Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
Common Injury Sites
Although bone stress injuries and fractures are not as frequent as other injuries seen in our Melbourne sports chiropractic practice, they are prevalent in active individuals and athletes. Stress fractures and bone stress injuries are more common in the lower extremity and include the bones in the feet (metatarsals and navicular), the leg bones (tibia and fibula), the thigh bone (femur), sacrum (pelvis), pars (lumbar spine). They can also occur in other less common areas like the humerus and wrist in tennis players and baseball pitchers.
Stress Versus Insufficiency Bone Fractures
When bone starts to fail there are two primary reasons for it. In the first instance normal healthy bone begins to fail under abnormal stress loading which is called a “stress fracture”. In the second instance there is abnormal bone which fails under normal stress loading called an “insufficiency fracture”. Insufficiency fractures occur when there is something systemically wrong within the body, resulting in abnormal bone health.
Bone Remodeling
Understanding bone health and how bones remodel is key to understanding why bone stress injuries and fractures occur. Two important cells in bone remodelling are osteoclasts and osteoblasts. Osteoclasts are like the demolition team who come in and break down old bone which is called “bone resorption”. Osteoblasts are the builders who come in a lay down new bone once the osteoclasts have removed the old bone which is called “bone formation”. This process is called “bone turnover” and in exercise is it vitally important, as bone turnover allows new bone to form and adapt to the stress loads that exercise is placing on the bone, helping the bone to adapt and become stronger. The entire process takes approximately 3-4 weeks under ideal conditions.
In the case of bone stress injuries and fractures the ideal conditions for bone turnover are compromised which can include alterations in bone nutrition; low vit d, low energy availability; rapidly increased training load; impaired endocrine function. Changes in these conditions ultimately leads to an imbalance between osteoclast and osteoblast activity, resulting in bone tissue break down occurring at a faster rate than new bone tissue can be laid down.
Bone Tissue Breakdown
To understand how this bone tissue breakdown process impacts bone health we need to think of bone health as a continuum. At one end of that continuum there is healthy bone and at the other end there is a fractured bone. Bone health can slide backwards and forwards along this continuum depending on those variables which impact bone health as mentioned above.
Let’s use an example to illustrate how bone moves down this continuum. For simplicity we will assume nutrition and endocrine function are normal. We will use a runner who is new to running with no prior running experience. Let’s assume they have a half marathon they are training for in 8 weeks. Because they have only a short period of time before the race, they start running 5 days a week. As they start running the osteoclasts begin breakdowning old bone so that new bone can be laid down to strengthen the bone as it adapts to the new impact loads going through the bone as a result of running. The more running, the more osteoclast activity occurs however, the osteoblast activity takes time to lay down new bone so an imbalance in the process begins to occur.
Initially this leads to microtrauma in the bone which will present clinically as a focal (specific) area of tenderness over the bone, mostly noticeable on impact activities like running, jumping, hopping etc This is called “bone marrow edema”. The runner notes this as ‘training pains’ as they are new to running. As they continue to run 5 days a week, bone tissue breakdown continues, while new bone formation is unable to keep pace due to the rapid increase in loading and lack of rest days. The microtrauma persists and the bone continues to slide down the continuum through the 4 stages of bone marrow edema finally resulting in macrotrauma to the bone tissue, creating a fracture site.
Clinically, this can present similar to an acute fracture where an instant acute pain is felt, or there can be continuously worsening acute pain which becomes present with simple activities like walking or weight bearing. Both force the individual to stop exercising and usually seek treatment.
Bone Stresss Injuries and Fracture Treatment
The way sports chiropractor Dr. Shannon at The Shannon Clinic – Melbourne Chiropractic and Sports Care treats bone stress injuries and stress fractures is through a complete and thorough work up which routinely includes other clinicians. The key questions that need to be established are “why has this injury occurred?” and “is this a bone health related injury or a training load injury?”. Our workups often include:
Looking at whether there is a prior history of bone injuries, as a prior stress fracture is a predictor of a future stress fracture injury.
