers said.


Participants with an infarct were slightly older (61 versus 58) and had a higher systolic blood pressure (132 versus 126 mm Hg).


Silent cerebral infarctions were significantly associated with the following risk factors:


Framingham Stroke Risk Profile score: OR 1.27, 95% CI 1.10 to 1.46, P<0.001
Systolic blood pressure: OR 1.23, 95% CI 1.07 to 1.42, P=0.005
Hypertension: OR 1.56, 95% CI 1.15 to 2.11, P=0.004
Atrial fibrillation: OR 2.16, 95% CI 1.07 to 4.40, P=0.033
Plasma homocysteine: OR 2.23, 95% CI 1.42 to 3.51, P<0.001
Carotid stenosis ³25%: OR 1.62, 95% CI 1.13 to 2.34, P=0.009
Common carotid artery intima media thickness: OR 1.20, 95% CI 1.02 to 1.40, P=0.026
Internal carotid artery intima-media thickness: OR 1.32, 95% CI 1.13 to 1.54, P<0.001

The researchers said the findings demonstrate a significant relationship between atrial fibrillation and silent cerebral infarction, although it is unclear from the data whether screening for and treating the heart condition would be useful.


They acknowledged that the findings may not be generalizable to patients who are not of European descent.


The study was also limited, they said, because the participants underwent only one MRI.


The study was supported by the Framingham Heart Study's National Heart, Lung, and Blood Institute contract and by grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke.


The authors made no disclosures.



Primary source: Stroke: Journal of the American Heart Association
Source reference:
Das R, et al "Prevalence and correlates of silent cerebral infarcts in the Framingham Offspring Study" Stroke 2008; DOI: 10.1161/STROKEAHA.108.516575.

Apfelmilch für Erkältungen

Apfelmilch vertreibt Husten und Fieber
von Sylvia Schneider

Probieren Sie einmal, ob Ihnen Apfelmilch bekommt. Dazu vermischen Sie 1/2 Liter Apfelsaft, 1/2 Liter Milch mit 2 bis 4 Esslöffeln Honig. Erhitzen Sie dieses Gemisch bis kurz vor dem Siedepunkt, dann seihen Sie es durch ein feines Leintuch ab.
Die Apfelmilch, von der Sie am Tag einen halben Liter in kleinen Portionen zu sich nehmen, hilft Ihnen bei Nervenschwäche, Verdauungsstörungen, Husten, Fieber, Erkältungen, Leber- und Gallenstörungen.

Red Wine May Curb Fat Cells

June 17, 2008, 9:08 am
Red Wine May Curb Fat Cells
wineAnother reason to drink red wine. (Owen Franken for The New York Times)

Red wine appears to protect the heart and prolong life. Now a new study suggests it may also be a weapon against obesity.

Resveratrol, a compound present in grapes and red wine, appears to inhibit the development of fat cells and have other anti-obesity properties, according to a report from researchers at the University of Ulm in Germany. The findings, to be presented this week at The Endocrine Society’s annual meeting in San Francisco, show that in laboratory experiments with so-called “pre-fat cells,'’ resveratrol prevented them from converting into mature fat cells. Resveratrol also hindered fat storage in the cells.

The compound also reduced production of certain cytokines, substances that may be linked to the development of obesity-related disorders like diabetes and clogged coronary arteries. Resveratrol also stimulated the formation of a protein called adiponectin. The substance, known to decrease risk of heart attack, is diminished by obesity.

“Resveratrol has anti-obesity properties by exerting its effects directly on the fat cells,” said the study’s lead author, Pamela Fischer-Posovszky, a pediatric endocrinology research fellow in the university’s diabetes and obesity unit. “Thus, resveratrol might help to prevent development of obesity or might be suited to treating obesity.”

Whether to add red wine to your daily diet must be balanced against other health risks. For people with alcohol dependency problems, the health benefits of red wine are far offset by the risks of drinking to excess. Excessive use of alcohol can lead to addiction, traffic accidents and potentially fatal medical problems.

Increasingly, studies support the idea that drinking a small amount of alcohol each day — no more than one to two servings — is better for you than not drinking, but the findings don’t apply to everyone. Even small amounts can increase risk for certain health worries, like breast and colon cancer. Although those risks are generally offset by the extra heart benefits, some people may decide it is not worth it.

