Mark Corson

By R. Urkrass. Summit University of Louisiana. 2018.

VitaminB6– Amino acid Bananas cheap 2.5mg altace with visa, brewer’s 2 mg Daily doses of pyridoxine metabolism; yeast 2.5 mg altace fast delivery, wheat over 500 mg absorption of B12; germ cheap altace 10mg on-line, green and should be production of red peppers, nuts, avoided. Vitamin B12 Protein and fatty Clams, oysters, 2mg No (cyancobali-min, acid metabolism; beef, eggs and cobalamin) production of red dairy products. Biotin – Metabolism of fats; Soya beans, 100 µ No member of the synthesis of ascorbic brown rice, nuts, B-complex acid; healthy skin; fruit, brewer’s family hair balding and yeast and milk. Folic acid – Cell growth; nucleic Raw leafy 200 µg None, up to folate – cofactor acid and protein vegetables, fruit, 5mg a day of the synthesis; formation carrots, avocados, B-complex of red blood cells beans and whole vitamins and protein wheat. Vitamin C – Cell growth; bones, Citrus fruits, hot 60 mg Vitamin C is ascorbic acid gums and teeth; chilli peppers, non-toxic but Water soluble bacterial resistance; broccoli, not antioxidant activity; tomatoes, green recommended absorption of iron. Vitamin D – Calcium and Sardines, herring 10 µ Ye s at h calciferol phosphate and dairy doses. Vitamin E – Enhancement of Wheat germ, 1mg α- No, but some tocopherol vitamin A function; whole grains, tocopherol effects at very Fat Soluble healing of scar vegetable oils, equivalent high doses. Vitamin K – Regulation of blood Leafy green 80 mg No, but menadione clotting vegetables, supplementation Fat soluble cauliflower, with synthetic soybean oil, kelp, vitamin K, cereal grain exceeding products, fruits 500 mg, is not and yoghurt. Their roles may be generalised within the areas of providing structure in the for- mation of bones and teeth, maintenance of normal heart rhythm, muscle contractility, neural conductivity, acid–base balance and the regulation of cellular metabolism through their activ- ity/structural associations with enzymes and hormones. Under ‘ideal’ conditions these systems must operate effi- ciently, but they must also be able to respond to unexpected shortages and demands, for example fighting, natural disasters, pregnancy, lactation, famine, injury and disease. Enzymes are crucial to metabolism because they allow organisms to drive desirable but energetically unfavourable reactions (usually anabolic) by coupling them to favourable ones (usually catabolic). Confusion and coma can result if blood glucose falls below 3 mM, while serious vascular damage may occur if it exceeds 8 mM for significant periods (see Table 2. After a meal, glucose concentrations in the portal venous blood can easily reach 20 mM. Stimulation of insulin release results in the uptake of glucose by the peripheral tissues (muscle and adipose tissue). Surplus glucose is stored locally in tissues as glycogen, but mostly it is converted into fats. This level of glucose is actively defended by the liver, which removes glucose when too high, and replenishes it when too low. Both the supply and the demand for glucose may vary more than 20-fold over a 24 hour period; both can change suddenly and sometimes without warning. The liver can both uptake and secrete glucose; it is one of the few tissues in the body to permit bi-directional glucose transport (enterocytes and kidney are others). Most tissues present a major barrier to glucose entry at the plasma membrane, and glucose is only allowed to enter the cells during periods of intense metabolic activity and in response to circulating insulin. Unlike the liver, most tissues have no export pathway for glucose; their glycogen reserves are strictly for internal use. Long-term shortages are made good via gluconeogenesis from non-carbohydrate precursors. Fats affect a number of metabolic controls that suppress the oxidation of carbo- hydrates. Most aerobic tissues, such as cardiac muscle, ‘prefer’ fats; this is reinforced by insulin signalling, and in the absence of insulin most tissues are essentially impermeable to glucose. They are useful for emergencies and short-term requirements, but are not a cost-effective fuel for longer-term requirements (see Table 2. The strategy is therefore to conserve limited carbohydrate stores (for emergency use), while fuelling basal metabolic activity with fats. Fat, in adipocytes, provides the major energy store in humans, although muscle proteins are also degraded when food intake is inadequate. Fatty acids cannot be converted to glucose, but triacylglycerol droplets comprise 6% by weight of glycerol; glycerol is converted to glyceraldehyde 3-phosphate, which can enter gluconeogenesis or glycolysis. Glycolysis can proceed under both anaerobic (without oxygen) and aerobic conditions. Through the Cori cycle, lactate produced in the skeletal muscles