Assessing bone health – DEXA, MRI, Vit D (serum 25) and Calcium blood tests
Assessing nutritional intake – energy availability
Assessing endocrine function
Assessing training load and volume
Assessing for biomechanical imbalances/weaknesses
Assessing for technique deficits
Fracture Healing Process
Once we have pertained the cause of the bone injury and have determined it is a training load injury and not a bone-related injury, we then move into treatment and education. Treatment to optimise bone health (nutritional and supplement support), strategies to allow the bone healing process to catch up, strengthening programs, education on training load management to mitigate the risk of reinjury, technique modification if required.
To book an appointment to have your bone pain assessed below and you will be in safe hands. Our sports chiropractic clinic is situated on Collins Street in the Melbourne CBD, opposite the City Square and Melbourne Town Hall.
Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
The COVID-19 pandemic created global disruption, uncertainty and with many countries enforced society into lockdowns, which made physical activity and exercise more onerous and challenging. However, one of the few exceptions to the lockdown rules was exercise, so Melbourne city chiropractor Dr. Shannon examines the evidence on exercise and immune function.
Does Acute Bouts of Intense Exercise Help or Hinder Immunity?
The “open window” hypothesis suggests that following a prolonged (>1.5hr) and vigorous acute bout of exercise or following chronic intense training (>1.5hr on most days) there is an “open window” which results in an increased risk of opportunistic infections such as URTI’s. The three principles underpinning this concept are:
1). Infection risk increases after prolonged vigorous aerobic exercise
2). Acute bouts of vigorous exercise can lead to temporary reductions in salivary immunoglobulins resulting in higher risk of opportunistic infections
3). A period of post exercise reduction in peripheral blood immune cells resulting in a period of immune suppression.
J Curve – relationship between the risk of infection and level of exercise intensity
Is The “open window” Hypothesis Still Relevant Today?
Recently though there has been emerging evidence suggesting this concept may be outdated. There is evidence, albeit small that indicates international athletes suffer from less URTI than national athletes. This raises the likelihood that infection susceptibility is more likely multifactorial including genetics, sleep, stress, nutrition, travel, circadian misalignment and increased exposure risks due to close proximity of crowds rather than being directly attributed to acute or chronic bouts of vigorous training. This also indicates that international athletes are potentially better supported, have access to better education helping them to improve their life-style behaviours over national athletes resulting in lower risks of infection.
Secondary to this, evidence supports the opposite of the three principles upholding the “open window” concept. With no changes seen in mucosal immunity which has previously been flagged as an indication of immune suppression. The reduction in blood immune cells (primarily lymphocytes) 1 to 2 hours post exercise reflects a transient and time dependent redistribution of immune cells to peripheral tissues resulting in a heighten state of immune surveillance and regulation leading to enhanced antibacterial and antiviral immunity, not suppression of the immune system.
Moderate to Vigorous Exercise Is Beneficial for Immunity
Further research is needed to confirm or refute the “open window” concept however, it currently appears that the infection risk post vigorous exercise is more likely to be associated with a multitude of other factors rather than purely post exercise immune suppression. So for athletes and non-athletes the message remain the same, regular moderate to vigorous exercise is beneficial to enhance immune function to reduce the risk of bacterial and viral infections including URTI’s. And remember that good hygiene practices (washing hands regularly, not touching your face), physical distancing, getting good quality sleep, reducing stress levels and eating healthy wholefoods are the keys keeping your immune system in peak condition. To read more on the importance of sleep you can find the Shannon Clinic Melbourne Chiropractic and Sports Care blog on sleep and performance here.
As a Melbourne city sports chiropractor Dr. Shannon advocates to all his patients the important of regularly exercise and utilizes exercise therapy with all patients. To work out what exercise is best, moderate continuouse or high intensity interval training check out our blog. If you are looking for an active way to rehabilitate your musculoskeletal injury book an appointment today at our Melbourne CBD chiropractic clinic on Collins Street in the Manchester Unity building opposite the Melbourne Town Hall and City Square.
Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
When people talk about the keys to living a healthy life and performing at your best, exercise and diet are always front and centre. Rightly so, as exercising at least 150 mins per week at moderate to vigorous intensity and eating a well-balanced diet rich in green leafy vegetables, fruits, grains and seafood and low in red meats and saturated fats are essential for longevity and a healthy life. But there is a third pillar that is regularly overlooked that is just as important as diet and exercise and that is sleep. In this blog Melbourne city chiropractor Dr. Shannon discusses the importance of sleep on athletic performance.
Sleep Deprivation
Sleep deprivation can be due to sleep disorders like insomnia and sleep apnoea. These disorders are often associated with symptoms such as difficulty falling asleep or maintaining sleep and require further clinical investigation. However, most sleep deprivation occurs due to poor sleep quality and duration. The average adult requires 7-9h of sleep per night yet those with sleep deprivation will get less than 5-6h of sleep per night. Some people pride themselves on their ability to work with very little sleep yet sleep deprivation has been shown to affect human (and athletic) performance in a myriad of ways including:
Impaired cognition effecting decision-making, judgment, mood, and reaction times
Metabolic disruption including diabetes and obesity
Weight gain to due craving more unhealthy and high carbohydrate foods and in larger portions
Immunological resulting in increased proinflammatory cytokines which impair immune function and impede muscle recovery and repair from damage
Cardiovascular dysfunction
An increased risk of injury
There is also a dose-dependent relationship between sleep and performance; the greater the sleep loss the greater the performance loss, with performance loss occurring with as little as 2-4h of sleep loss. And for those who believe they are able to recoup the sleep they lose during the week on the weekends, the evidence says the contrary.
Improving Sleep Quality and Duration
The two sleep interventions that have received most research are sleep extension and sleep hygiene. Sleep extension and napping involves extra sleeping time to make sure the 7-9h daily limit is being met; this is especially useful when one knows they have a day of potential sleep deficit ahead. Sleep extension might involve going to sleep earlier or utilization day time naps that are more than 20 mins but less than 60 minutes and occur before 3pm. Sleep hygiene helps to improve sleep quality and duration and essentially involves a healthy sleep routine such as:
Don’t go to bed if you aren’t sleepy
Rise at the same time every morning, including on the weekends
The bed is for sleeping only, don’t watch TV or use electronic devices in bed
Avoid caffeine after lunch
Avoid alcohol, especially before bed
Avoid high intensity interval training before bed
Try to create a dark, quiet and cool space to sleep (ambient temperature is 19+/-2 degrees)
Improvements in sleep extension can lead to improved skill specific execution in sports, improved cognition including reaction times. mood, alertness and vigor. While improved sleep hygiene results in less fatigue and sleepiness.
Final Thoughts on Sleep and Performance
Whether the goal is optimizing performance at work, in sport or about doing all you can to live a healthy life, sleep needs to be given as much attention as diet and exercise. By improving the quality and duration of sleep through better sleep hygiene and sleep extension one will yield benefits such as, reducing the risks of preventable disease like diabetes, obesity, cardiovascular disease, improved judgment and decision-making and optimized athletic performance and recovery.
If you are looking for other blogs on ways to improve performance check out Melbourne city chiropractor Dr. Shannon’s blog on how to improve your athletic performance in just 15 minutes with mental imagery or on the promising results seen with NMN supplementation in middle and older aged adults. To make an appointment with Melbourne city sports chiropractor Dr. Shannon or remedials massage therapist Paula Pena you can book below. Our Melbourne CBD chiropractic clinic is located on Collins Street, opposite the Melbourne Town Hall.
Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
Sedentary behaviour and your health
It might seem strange to hear the average working week in Australia has reduced by 2 hours per week however, that doesn’t mean people are working less, it purely represents a shift from productivity to outcome based performance measurements. Tied together with the development of new technologies and the introduction of flexible working options including working from home, it means workers days are stretched longer, they are available more of the time and are working more hours they don’t register.
Ultimately this leads to more sedentary behaviour at work. Anecdotally, Melbourne city chiropractor Dr. Shannon says this trend has become more pronounced since the pandemic, which is also coupled with a significant reduction in physical activity levels to well below the recommended guidelines of 150mins per week of moderate to vigorous activity.