Prolotherapy + Inflammation -- the good kind.

How Many Shots?
While the notion of getting a lot of injections into your body may not be appealing, surely you want every area of your body treated that is causing pain? Is it any wonder when a person goes to a Prolotherapy doctor and gets two or three shots why they don’t get completely better?

We all know conceptually if you injure a structure in a joint that over time that injury is going to affect all the structures of the joint. Most people come to a Prolotherapist after they have had the pain for several years. What may have started out as a simple ligament sprain, after 3-6 years is now a total joint problem. All the structures of the joint and around the joint (or at least the majority of them) need to be treated with Prolotherapy to completely alleviate the pain!

It is common for me to see patients for the first time who talk about the one shot Prolotherapy they received at another office. While in the most technical sense, this might be Prolotherapy, (because they used a Prolotherapy solution), it may not be effective. To be effective, the Prolotherapist must do the following:

*

Stimulate all the structures that are injured to heal.
*

Use enough solution per structure to induce a sufficient healing reaction.
*

Use a strong enough solution per structure to induce a sufficient healing reaction.
*

Help the person obtain maximum health if their health is not good.
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Assist the person in getting off medications, supplements, or traditional hormones (like birth control pills) that inhibit healing.
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Assist the person to get their lifestyle and relationships such that they help, rather than hinder, progress.

There is obviously more to it than the above, but the main point here is that in the history of Caring Medical, we have never had one patient ever leave the office disappointed that they didn’t get enough shots!

Prolotherapy Not Working?
Don't Stop The Inflammation
This means you should not be taking any anti-inflammatories or narcotic medications, which inhibit the immune system and inflammation. Tylenol, acetaminophen, muscle relaxers, and Ultram are okay. These help decrease pain, but do not inhibit the inflammatory response. Herbs, enzymes and vitamins are also very helpful, but avoid ginger as this inhibits prostaglandin synthesis which is needed for proper inflammation.

Knee Pain - Experimental Treatments

Novel Remedies for the Aching Knees of Summer
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By VICKY LOWRY
Published: June 29, 2004
The start of summer is a busy time for Dr. Robert S. Gotlin, director of orthopedic and sports rehabilitation at the Beth Israel Medical Center in Manhattan. That is when his waiting room swells with patients who want to see him about their knees.

''The complaints of knee pain are directly proportional to the change in seasons,'' Dr. Gotlin said. ''People run more in the spring and summer, and the pain usually comes from upping the mileage. It's hard not to overdo it when the weather is so nice.''

Knee pain, Dr. Gotlin added, ''is catching up to back pain as the No.1 physical disability seen by sports medicine physicians.''

Overdoing it, as Dr. Gotlin put it, is a major cause of sore knees and can lead to osteoarthritis. Knee pain can also result from torn ligaments, supporting excess weight and mechanical problems like having one leg shorter than the other or misalignment of the knee.

In the most severe cases, surgery may be necessary. But in recent years, more non-surgical treatments have become available, including new drugs that can be injected, applied topically or taken as pills.

The first course of action for a sore knee, experts say, is to turn to familiar home remedies for sports injuries, including ice, heat and over-the-counter anti-inflammatory medications like ibuprofen to reduce swelling and control pain. Doctors often recommend icing the knee in several short sessions at a time for the first 24 to 48 hours.

''I tell my patients to ice twice a day, for five minutes at a time, five minutes on, five minutes off, for a total of 15 minutes with the ice on,'' Dr. Gotlin said, adding that a bag of frozen peas can cover the knee or an icepack can be placed on a thin sheet of fabric to avoid freezing the skin.

After two days, patients can try heat, preferably moist heat like a hot-water bottle or a warm soaking in the tub, to relax tissues and increase blood flow.

If the pain does not go away in a few weeks, then it is probably time to see a doctor, who may prescribe stronger drugs, nonsteroidal anti-inflammatory medications like Vioxx, Bextra or Celebrex to reduce swelling quickly.