can be delivered to the liver and used to regenerate glucose, through gluconeogenesis. The Cori cycle refers to the metabolic pathway in which lactate, produced by anaero- bic glycolysis in the muscle, moves to the liver and is converted to glucose, through gluconeogenesis; glucose can then return to supply the muscle. The ‘chain’ consists of a number of redox components, each capable of accepting and donating electrons. Substrates are oxidised (they lose an electron), and the electron passes through the redox chain, directionally from a low to a high redox potential, eventually being added to oxygen and reducing it to water. As electrons pass through the different redox components, low to higher potential, they release energy. This process is a normal physiological function of ‘brown’ adipose tissue, so called because of the high density of mitochondria in the individual adipose cells. The mitochondria in brown fat contain a protein called thermogenin (also called uncoupling protein 1). Thermogenin acts as a channel in the inner mitochondrial membrane to control the permeability of the membrane to protons. Newborn babies contain brown fat in their necks and upper backs that serves the function of nonshivering thermogenesis. The process of thermogenesis in brown fat is initiated by the release of free fatty acids from the triacylglycerol stored in the adipose cells (Figure 2. When noradrenaline is released in response to cold sensation it binds to β-adrenergic receptors on the surface of brown adipocytes, triggering the activation of adenyl cyclase. The released fatty acids bind to thermogenin, triggering an uncoupling of the proton gradient and the release of the energy of the gradient as heat. The mitochondrial electron transfer chain is localised within the inner mitochondrial membrane.

Journal of Psychosomatic Research 41(5):481–493 Hackett G discount altace 5 mg with mastercard, Hemwall G cheap altace 5 mg on line, Montgomery G 2002f Ligament and tendon relaxation treated by prolotherapy discount altace 2.5mg without prescription, 5th edn. Canadian Henderson D, Cassidy J 1988 Vertebral artery Medical Association Journal 165(7):905–906 syndrome. Williams & Haldeman S, Kohlbeck F, McGregor M 2002a Wilkins, Baltimore, p 195–222 Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of Hernandez-Reif M, Field T, Theakston H 1998 Multiple sixty-four cases after cervical spine manipulation. Journal of Psychosomatic Medicine and Science in Sports and Exercise Research 57(1):45–52 30(10):1543–1547 Herzog S 2002 Internal forces sustained by the vertebral Ikimi F, Hunt J, Hanna G et al 1996 Interstitial fluid artery during spinal manipulative therapy. Journal of plasma protein, colloid, and leukocyte uptake into Manipulative and Physiological Therapeutics 8:504–510 initial lymphatics. Journal of Applied Physiology Herzog W 2002 Testimony at Lewis Inquest, Coroner’s 81(5):2060–2067 Court, Toronto, November 26, 2002 Ironson G, Field T, Scafidi F et al 1996 Massage therapy Hill M 2003 Cervical artery dissection, imaging, trauma associated with enhancement of immune systems and causal inference. International Journal of Sciences 30:302–303 Neuroscience 84:205–217 Hoag J 1969 Osteopathic medicine. Journal of the American Osteopathic Evaluation of transvaginal Theile massage as a Association 89(8):1037–1045 therapeutic intervention for women with interstitial cystitis. Williams Hooper R, Ding M 2004 Retrospective case series on & Wilkins, Baltimore patients with chronic spinal pain treated with dextrose Janse J, Houser R, Wells B 1947 Chiropractic principles prolotherapy. Manual Therapy 7(2):103–107 Improvement of cardiac autonomic regulation Hou C-R, Tsai L-C, Cheng K-F 2002 Immediate effects following spinal manipulative therapy. In: Cleveland C, of various physical therapeutic modalities on cervical Haldeman S (eds) Conference Proceedings of myofascial pain and trigger-point sensitivity. Archives Chiropractic Centennial Foundation, Davenport, Iowa, of Physical and Medical Rehabilitation 83:1406–1414 p 359 Hovind H, Nielsen S 1974 Effect of massage on blood Jaskoviak P 1980 Complications arising from flow in skeletal muscle. Journal of Rehabilitation Medicine 6:74–77 Manipulative and Physiological Therapeutics Hoyland J, Freemont A, Jayson M 1989 Intervertebral 3:213–219 foramen venous obstruction. Spine 14(6):558–568 Jayson M, Sim-Williams H, Young S et al 1981 Hunt A 1978 Electronic evidence of auras, chakras in Mobilization and manipulation for low-back pain. Brain/Mind Bulletin 3:9 Spine 6:409–416 Hurwitz E, Haldeman S 2004 Manual therapy including Jensen K 2004 University of Wisconsin, Department of manipulation for acute and chronic neck pain. Presented at the Hackett Hemwall Foundation Annual American Academy of Orthopedic Surgeons, Rosemont, Prolotherapy Conference 