Interestingly, the first occupational study looking at health outcomes in those who were physical active at work versus those who weren’t was published way back in 1951. The Morris paper looked at the rates of coronary heart disease (CHD) in bus drivers compared to ticket conductors and it was no surprise to see bus drivers had a higher incident of CHD compared to ticket conductors. To confirm these findings Morris and Crawford then compared the risk of heart attacks between postmen and government clerks and found a similar result; government clerks more often suffered heart attacks than postmen.
Fast-foward to 2019 where we now know that sedentary behaviour is associated with higher blood pressure, total cholesterol and poor cognition and academic performance. It is also strongly associated with all cause mortality, fatal and non-fatal cardiovascular disease, type 2 diabetes, metabolic syndrome along with being moderately associated with ovarian, colon and endometrial cancer.
Time to get moving!
As Morris showed in his studies, workers who were more active had lower incidents of cardiovascular disease (CVD) and this rings true today. In 2018 the Physical Activity Guidelines Advisory Committee Scientific Report highlighted the importance of physical activity which is linked to improved sleep, cognition, immune function, minimizing weight gain, reduced risks of depression, anxiety, dementia, colon, breast, bladder, endometrial, oesophagus, stomach, kidney and lung cancer as well as reduced risks of chronic preventable diseases like high blood pressure, type 2 diabetes and cardiovascular disease. There is also low grade evidence indicating sit to stand desk (ie. being more active) reduces low back pain in office workers.
Breaking up sedentary behaviour doesn’t need to be difficult, it might involve introducing a sit to stand desk to help modulate posture throughout the day, getting up from the desk and walking around the office at regular intervals, it could include exercising during the lunch break and for the extremely busy people think about replacing your car commute to work with a ride or run. Whatever it is you chose to break up your sedentary behaviour with, it is important that you are reaching the minimum guidelines for physical activity – 150 minutes of moderate to vigorous activity per week.
As a Melbourne city sports chiropractor Dr. Shannon advocates strongly the importance of physical activity, and utilizes exercise therapy with all his patient. If you would like to make an appointment to see chiropractor Dr. Shannon, or remedial massage therapist Paula Pena at our Melbourne CBD chiropractic clinic book below. Our Melbourne city chiropractic clinic is located on Collins Street, opposite the Melbourne Town Hall.
Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
In this blog Melbourne city chiropractor Dr. Shannon uses the wealth of knowledge he has in sports nutrition and nutrition for chronic disease prevention to discuss diets; as every other week there is a news article talking about the “best” diet for weight loss. There is the high protein diet, the low carbohydrate ketogenic diet, there are experts who say dieting doesn’t work, bloggers spruiking the benefits of the intermittent fasting diet, Instagram influencers telling us the key to weight loss is exercise, and of course it wouldn’t be complete without the latest celebrity diet.
Which Diet Is Best?
With all of this information it is hard to know who is right. In 2014 a meta analysis looked at a variety of diets to see how they compared against each other in relation to weight loss. They compared popular diets like the Atkins, Zone, Weight Watchers and Jenny Craig diets in overweight and obese adults. After 12 months, they found no difference between the diets, with all diets resulting in weight loss.
What about the argument that a well balanced diet is the key? A meta analysis in 2014 compared obese and overweight adults with and without diabetes, who were assigned either a balance diet or a low carbohydrate diet. There were no differences in weight loss between the groups, nor any differences in blood pressure, cholesterol, triglycerides, low-density lipoproteins and high-density lipoproteins (bad and good fats).
Is Exercise The Key To Weightloss?
How about exercise then, with the rise of social media there are plenty of “influencers” promoting their own weight loss exercise regimes, could it be they are right? Unfortunately not, the importance of exercise in weight loss is one of the greatest misconceptions. 100% of our energy intake comes from food, yet only 10-30% can be burned through physical activity. Physical activity is extremely important and is associated with a multitude of health benefits, however for weight loss it is only one piece of the puzzle.
Which Diet Is Best For Me?