Vioxx and its pharmaceutical cousins are not the only pills that runners and other active people use for pain. In the last 10 years, glucosamine and chondroitin, two substances that occur naturally in the body and are sold as nutritional supplements, often combined in one tablet, have gone from being largely ignored to being widely recommended for treating osteoarthritis of the knee. Unlike traditional anti-inflammatory medications, glucosamine and chondroitin are thought to work against osteoarthritis by decreasing the rate of cartilage destruction involved in the disease and possibly increasing the formation of new cartilage.

The federal government is financing a major study on the effectiveness of the supplements, to be completed in 2005. A variety of other, smaller trials have found positive results, and anecdotal accounts of their ability to relieve arthritic pain abound.

''Dogs don't lie,'' said Dr. William Cabot, an orthopedic surgeon in Atlanta. ''My friend had a golden retriever with arthritis. Homer couldn't even get up off the floor. At the end of several months of taking glucosamine, he was jumping up on the bed. That tells me it works.''

One drawback to glucosamine-chondroitin combinations is that they take a while to have an effect, at least four to six weeks of taking up to 1,500 milligrams a day, Dr. Cabot said. ''That's why a lot of people just stop using it,'' he added.

A common spice could turn out to offer quicker relief, but its effectiveness is not yet proven. Ginger, whose active ingredient is an oil called gingerol, has been used to treat the common cold and motion sickness. In a recent study conducted by researchers from Miami Veterans Affairs Medical Center and the University of Miami, patients with osteoarthritis of the knee who took ginger extract had a noticeable reduction of knee pain on standing, as well as an increase in knee function.

''Ginger works in a similar fashion to traditional anti-inflammatory medication like ibuprofen by decreasing the production of inflammatory substances like prostaglandins,'' said Dr. Cabot, a member of the committee on complementary and alternative medicine of the American Academy of Orthopaedic Surgeons.

But some scientists have said the study's results are not definitive. In addition, ginger is not without side effects. ''It can cause bleeding from the stomach, and can cause stomach upset, if you take enough of it,'' Dr. Cabot warned.

Taking too much vitamin C may not be good for people with knee pain, experts say. A study published this month in the Journal Arthritis and Rheumatism by researchers at Duke found that prolonged use of high doses of vitamin C seemed to make knee osteoarthritis worse in guinea pigs. The animals exposed to the highest doses of vitamin C over an eight-month period had more severe arthritis than those exposed to low or medium doses, the investigators reported.

In some cases, more aggressive approaches to knee pain, including surgery, may be necessary. Many doctors are now injecting knees with hyaluronic acid, a thick fluid that the body manufactures in the joints and that can be extracted from a rooster's comb. Hyaluronate injections, first used in the 1970's to treat post-traumatic arthritis in race horses, were approved for use in humans by the Food and Drug Administration in 1997. They have shown promise for lubricating the knee joint and soothing pain. (The injections are also used to reduce wrinkles on the face).

Dr. Kevin Plancher, an orthopedic surgeon with offices in Manhattan and Greenwich, Conn., said the shots ''play a definite role in my practice.''

The injections can also be given after surgery.

While scientists are not exactly sure why hyaluronic acid seems to work -- it may reduce inflammation or have an analgesic effect -- the benefits from a single shot can last up to six months, Dr. Plancher said.

Another new practice, injecting a common antibiotic not yet approved for use in the knee, may not only reduce pain but may halt cartilage loss in osteoarthritis. In a study of 431 women, ages 45 to 64, all of whom had osteoarthritis in one knee at the start of the trial, half the participants were injected twice a day with doxycycline, a prescription medicine used to treat infections. At the end of the 30-month trial, the researchers found, X-rays showed a significant slowing of cartilage loss in the women who received doxycycline. The study was presented last fall at the meeting of the American College of Rheumatology.

''Many of the medicines used to treat osteoarthritis -- nonsteroidal anti-inflammatory drugs like Vioxx and Celebrex -- deal with the symptoms, not with the basic pathology of the joints,'' said Dr. Kenneth Brandt, the study's principal investigator and a professor of medicine and of orthopedic surgery at Indiana University School of Medicine.

Some topical painkillers also show promise for treating osteoarthritis. Celadrin, a cream containing cetylated fatty acids, eased pain and improved knee function and mobility in patients with osteoarthritis, according to a recent study published in The Journal of Rheumatology. The benefits appeared as quickly as 30 minutes after the cream was applied, the researchers reported.