2004. Spine Johnson A 1939 Principles and practice of drugless 30:1477–1484 therapeutics. Straube, Los Angeles Chapter 7 • Modalities, Methods and Techniques 289 Johnson A 1977 Chiropractic physiological therapeutics. In: Twomey L, Taylor J (eds) Physical Klougart N, Leboeuf-Yde C, Rasmussen L 1996 Safety therapy for the low back. Part 1: The occurrence of Churchill Livingstone, New York cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. Churchill Livingstone, Edinburgh Bantam, New York Keating J Jr 1992 Toward a philosophy of the science of Knebl J 2002 The Spencer sequence. Journal of the 31(2):452–458 American Osteopathic Association 70:570–592 Konstantinou K, Foster N, Rushton A et al 2002 The use Kenna C, Murtagh J 1989 Back pain and spinal and reported effects of mobilization with movement manipulation, 2nd edn. Butterworth-Heinemann, techniques in low back pain management; a cross- Oxford sectional descriptive survey of physiotherapists in Kent P, Marks D, Pearson W et al 2005 Does clinician Britain. Journal of Vertebral Subluxation Research Korr I 1981 Axonal transport and neurotrophic function 2(1):43–49 in relation to somatic dysfunction. Journal of Manipulative and Physiological Therapeutics Kuchera W 1997 Lumbar and abdominal region. Williams & Wilkins, Baltimore, p 581–599 Khumar S, Kaur P, Kaur S 1993 Effectiveness of Shavasana on depression among university students. A Kurz I 1986 Textbook of Dr Vodder’s manual lymph retrospective case control design study. Churchill Livingstone, Edinburgh, Haug, Heidelberg p 277–293 Kurtz R 1990 Body-centered psychotherapy: the Lederman E 2005c Science and practice of manual Hakomi method. Churchill Livingstone, Edinburgh, Lange C, Unnithan V, Larkam E et al 2000 Maximizing p 71–72 the benefits of Pilates-inspired exercise for learning Lederman E 2005d Science and practice of manual functional motor skills. Churchill Livingstone, Edinburgh, Movement Therapies 4(2):99–108 p 43, 44 Langevin H, Sherman K 2006 Pathophysiological model Lederman E, Brown S 1996 Effects of active and passive for chronic low back pain integrating connective tissue oscillation technique of the knee joint on the stretch and nervous system mechanisms. British School of 68(1):74–80 Osteopathy, London Langevin H, Bouffard N, Badger G et al 2005 Dynamic Lee D 1997 Instability of the sacroiliac joint. In: fibroblast cytoskeletal response to subcutaneous tissue Vleeming A, Mooney V, Dorman T, Snijders C, stretch ex vivo and in vivo. American Journal of Stoeckart R (eds) Movement, stability and low back Physiology, Cell Physiology 288:C747–756 pain. Churchill Livingstone, Edinburgh, p 231–235 Larsson S, Bodegard L, Henrikssn K et al 1990 Chronic Lee D 2001 An integrated model of ‘joint function and trapezius myalgia: morphology and blood flow. Neurologic complications following chiropractic Spine 5(4):370–380 manipulation: a survey of California neurologists. Latha D, Kaliappan K 1992 Efficacy of yoga therapy in Neurology 45(6):1213–1215 the management of headaches. Journal of Osteopathic Medicine 6(1):13–18 Therapy Journal 33(1):28–35 Levine P, Frederick A 1997 Waking the tiger: Le Vu B, Dumortier A, Guillaume M et al 1997 Efficacy healing trauma: the innate capacity to transform of massage and mobilization of the upper limb after overwhelming experiences. Butterworth- and mechanical compromise of peripheral nerves of the Heinemann, Oxford upper extremity. 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Aseptic thrombosis of the cavernous sinus leading to painful uni- or bilateral ophthalmoplegia has to be differentiated from the Tolosa-Hunt syndrome generic altace 2.5mg on-line. Chapter 11: Cerebral venous thrombosis intravenous application of iodinated contrast media cheap altace 10 mg line, brain edema cheap altace 10 mg on line. The main indication is to rule out the dura mater of the sinuses will show a distinct other conditions. Magnetic resonance imaging (T1-weighted images after intravenous injection of paramagnetic contrast media) in a patient 169 with thrombosis of the superior sagittal, straight and right transverse sinus. During the second suspicion cannot be corroborated by other neuroima- week after clot formation, red blood cells are des- ging techniques. After 2 weeks, the thrombus becomes hypointense on T1- and hyperintense on T2-weighted images, and recanalization may occur with the re-appearance Other diagnostic findings of flow void signaling. They allow direct imaging of the thrombus; the Most routine laboratory findings in the acute signal intensity depends on clot age. However, elevated D-dimers just indicate active structures after intra-arterial injection of iodinated thrombosis (anywhere in the body), and normal contrast media (Figure 11. Digital subtraction angiography in a patient with isolated