About now the question becomes, “if there are no differences between diets and exercise doesn’t contribute greatly to weight loss, then what is the best way forward?” The key to losing weight is adherence. Adhering to a nutritional regime that can be stuck to long term. Low carbohydrate diets and low carbohydrate Mediterranean diets are great for weight loss, especially in obese diabetic individuals, however if it can’t be adhered to long term the weight will return. This behaviour pattern of short term weight loss followed by longer term weight gain is consistent with most weight loss diet research.
If your goal is to lose weight long term, forget the latest fads, ignore social media, and stick to the following key principles.
To learn more about ketogenic diets the Shannon Clinic – Melbourne Chiropractic and Sports Care has a great blog on keto diets and performance. To book an appointment with Melbourne city sports chiro Dr. Shannon or remedial massage therapist Paula Pena click below. Our Melbourne CBD chiropractic clinic is located on Collins Street, opposite the Melbourne Town Hall.
Shannon Clinic – Melbourne Chiropractic and Sports Care Blog
In November 2017, Melbourne city chiropractor Dr. Shannnon wrote an article for The Australian Chiropractor outlining the importance of exercise as medicine and the role chiropractors can play in prescribing exercise therapy to their patients. This is a copy of text published in the magazine article.
Exercise Medicine – A Chiropractors Domain
When people think of sports and exercise medicine they conjure up images of locker rooms, being pitch side, working and traveling with teams and athletes, and to some extent this would be right. However, sports and exercise medicine is also about the promotion and advocation of exercise medicine. That is, prescribing exercise and dietary advice for the treatment and prevention of chronic diseases.
Today’s society is driven by technology, phones, tablets, laptops, watches, automated machines and cars, all there to make our lives easier. Yet the more we rely on technology the more sedentary we have become. People can spend as much as half of their waking day sitting, with relatively idle muscles, and as little as 4-5% of their day spent in moderate to vigorous exercise 1,2.
Sedentary Lifestyle and Physically Inactivity
This sedentary lifestyle is in part responsible for the rapid escalation in chronic preventable diseases, where global type II diabetes rates have risen from 4.7% in 1980 to 8.5% in 2016, and worldwide obesity rates have jumped significantly between 1980 and 2013, with a 9% increase in the male population and a 10% increase in the female population3,4. With developed countries such as the US, UK, Australia and New Zealand driving these alarming trends 5.
Physical inactivity is responsible for approximately 9% of premature deaths worldwide and is the 4th ranked leading risk factor for mortality 6,7. Where those who spend 10 or more hours in a car per week, have an 82% greater risk of cardiovascular disease mortality compared to those who spend 4 hours or less8. This sedentary behaviour is leading to weight gain, even when food intake is accounted for, and there is a growing body of evidence linking sedentary behaviour to an increased risk of mortality from cardiovascular disease, type II diabetes and obesity 9.
This link is not hard to appreciate when the risk factors for cardiovascular disease, type II diabetes and obesity are examined, as all include physical inactivity 10,11,12. However, it is not only these three chronic preventable diseases that are important. Overweight and obese people have a greater risk of developing prostate and colon cancer, and weight gain is also associated with hypertension, asthma, arthritis and fair to poor health 13,14.
It is for this very reason the American College of Sports Medicine established the Exercise is Medicine® initiative to encourage primary care professionals to include exercise when designing treatment plans for patients. As primary care practitioners, it is vitally important that Chiropractors take up the mantra “exercise is medicine” and incorporate dietary advice and exercise into patient treatment plans to improve patient outcomes.
The Importance of Physical Activity
Why is exercise medicine so important? Physical activity reduces the risk of developing cardiovascular disease by 30% 15. It reduces the risk for death and disability due to diabetes, chronic kidney disease and lower respiratory disease 16. It has also been shown to reduce the risk of breast and colon cancer, with growing evidence showing it may be beneficial in reducing the risk of pancreatic and lung cancer 15. The benefits of physical activity aren’t confined to chronic diseases, it results in lower blood pressure, enhanced insulin sensitivity, increased high density lipoproteins, lower triglycerides and it helps with weight management 17,18.