''Every patient in the study who used the compound got some level of relief,'' said Dr. William Kraemer, the study's lead author, who is a professor of kinesiology at the University of Connecticut in Storrs.

In another study, an analgesic patch containing lidocaine provided significant pain relief, according to the subjects who wore the patch over the most painful area of one or both knees for two weeks. ''It produces an analgesic effect without numbing the skin,'' said Dr. Joseph Gimbel, medical director of the Arizona Research Center in Phoenix and one of the study's principal investigators.

The patch, currently approved for use in treating shingles pain, is expected to receive F.D.A. approval as a treatment for knee pain within two years, Dr. Gimbel said.

In the meantime, for runners on the verge of overdoing it, maintaining a regular stretching and strengthening program throughout the year may be the best protection for knees, experts say.

''Don't wait until summer to start running more,'' Dr. Gotlin said. ''Working out year-round is the best preparation for when it comes time to pick up the pace. You'll be more physically fit and have less chance of injury.''

It's Tangy, But It May Not Stop Your Knees From Aching


Several studies conducted within the last three years suggest that ginger may reduce knee pain. But is the evidence good enough?

The largest trial to date of ginger's merits as a knee treatment was a six-week, placebo-controlled trial by researchers at Miami Veterans Affairs Medical Center and the University of Miami. Its results were published in 2001 in Arthritis and Rheumatism, the monthly journal of the American College of Rheumatology. At the end of the study, the subjects with knee osteoarthritis who took ginger had less pain and greater knee function.

Dr. David Pisetsky, a professor of medicine at Duke and the editor of the arthritis journal, said the study's methodology was scientifically rigorous enough that the findings ''should get a fair hearing.''

Nonetheless, in an accompanying editorial, the journal's editors said ''ginger should not be recommended at present for treatment of arthritis because of the limited efficacy shown in this study,'' and ''the lack of meaningful information about its safety.''

Other researchers agreed that more evidence was needed. ''A study would have to be done on a bigger scale with more impressive results than this before I would be impressed,'' said Dr. Gimbel, the medical director of the Arizona Research Center in Phoenix, an independent research site that conducts clinical drug trials.

For now, ginger may be best for treating a hankering for Chinese takeout. As for pain relief, the jury is still out. Vicky Lowry


Correction: July 6, 2004, Tuesday An article in Science Times last Tuesday about nonsurgical treatments for knee pain misstated a method used in a study of doxycycline as a treatment for osteoarthritis. The drug, an antibiotic, was given by mouth, not injected. The article also misstated a finding of the study about the drug's effect. The subjects who received it were less likely to report that mild knee pain had worsened; their pain was not reduced. The article also referred incorrectly to the status of doxycycline treatment for knee pain. It is experimental, not yet a practice.

Pain - not enough done!

February 15, 2005
PERSONAL HEALTH
When It Comes to Severe Pain, Doctors Still Have Much to Learn
By JANE E. BRODY

y surgeon did a marvelous job replacing my arthritic knees and, at the same time, straightening my terribly bowed legs when, at 63, I decided to have knee replacement surgery.

Although a class given at the hospital before the operation repeatedly emphasized the importance of adequate pain control, the surgeon and his helpers were not experts in treating prolonged, debilitating postoperative pain.

They are hardly alone. Pain management is not generally taught as a part of medical education, not even to residents in orthopedic surgery. As a result, most doctors are clueless or unnecessarily cautious about treating pain, especially chronic pain like that caused by incurable neurological or muscular disorders.

They are especially ill-informed about opioids, which are synthetic versions of morphine, the most potent painkillers that can be taken by mouth.

As Dr. Jennifer P. Schneider writes about opioids in her book "Living With Chronic Pain" (Healthy Living Books, $15.95), "Fear and lack of knowledge of these drugs prevent many doctors from prescribing them for people whose pain is caused by anything other than cancer."

Yet, she continues, in 1995 The Journal of the American Medical Association lamented the reluctance of physicians to prescribe needed pain medication. The journal stated: "Bringing about significant change may depend on empowering patients to demand adequate pain treatment. This empowerment will not come easily, especially if opioids must be used for pain relief and if the pain is of a nonmalignant origin."