thrombosis of the right inferior anastomotic vein of Labbe (right), in contrast to physiological imaging of the cerebral vein findings of the contralateral hemisphere (left). Impaired consciousness and cerebral hemorrhage on Anticardiolipin IgG and IgM antibodies admission are associated with a poor outcome. The first study was ter- The advantage of dose-adjusted intravenous heparin minated after inclusion of 10 patients in each group, therapy, particularly in critical ill patients, may be the as an interim analysis documented a beneficial effect fact that the activated partial thromboplastin time of heparin treatment on morbidity and mortality. Both studies were tory effect of heparin may be immediately antagonized criticized for inadequately small sample size [8]or with protamin, while such an antidote is not available baseline imbalance favoring the placebo group [6]. Immediate anticoagulation is recommended, even A meta-analysis of the studies on immediate anti- in the presence of hemorrhagic venous infarcts. Chapter 11: Cerebral venous thrombosis According to current guidelines [1], oral anti- complications. Acetylsalicylic Thrombolysis acid should be avoided, as the patients’ bleeding risk may be increased due to the concomitant anticoagu- Despite immediate anticoagulation, some patients lation treatment. Severe headache may require treat- show a distinct deterioration of their clinical condi- ment with opioids, but dose titration should be tion, and this risk seems to be especially high in performed cautiously in order to avoid over-sedation. A potential publication bias in the For the treatment of headaches, paracetamol current published work has been assumed, with pos- should be preferred over acetylsalicylic acid 173 sible under-reporting of cases with poor outcome and because of the patients’ bleeding risk. One study identified focal sensory deficits rapid improvement of headache and visual function. A hemorrhagic lesion diuretic drugs are not as quickly eliminated from in the acute brain scan was the strongest predictor of the intracerebral circulation as in other conditions post-acute seizures [22]. Osmodiuretics common in patients with early symptomatic seizures may thus reduce venous drainage and should there- than in those patients with none. Increased intracranial pressure in most cases Epileptic seizures should be treated with paren- responds to improved venous drainage after anti- terally administered antiepileptic drugs (phenytoin, coagulation. Chapter 11: Cerebral venous thrombosis occluded cerebral veins, but also in order to prevent Infectious thrombosis the recurrence of intra- or extracerebral thrombosis. Antithrombo- ingly favorable, with an overall death or dependency tic prophylaxis during pregnancy is probably unneces- rate of about 15% [2]. However, women on vitamin K antagonists nancy, deep venous system thrombosis, intracranial should be advised not to become pregnant because of hemorrhage, coma upon admission, age and male sex. The main causes of acute death are transtentorial herniation secondary to a large hemorrhagic lesion, multiple brain lesions or diffuse Special aspects brain edema. Fatalities after the acute phase are predominantly eclampsia, gestational or chronic diabetes mellitus). There is a high incidence of intracranial hemorrhages (40–60% hemorrhagic infarctions, 20% intraventricular bleedings). A significant number of Recurrence of cerebral venous children are left with a considerable impairment thrombosis (motor or cognitive deficits, epilepsy). Future developments Treatment of bacterial infections with broad antibiotics and surgery. Open questions con- Treatment of epileptic seizures with parenterally cern many of our current management decisions, administered antiepileptic drugs (phenytoin, such as the role of local or systemic thrombolysis, valproic acid, levetiracetam). It is mandatory to increase the level of evidence supporting our diagnostic or Acknowledgement therapeutic decisions through prospective registries, The author expresses his gratitude to Dr Ioannis case–control studies, and, whenever possible, random- Tsitouridis, Director of the Department of Diagnostic ized controlled trials. Prognosis of The most common and frequently the first cerebral vein and dural sinus thrombosis. Martins and Lara Caeiro Cognitive functions are related to our ability to build lesions are circumscribed, the conceptual representa- an internal representation of the world, the concep- tion system is not affected and these patients are not tual representation system, based on a large-scale demented. Although tion, organized according to their specific processing these tests are also included in brief exams of cogni- capacities. In fact, language impairment will affect typed, since it follows the distribution of the vascular