Its tough keeping motivated to exercise once there is a shortage of daylight and the cold weather hits but there are many benefits to exercising in the cold. You use more energy in winter which equates to burning more kilojoules and as you are burning more energy you sleep better at night.

Regular exercise is also one of the best ways to boost your immune system and fend off winter colds and other illnesses and research shows that 30% of us do no form of exercise during the winter months.

Here are a few tips that may help

1. Put your exercise clothes in the dryer the night before so that in the morning you can turn it on for a few minutes so the transition from bed into warm clothes will be easy and this also gives you a leg up on your warm up. Warm up by either having a hot shower before heading out or run up and down stairs for a few minutes but don’t get sweaty before you go out or you will get cold. Once outside start walking at a brisk pace until you start to feel warmer then increase your pace
2. Exercise outside even if you only do half your exercises outside. Start inside then go outside and do a 5 to 10 minute walk or jog then come back inside to finish. It can be rejuvenating and refreshing
3. Layer up if you exercise outside then you can regulate your own temperature. Start with a base layer that keeps you warm but allows sweat to evaporate like wool then a layer of fleece to keep you warm and dry and finally a jacket that’s both wind and water resistant while still breathable and don’t forget the hat and gloves. Also lighten up by wearing light colors or reflective outer layers
4. Moisturize lips, hands and face as they may be susceptible to the drying effects of colder air
5. Drink plenty of water. Most people forget the importance of hydration during the colder months
6. Those prone to asthma may be more susceptible to the cold air so carry your medication
7. If you stop or pause remove any items of wet clothing and replace with a jacket or warm up pants
8. Mix things up. If indoor workouts are your thing keep yourself interested by mixing strength training with cardio. Choose 3 cardio machines and hit each one for 10 minutes, it makes the workout seem shorter and more interesting
9. Try new exercises. If you find yourself staring at the treadmill with something close to dread that’s a good sign you need to try something different.
10. Reward yourself with a coffee after the workout or a movie at weeks end or a new pair of running shoes at months end or whatever works for you.

By staying fit during winter we can avoid gaining weight, we get a head start on swimsuit season….. And we can avoid losing strength and stamina so that we bloom in spring.

Vanessa

A Current Affair showcased Provent, a recently developed treatment for OSA. Provent has been discussed in our blog on a few occasions and currently we have several patients trialling this treatment. Watch the segment here.

Next The Project featured a story on sleep deprivation and the dire effect it has on the body. To highlight the consequences the reporter went for 50 hours without sleep. A simulated driving test was held before and after with the results deteriorating significantly after 50 hours of wakefulness. Studies have demonstrated the periods of sleep deprivation are akin to having a blood alcohol level of .05. Watch segment here

Jessica

Irene has just finished facilitating the latest group Obstructive Sleep Apnoea (OSA) session. The group therapy for OSA encompasses 2 X 1.5 hours sessions. The target group is patients that have been diagnosed with OSA in the previous 6 months and their families. The aim of the group is to help support and educate patients on OSA and cpap therapy, thus leading to higher compliance rates and enhanced health outcomes.

Research endorses the use of group therapy for patients with OSA. A study by Richards et al (2007) published in SLEEP, Vol. 30, No. 5, 2007 found that using cognitive behavioural therapy (CBT) in a group setting increased both the ‘uptake’ and  compliance of cpap, therefore reducing the social, economic and health related consequences of untreated OSA.

The study was an randomized controlled trial (RCT) with subjects either allocated into the group therapy (CBT) or treatment as usual group. Compliance levels were taken at 7 and 28 days, with compliance defined as at least 4 hours use per night.

The CBT group had a higher uptake of cpap, as well as enhanced compliance. The CBT group at 28 days used cpap on average 2.9 hours longer per night. The mean mask time usage for the CBT group was 5.38 hours, compared to 2.51 hours for the treatment as usual group.

The most significant figures was that a 28 days 77% of the CBT group were using cpap for at least 4 hours per night and 50% were using it for 6 hours. In contrast in the treatment as normal group only 31% were using cpap for at least 4 hours and 15% were using for at least 6 hours.