In the elderly it preserves bone mass and reduces the risk of falling19. It helps to prevent and improve mild to moderate depressive disorders and anxiety, and is associated with a lower risk of cognitive decline and dementia19. It is also beneficial in the treatment of back pain by reducing pain levels and improving physical and psychological function 20,21.
Considering the benefits of physical activity for back pain, in addition to the high-quality evidence showing that NSAID’s and paracetamol are ineffective in the treatment of back pain 22,23. Chiropractors are in a strong position to use this evidence to advocate and prescribe physical activity as a part of their patient’s treatment plan, to enhance their clinical outcomes.
They should also be advocating physical activity and dietary changes to reduce their patient’s chronic disease mortality and morbidity rates. As a result, those ‘at-risk’ patients will reduce their risk factors and aid in lowering their Metformin, anti-hypertensive and statin medications. There is growing strong evidence supporting the benefits of diet such as, the Mediterranean diet and low carbohydrate diets and physical activity, in the treatment of type II diabetes, hypertension and high cholesterol 24,25,26,27,28,29.
Physical Activity Guidelines
So, what and how much physical activity should we be doing? Well, according to the American College of Sports Medicine position paper on exercise, they recommend a comprehensive exercise program consisting of cardiovascular exercise, resistance, flexibility and neuromuscular exercises 19. This should involve at least 150 minutes per week of moderate intensity physical activity 19. With several studies showing a dose response between chronic physical activity and health outcomes, meaning the more one is physical activity the greater the benefits are 30.
For those patients who are at risk of cardiovascular disease, they should undertake at least 120 minutes per week of moderate to high intensity aerobic exercise 18,31. For those looking to lose weight and prevent weight gain, they should be engaging in 150-250 minutes of moderate intensity exercise along with resistance training 31,32.
Chiropractors Should Be Advocating Exercise Medicine
Assessing patients risk factors for chronic preventable diseases is not outside the scope of a Chiropractors practice and can be easily assessed using measurements such as BMI, blood pressure, waist circumference, and if available blood lipids. There is a wealth of heart health diet questionnaires available online and The Heart Foundation provides charts and calculators for establishing a patient’s 5-year cardiovascular disease risk. Whether you are involved with sports and exercise medicine or not, advocating exercise and dietary advice to improve patient outcomes, mortality and morbidity rates should be a part of all Chiropractors treatment plans.
As a Melbourne sports chiropractor Dr. Shannon utilizes exercise therapy and advocates for reductions in sedentary behaviour and increases in moderate to vigorous physical activity. If you are interested in reading more about the benefits of exercise read you blog on why exercise is beneficial for immune function. To book an appointment with Melbourne city chiropractor Dr. Shannon or remedial massage therapist Paula Pena you can book below. Our Melbourne CBD chiropractic clinic is ideally located on Collins Street in the CBD of Melbourne opposite the Melbourne Town Hall and City Square.
1). Hamilton MT, Hamilton DG, Zderic TW. Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes and Cardiovascular Disease. Diabetes. 2007; 56(11): 2655-2667.
2). Bauman ON, Brown W. Too much sitting: a novel and important predictor of chronic disease risk? Br J Sports Med. 2009; 43: 81-83.
3). World Health Organisation. Global Report on Diabetes. Geneva: World Health Organisation; 2016. P. 6. Available from: http://apps.who.int/iris/bitstream/10665/204871/1/9789241565257_eng.pdf
4). González K, Fuentes J, Márquez JL. Physical Inactivity, Sedentary Behavior and Chronic Diseases. Korean Journal of Family Medicine. 2017; 38(3): 111-115.
5). Mariel M, Finucane AB, Gretchen A, Stevens Dsc, Melanie J et al. National, regional and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country years and 9.1 million participants. The Lancet. 2011; 377(9765): 557-567.
6). Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012; 380(9838): 219–29.
7). World Health Organization. Global Recommendations on Physical Activity for Health. Geneva: World Health Organization; 2010. p. 60. Available from: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/
8). Warren TY, Barry V, Hooker SP, Sui X, Church TS, Blair SN. Sedentary behaviors increase risk of cardiovascular disease mortality in men. Med Sci Sports Exerc. 2010; 42: 879–885.