Pay attention, current and future patients. The journal's message is really for you: Learn what you can about pain control and insist that experts in treating pain help you through it.

A Painful Lesson

I did not know that the dose of the sustained-release opioid OxyContin (oxycodone) that I was taking - 20 milligrams twice a day - was a "low" dose until seven weeks after surgery.

I also did not know that the other pain drug I was prescribed for breakthrough pain, Percocet, was really short-acting oxycodone plus acetaminophen. Because my pain was frequently intolerable despite the two doses of OxyContin, I was taking as many as 10 Percocets a day, incorrectly using it as a maintenance drug.

Yet, when I complained about the severity of my pain, which had me crying for several hours a day, the surgeon added an anti-inflammatory drug and told me to take half the OxyContin and Percocet. No surprise that my pain remained unrelenting and occasionally worsened.

I called the surgeon's office weekly and reported my minimal progress in pain control, but at no point was an increase in pain medication suggested, nor was I referred to a pain management specialist on the hospital staff.

When, at seven weeks after surgery, I spoke to Dr. Schneider, a Tucson-based specialist in pain management and addiction medicine, she chastised me for not being more insistent about getting adequate pain relief. The trouble is, when you're experiencing intense pain, it's hard to be proactive about anything.

I know now from speaking with several doctors who routinely treat chronic pain patients that my story is hardly unique. Millions of people suffer needlessly year after year because their doctors do not know how to treat pain properly and don't refer patients to doctors who do know.

Many doctors are afraid to prescribe narcotic drugs like oxycodone, fearing they will create addiction problems. But that in fact rarely happens to chronic pain patients who don't have a history of addiction. When a pain patient needs increasing doses of a narcotic, it's nearly always because the pain worsens, as often happens in patients with advanced cancer. Patients do become tolerant to side effects, like grogginess, but rarely to the pain-relieving properties of these drugs.

When the Nerves Respond

Furthermore, undertreatment of pain can actually cause a chronic problem when the nervous system changes in response to continuing pain signals. Nerves can become permanently hypersensitive to painful and nonpainful stimuli, like touch or vibration. With chronically undertreated pain, the painful area can also spread well beyond the original injured site, as happened to a man I know who now has to take 500 milligrams a day of OxyContin.

"The way to prevent this undesirable outcome is to avoid repeated pain signals," Dr. Schneider said. "Long-acting opioids like OxyContin, which provide many hours of consistent pain relief, are more effective than short-acting opioids, like Percocet, at preventing pain. It takes less drug to prevent recurring pain than it takes to treat it."

However, Dr. Schneider wrote, "Because breakthrough pain is common in patients with chronic pain, patients being treated with long-acting opioids often need a second prescription for an opioid with rapid onset" to treat breakthrough pain. These second medications are "meant for transiently increased pain, not as part of your regular pain regimen," she explained.

When I read this, I realized I was on the wrong track, taking too little of the long-acting drug and too much of the short-acting one. The latter had, in effect, become my maintenance drug rather than the one I used now and then when, say, I had physical therapy or spent hours riding in a car.

Surgeons may know a great deal about cutting, repairing and sewing up, but they are not experts on pain control, though I think they should be. I know of an orthopedic surgeon in New Jersey who won't see his knee replacement patients for two months after surgery because he doesn't want to see them when they're suffering.

As it turned out, my internist knew far more than my surgeon about treating pain. He has many elderly patients with chronic pain and knows very well how to treat it. I realize now I should have sought his help from the beginning. Or I should have asked to be referred to a pain management specialist at the hospital where I had my surgery.

Let's Fix What's Broken

First and foremost, patients need to be proactive and insist on the help they need. If patients are not able to do this for themselves, an advocate should do it for them.

Second, every person with prolonged or chronic pain should become educated about the huge range of medications, therapies and complementary remedies available to treat pain.

"Most chronic pain patients receive more than one type of drug and end up taking a cocktail of pills," Dr. Schneider said. The many possibilities include anti-inflammatory drugs, muscle relaxants, drugs like anticonvulsants that treat nerve pain, antidepressants (in doses much lower than that used to treat depression), topical analgesics and sleeping pills.