the majority of cognitive functions and needs to be territories. However, in the hyperacute stage symp- ruled out before proceeding to the assessment of toms are likely to be amplified by additional regions orientation, memory or executive functions. It is also a rough plasticity mechanisms make neuroanatomical corre- measure of aphasia severity. Presented objects should be venous thrombosis the pattern of cognitive defects is common and easily recognized (spoon, comb, spec- less stereotyped due to the variability of lesion local- tacles, pencil, wristwatch), to make the task specific ization, size and number, or particular pathogenic for aphasia and not sensitive to cultural factors or mechanisms that may cause diffuse impairment. Patients’ responses vary from pauses (word- In this chapter we will present the most common finding difficulties), tip-of-the tongue phenomenon, cognitive and neurobehavioral deficits secondary to paraphasias, the use of supraordinal responses (fruit stroke, according to symptom presentation. There are rare patients who suffer from a selective naming difficulty affecting a single category of names Language disorders (“category-specific impairments”), such as living Language disorders, or aphasia, occur following peri- entities, actions but not objects, or proper names sylvian lesions (middle cerebral artery territory) of the but not common names.

In open-minded Westerner is likely to actually perceive the the West generic 10 mg altace with amex, such water supplies were most commonly benefit of the cultivation of chi as a result of the sanitized through distillation buy altace 10mg lowest price. In the East purchase 5 mg altace mastercard, water supplies interaction between increased oxygen and well-hydrated were most commonly sanitized through boiling the water cellular machinery (for further discussion of cellular and adding leaves with high antioxidant levels. Paramagnetic materials biochemical environment and is a classic example of attract and repel like normal magnets when subject to metabolic typing, or biochemical individuality in action. It is interesting to note that many natural health • Diamagnetism is a form of magnetism that is only authorities suggest that because Western social drinks exhibited in the presence of an external magnetic field. Though to some this may seem a disadvantage, it also means that people with this profile have very low risk of alcoholism. Janda (1994), for example, discusses the fact that crisis may affect the firing of the deep, local stabilizer some muscles in the neck, the levator scapulae in par- system. Since the system is tonic, we might expect that ticular, may be used to literally ‘dump’ excessive it would become facilitated and tight (as does the neural drive from the limbic-emotional system. This pectoralis minor or the levator scapulae), but this enhanced neural drive to the levator and other pos- depends on the nature of the stimulus and whether tural muscles results in the hunched, red-light or that stimulus arrives at the cord via the alpha-afferent upper crossed posture we are all familiar with in or the beta-afferent system. The former (low threshold stressed states (whether they be emotional, physical, system) may acutely alter postural reflexes, such as thermal, etc. The common outcome of this is tension in stimulus will upregulate, while a high stimulus will the tonic muscle system and relative inhibition in the inhibit physiological processes, so the response of the phasic muscle system, though there are exceptions motor nerve at any given level will depend entirely (see Table 9. The multifidus, transversus and other deep stabi- The notion of the musculoskeletal system as a damp- lizer muscles have a lower threshold to stimulus (Sahr- ener for aberrant energies from the organ systems, mann 2002) and therefore are the first muscles to be from emotional input or from pain generators is con- affected by aberrant neural events at the cord level. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 389 Psychology of corrective exercise Box 9. Bear in mind socioeconomic effects of pain: patients about their condition as well as to offer advice and coaching as to how to make better choices, • Job performance whether this involves exercise, nutrition or other life- • Sports performance style choices. Bear in mind sexual activity being affected by pain: (1999) has described some of the following concepts • Does the pain affect libido? Any other lifestyle changes or compromises due to that 85% of patients presenting for orthopedic consul- the pain tation have an unknown causative onset of their pain. Distinguish between hurt and harm: This, of course, suggests that the problem is one of • Pain during an exercise cumulative microtrauma based on dysfunctional bio- • Pain during a stretch