9). Hamilton MT, Hamilton DG, Zderic TW. Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes and Cardiovascular Disease. Diabetes. 2007; 56(11): 2655-2667.
10). Capewell S, Morrison CE, McMurray JJ. Contribution of modern cardiovascular treatment and risk factor changes to the decline in coronary heart disease mortality in Scotland between 1975 and 1994. Heart. 1999; 81(4): 380–6.
11). Li J, Siegrist J. Physical Activity and Risk of Cardiovascular Disease-A Metat-Analysis of Prospective Cohort Studies. Int J Environ Res Public Health. 2012; 9(2): 391-407.
12). Edelmen SV. Type II Diabetes Mellitus. Adv Inter Med. 1998; 43: 449-500.
13). Guh DP, Zhang W, Bansback N, Amarsi Z, Birminghan CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis. BMC Public Health. 2009; 9(88): https://doi.org/10.1186/1471-2458-9-88
14). Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, et al. Prevalence of Obesity, Diabetes and Obesity-Related Health Risk Factors, 2001. JAMA. 2003; 289(1): 76-79.
15). Chomistek AK, Cook NR, Flint AJ, Rimm EB. Vigorous-Intensity Leisure-Time Physical Activity and Risk of Major Chronic Disease in Men. Med Sci Sports Exerc. 2012; 44(10): 1898-1905.
16). Brawner CA, Churilla JR, Keteyian SJ. Prevalence of Physical Activity Is Lower among Individuals with Chronic Disease. Med Sci Sports Exerc. 2016; 48(6): 1062-1067.
17). US Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): ODPHP Publication No. U0049. 2008 [cited 2010 Sep 24]. 683 p. Available from: http://www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf.
18). Kodama S, Tanaka S, Saito K, Shu M, Sone Y, et al. Effect of Aerobic Exercise Training on Serum Levels of High-Density Lipoprotein Cholesterol: A Meta-analysis. Arch Intern Med. 2007; 167(10): 999-1008.
19). Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, et al. Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculosketelal, and Neuromotor Fitness In Apparently Healthy Adults: Guidance for Prescribing Exercise. Med Sci Sports Exerc. 2011; 43(7): 1334-1359.
20). Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil. 2015; 29(12): 1155-1167.
21). Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil. 2015; 94(5): 358-65.
22). Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015; 31(35): doi: 10.1136/bmj.h1225.
23). Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017; 76(7): 1269-1278.
24). Varady KA, Jones PHJ. Combination Diet and Exercise Interventions for the Treatment of Dyslipidemia: an Effective Preliminary Strategy to Lower Cholesterol Levels? J Nutr. 2005; 135(8): 1829-35.
25). Elhayany, A., Lustman, A., Abel, R., Attal-Singer, J. and Vinker, S. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism. 2010; 12: 204–209.
26). Kelley G, McClellan P. Antihypertensive Effects of Aerobic Exercise: A Brief Meta-Analytic Review of Randomized Controlled Trials. Am J Hypertens. 1994; 7(2): 115-119.
27). Börjesson M, Onerup A, Lundqvist S, Dahlof B. Physical activity and exercise lower blood pressure in individuals with hypertension: narrative review of 27 RCTs. Br J Sports Med. 2016; 50: 356-361.
28). Esposito K, Maiorino MI, Di Palo C, Giugliano D. Adherence to a Mediterranean diet and glycaemic control in Type 2 diabetes mellitus: For the Campanian Postprandial Hyperglycemia Study Group. Diabetic Medicine. 2009; 26: 900–907.
29). Elhayany, A., Lustman, A., Abel, R., Attal-Singer, J. and Vinker, S. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Diabetes, Obesity and Metabolism. 2010; 12: 204–209.
30). Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007; 39(8): 1423-34.
31). Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports. 2006; 16(1): 3-63.
32). Donnelly JE, Blair SN, Jacicic JM, Manore MM, Rankin JW, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009; 41(2) 459-71.