In addition to using combinations of drugs to control pain that does not respond to one remedy alone, Dr. Schneider writes that patients may be helped by physical therapy, exercise, acupuncture, electrical stimulation, heat, massage, yoga, hypnosis (including self-hypnosis), cognitive-behavioral therapy, biofeedback and various relaxation techniques like guided imagery, meditation and progressive muscle relaxation.

Dizziness

Breakthrough Findings on Dizziness


Jeffrey P. Staab, MD
University of Pennsylvania Health System

magine waking up in the morning and deciding what to do that day based on how dizzy you feel. Are you stable enough to walk down the stairs... drive a car... lift your grandchild? Now imagine that doctors have told you they could not find a cause and there was nothing more they could do to help.
Up to 15 million people in the US have recurrent episodes of dizziness, and about 3 million feel dizzy nearly every day. These are not cases of mild light-headedness, but true dizziness that can affect a person's ability to work, shop, take care of his/her family and perform other daily tasks.
Latest development: New research is enabling doctors to properly diagnose nearly everyone who suffers from chronic dizziness -- and offer treatments that may eliminate or significantly reduce symptoms.
WHAT IS DIZZINESS?
Two main categories of dizziness...
Vertigo. People with vertigo experience "rotary motion" -- they feel that they are spinning or tumbling or that the world is spinning around them. Vertigo is caused by a problem in the inner ear or in the balance center of the brain.
The most common causes of vertigo are relatively easy to diagnose. They include benign paroxysmal positional vertigo (BPPV), in which calcium crystals in the inner ear break loose and enter one of the semicircular canals that help with balance... viruses that infect the vestibular nerve (which carries balance and coordination signals to the brain) or the inner ear... and Ménière's disease (which is associated with abnormal buildup of fluid in the inner ear). A physical exam, balance function tests and a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the brain may be needed to diagnose the specific cause of vertigo.
No vertigo. Some patients develop chronic dizziness without ever having vertigo. Others have had bouts of vertigo in the past but now have chronic dizziness with no vertigo. In both cases, there may be no overt signs of inner ear damage or disease.
In the last few years, a condition called chronic subjective dizziness (CSD) has been described in medical literature to help doctors understand patients who have persistent dizziness without vertigo. People with CSD have a sense of being unsteady, swaying or rocking, but not spinning. They are sensitive to motion -- they can feel dizzy when they are physically active... or even in a mall or crowded party, where there is a great deal of visual stimuli.
HIDDEN CAUSES OF DIZZINESS
Until recently, about 25% to 30% of people with chronic dizziness were considered medical mysteries, and their dizziness went untreated because no definite physical cause could be found.
Now: A February 2007 study of 345 people with CSD found that all of these cases were due to one of the following causes...
Anxiety-related hypersensitivity to motion cues. Sudden episodes of dizziness can be caused by a physical illness, such as those described above, or a psychiatric condition, such as a panic disorder.
Patients who experience acute attacks of dizziness may develop hypersensitivity to motion cues -- that is, they become cautious about their own movements and hypervigilant about the motion of objects around them. Motion hypersensitivity may last for many years, even after the problem that triggered the original symptoms has resolved.
Migraine. In migraine sufferers, dizziness can occur before, during or after the headache. Some migraine patients don't experience severe headaches but rather a sensation of pressure in the head or behind the eyes.
Mild concussion. A mild concussion is a head injury that does not cause visible physical damage to the brain but is characterized by headache, moodiness, dizziness, confusion and/or memory problems. In this case, the dizziness is thought to be due to fraying of the nerve connections in the brain that regulate balance.
Autonomic dysfunction (dysautonomia). As we get older, our autonomic nervous system, which regulates such vital functions as breathing and heartbeat, begins to function less efficiently, and we lose the ability to adjust to the effects of gravity on blood flow. When we change position, such as when getting out of bed, gravity pulls our blood toward our feet.
The autonomic nervous system counteracts this effect, preserving blood flow to the brain and other vital organs. But people with autonomic dysfunction become dizzy when they get up quickly or stand for long periods of time.
Heart problems. Disturbance of heart rhythms (arrhythmias) may cause dizziness, usually in spells lasting for minutes to hours. People who experience episodic (not constant) feelings of dizziness, along with palpitations (a rapid or fluttering heartbeat) and shortness of breath, should be evaluated as soon as possible for heart problems.
BEST TREATMENTS
Research shows that three treatments can reduce or eliminate dizziness in most people who experience CSD...
Antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) -- such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft) -- can decrease or eliminate dizziness, even in people who don't feel depressed or anxious. These medications may work by reducing activity in parts of the brain that promote motion sensitivity.
Physical therapy. A special treatment called vestibular and balance rehabilitation therapy (VBRT) helps patients identify movements and situations that trigger their symptoms. A specially trained physical therapist can develop a plan that includes a variety of movements designed to improve balance reflexes and decrease sensitivity to motion. To find a physical therapist trained in VBRT, consult the neurology section of the American Physical Therapy Association (800-999-2782, www.neuropt.org).
Cognitive behavioral therapy (CBT). Cognitive behavioral therapists can help patients counteract worries about the consequences of being dizzy and resume a more normal lifestyle. To find a CBT practitioner, consult the American Psychological Association (800-964-2000, http://locator.apa.org).