mechanical, biochemical or emotional patterns. Manage your patient properly by offering Movement approaches and mood comprehensive information 8. Flare-ups are not failures to manage the pain, but Depressive symptomatology is more prevalent among education as to how to better manage the pain in sedentary than physically active individuals (Berlin et future al 2006). Focus your patient on function rather than pain mental health problems account for 30% of total dura- 10. Progress should be monitored every 2–4 weeks be defined as either acute or chronic. The acute effects to give patients accurate feedback of their of exercise on mood tend to focus on state anxiety. The changes/improvements vast majority of research into the effects of exercise on 13. Assess using pain provocation tests/quantifiable psychological well-being has been conducted using testing to demonstrate gains aerobic exercise. Nevertheless, activities such as weight or strength training, yoga, and other ‘non- aerobic’ exercises have produced positive effects on psychological health (Weinberg & Gould 1999). How this occurs probably involves many mecha- Higher levels of physical activity in depressed nisms, including the fact that exercise is commonly patients have been shown to be associated with less performed in an outdoor environment which allows concurrent depression, even after controlling for exposure to sunlight, known to have antidepressant gender, age, medical problems and negative life effects and to help to re-regulate circadian rhythms. Physical activity counter- The exercise itself may also help to re-regulate a dis- acted the effects of medical conditions and negative rupted circadian rhythm, thereby aiding sleep and life events on depression. If the circadian rhythm is Exercise has been shown to have an irrefutable disrupted, this alone may be a major cause of depres- benefit in helping to optimize mood – both in those sion (Spiegel et al 2003). Other benefits of exercise on who are non-symptomatic and in those with clinically mood will be due to the ability of exercise to exert a defined depressive episodes (Warburton et al 2006). Some of this also known to increase opiate-like endorphin produc- evidence is described in Chapter 10. Governmental tion in the brain, and may contribute to a natural high physical activity guidelines are variable but com- from exercise – alongside the possibility of a feel-good monly fall within the approximate range of 20–30 factor from knowing that time has been used con- minutes’ duration of >60% of maximal heart rate three structively and to move towards a positive goal. Such Similar to antidepressants, exercise has been hypoth- guidelines are sufficient to elicit health benefits, espe- esized to increase the synthesis of new neurons in the cially in previously sedentary people. Studies on rats reveal a two- to threefold those unaccustomed to exercise use their lack of exer- increase in hippocampal neurogenesis with regular cise history as an excuse for not taking on the advice access to a running wheel when compared with of the clinician to do an exercise program; however, control animals (Ernst et al 2006). Recent rat studies the less conditioned they are, the greater the benefits also show that exercise (in this instance swimming) they will receive (Warburton et al 2006). Many people who suffer with depression are focused In one study (Berlin et al 2006), 40 regular exercisers on one or multiple earlier life experiences (such as were deliberately deprived of exercise across just 2 a bereavement, a divorce, or a time(s) they have felt weeks and assessed using multiple profiles and testing cheated). Alternatively, such individuals may be procedures to measure fatigue and somatic depres- focused on a kind of hopelessness about the future sive symptoms. Both fatigue and depressive symp- and how certain past (or anticipated future) events toms emerged after just 1 week of exercise withdrawal may impact the potential for future happiness. Exercise withdrawal also resulted future events that may never happen (Tolle 2001). Depressed mood and fatigue are commonly engagement in exercise encourages the participant observed in individuals deprived of usual exercise into the present, into the now, potentially decreasing activities, and the increase in fatigue may be partially pain, increasing endorphins, and enhancing self- mediated by reduced fitness levels. This is of particular psy- While effective motor control and sequencing is far chosocial importance for those whose careers, identi- more important to biomechanical function than body ties or social activities are built around a given sport fat levels, it is a general trend that if body fat is high, or activity (see Liebenson’s recommendations in Box muscle activation and sequencing may be compro- 9.