Bottom Line/Health interviewed Jeffrey P. Staab, MD, attending psychiatrist at the University of Pennsylvania Health System's Balance Center in Philadelphia. Dr. Staab was a contributing writer for The Consumer Handbook on Dizziness and Vertigo (Auricle Ink) and has published more than 30 journal articles on dizziness and anxiety.

Recovery after Sport

June 1, 2008
Phys Ed
Swallow This
By GRETCHEN REYNOLDS
From the perspective of an athlete, few things top the virtuous satisfaction that comes from a hard workout. That 10-mile run, that 1,500-meter pool sprint, that hour with the free weights. Makes you feel great, right? You’ll do it again tomorrow, for sure. But then it hits — the aftermath.

Within a few hours, your muscles begin sending vicious little reminders about your impressive efforts. Delayed-onset muscle soreness, as it’s called, settles in roughly 12 to 24 hours after an intense bout of training, especially if it involved unfamiliar or extreme movements. The affected muscles become so tender and strained that the process of rising from bed the next morning becomes a challenge.

Even if you haven’t arrived at this sorry state, repeated hard workouts can tax the body in insidious ways. Muscles, over the course of an hour or so of serious work, use up most of their stored energy. Without remediation, those muscles won’t respond as well during your next workout. They’ll be more prone to injury. You’ll be slower. The 70-year-old from down the street will pass you on the running path.

Completing a hard workout, then, is just the first step. You also have to undo all the damage you’ve just done.

Start with your postworkout meal. The regeneration of your muscles begins, improbably as it may seem, with that. “Back in the early ’90s, most athletes, especially runners and cyclists, were preoccupied with carbohydrates,” says John Ivy, the chairman of the department of kinesiology and health education at the University of Texas in Austin and one of the pioneers of research into exercise recovery. This was in the heyday of carbo-loading, when athletes were convinced that the more pasta and bread they ate before a hard workout, the more stored energy they’d have.

But carbo-loading in advance of exercise is not the most efficient way to stock muscles with fuel, physiologists now know, thanks in large part to research conducted by Ivy. When reviewing studies of diabetics, he became intrigued by similarities with his own tests on cyclists: for both groups, insulin in the blood was more effective at carrying energy into the muscles if those muscles had recently been active. “Exercise makes your muscles more responsive to insulin, and this insulin, in turn, increases glycogen muscle uptake,” he says. In other words, exercise prompts your muscles to absorb more fuel — glucose, which is stored as glycogen — from the bloodstream. (Carbo-loading can’t take advantage of this insulin response because it precedes, rather than follows, a workout.) Your body is actually primed by the exercise to help itself replenish lost fuel.

This improved insulin response, however, lasts only for a brief time after a workout. “You have a window of about 30 to 45 minutes,” Ivy says. After that, muscles become resistant to insulin and much less able to absorb glucose. Drinking or eating carbohydrates immediately after a strenuous workout, at a level of at least one gram per kilogram of body weight, is therefore essential to restoring the glycogen you’ve burned. Wait even a few hours and your ability to replenish that fuel drops by half.

It’s also crucial that you take in some protein. Though it poses challenges to strict vegetarians, the latest research shows quite definitively that protein spurs even more of an insulin response than do exercise and carbohydrates alone. “Protein co-ingestion can accelerate muscle glycogen repletion by stimulating endogenous insulin release,” says Luc van Loon, an associate professor of human movement sciences at Maastricht University in the Netherlands and the author of several important studies about recovery. Translation: coupling protein with carbohydrates prompts your muscles to store even more glycogen for use during your next workout.

“I’d advise people to have their recovery drink ready and waiting for them before they leave on a run or long bike ride,” Ivy says. Ivy himself often drinks low-fat chocolate milk, but any food or drink that includes both carbohydrates and protein — a recovery drink, a smoothie, yogurt — will work.

Then have a real meal within two hours. “You can maintain increased insulin levels and accelerated rates of recovery for about four to six hours if you continue eating,” Ivy says. Of course, you can also get by without such diet timing. “But you won’t recover as well,” Ivy continues. “You probably won’t be able to work out as hard on a daily basis.” The old guy who chugs his milk and Hershey’s syrup will not only pass you — he’ll lap you.

Meanwhile, there’s the physical damage inside your muscles to consider. Skeletal muscle is a unique kind of tissue, made up of long, thin fibers composed of several different proteins. These proteins interlock like Legos inside fibrous compartments called sarcomeres. Sarcomeres can stretch, but only so far.

During certain kinds of movements, some sarcomeres are pulled past their tolerance. The proteins inside separate, resulting in micro-tears throughout your muscle tissue. After a few hours, this leads to inflammation, swelling, stiffness and pain. (Eccentric muscle contractions, which lengthen muscles, are the main culprit in delayed-onset muscle soreness. Concentric contractions, in which muscles shorten — the upward motion of a biceps curl, for instance — cause less damage. That’s why running downhill makes you more sore the next day than running on flat ground.)

“This soreness is actually a good thing,” says Thomas Swensen, a professor of exercise and sports science at Ithaca College in Ithaca, N.Y., and a leading researcher into exercise recovery. “You want to stress the muscles. They will adapt positively.” The muscles will rebuild themselves, becoming stronger and more pliable. “That’s the whole point of hard training,” he says. “But it’s only effective if you recover fully.”

Which is another reason it’s important to up your protein intake after a workout; that same protein will also help speed muscle repair. “Exercise stimulates muscle protein synthesis and protein breakdown,” van Loon says. “However, without protein or amino acid ingestion, the net balance between protein synthesis and breakdown will remain negative” — i.e., your workouts, in the long run, may do your muscles more harm than good. But eat enough protein immediately after exercising and your muscles will repair themselves fully and become stronger.

Other postworkout recovery strategies, including many that athletes swear by, have far less scientific backing. Take massage. A 2000 study of British boxers showed that postworkout massage made the athletes only feel as if they were recovering quickly; they did not perform any better than those not massaged. Swensen’s own 2003 study of massage and recovery produced similar results as the British research.

These studies, however, like many others that have examined massage and exercise, were small and short-term. “It’s possible that if you followed athletes over the course of several months,” Swensen says, “you might see some benefits from massage. Those studies haven’t been done.”

Similar ambiguity clouds the use of ibuprofen after exercise. Although advertised as an anti-inflammatory, ibuprofen doesn’t always work as expected. A 2006 study of the drug’s use among ultra-marathoners found that it did not lessen muscle damage or soreness or reduce inflammation. And although most users do not experience side effects, ibuprofen has been associated with kidney damage and gastrointestinal bleeding.

Finally, there are ice and heat. Many elite athletes swear by a limb-numbing ice bath, and others prefer a soak in a hot tub — although little scientific evidence supports either remedy. Ice will effectively block the swelling associated with a serious injury, such as a sprain, but has not been proven to speed the healing of muscle tissue stressed by a workout. In a study published last year in the British Journal of Sports Medicine, people treated with ice after strenuous exercise later reported more pain upon standing than people immersed in tepid water. The study’s authors bluntly concluded that their research “challenges the wide use of [icing] as a recovery strategy by athletes.” Similarly, a study published in March in the European Journal of Applied Physiology found that, when it came to muscle recovery, a hot bath was little better than merely sitting quietly for a while.

So where does that leave you, the athlete who has just worked out so diligently? Mixing a smoothie or glass of chocolate milk, the one recovery strategy that satisfies both your inner physiologist and inner child. .