A limitation of the study was that it does not give a long term compliance picture for the two different groups. Research has demonstrated their is a significant decline in cpap use after the first month of use. It would be interesting to see if the researchers followed up the participants now what their current cpap complaince levels would be.

We plan to continue to facilitate our group OSA support session and aim to have some group sessions offered in locations in other than Hamilton in the near further.

Jessica

This is going to be a ramble!

My last post focussed on interstitial lung disease.  I neglected to mention the international treatment guidelines for idiopathic pulmonary fibrosis, which were published in the blue journal last year.  (You may recall that I mentioned the ‘established’ treatment for IPF, low dose prednisolone with azathioprine combined with n-acetylcysteine, has been demonstrated in a recent trial to actually increase the risk of death over n-acetylcysteine alone and over placebo).  It is now recommended that patients with IPF not be started on oral prednisolone (in a complete about face from previous management).  There are other agents being studied – including n-acetylcysteine and pirfenidone – and there is conflicting evidence.  However, on the evidence of three trials of pirfenidone which do suggest a 30% increase in progression-free survival that drug is now licenced for use in treatment of IPF in Europe, and also available in Japan or India.  It’s not available in the USA.  There is currently a trial underway of this medication in Australia, but that’s the only way you can get access to it here.

I also went to part of a session on the management of difficult asthma (it overlapped with the interstitial lung disease session).

We were helpfully reminded that when we talk about severe asthma we should think about different ‘categories’.  These include:

• untreated severe asthma
• difficult to treat severe asthma
• treatment resistant severe asthma.

According to my notes, 7% of asthmatics fit into the ‘severe asthma on treatment’, but only 1% into the ‘treatment resistant’ category.

Of patients referred to clinics that only look after patients with severe asthma, 12% actually do not have asthma at all.  That number is higher in a ‘general respiratory medicine’ context such as ours  (ie an even higher proportion of patients than that who are labelled ‘severe asthma’ don’t have asthma at all).   20% of patients in such clinics can have their disease control greatly improved by simple attention to device technique. Don’t forget the basics!

Many patients with severe asthma suffer from other diseases, and often they will experience symptoms of those diseases as ‘asthma’.  This includes such problems as vocal-chord dysfunction, obstructive sleep apnoea, obesity with physical deconditioning, anxiety disorder, heart disease.  (NB asthma inhalers don’t help with any of those problems!).

In overweight patients with asthma, weight loss leads to improved asthma control and quality of life.

It’s worth remembering that there are a range of treatments for asthma.  Not all inhalers are equivalent.  The concept of the ‘N=1 trial’ was suggested.  That is, it’s sometimes OK to establish exactly what the problem is in a solitary individual patient, define a treatment goal, discuss the options, initiate a treatment, assess the benefit (as objectively as possible using a variety of physiological and ‘quality of life’ measures), then maybe even withdraw the treatment and review.  We get into problems when new treatments are added on top of each other without rational evaluation of their impact and the necessity for their continued use. So when a new medication is introduced it’s important to be clear about whether this is an ‘everafter’ medication, or a ‘try it and see’ medication.

Andrew

A study by Sharwood et al (2012) looked at subjective versus objective assessment of OSA in commercial long haul drivers.

The cross sectional survey took a random sample (n=517) of commercial truck drivers from two large road networks in Australians.

The questions asked pertained to their driving experience, health, shift schedule, payments and information about their own sleep and perceived levels of tiredness. They also undertook “at home”  sleep monitoring. It was not completely transparent what tool was utilised in the home setting but as it identified those ‘at risk’ it seems it is a device such as an apnoea link.

In the sample size, 4.4% had previously been diagnosed with OSA. From the interview questions, 12% of drivers indicated elevated levels of daytime tiredness but from the “at home” monitoring 44% of the sample were deemed at risk of having OSA. Therefore the self reported levels of tiredness vary vastly from those who are actually at risk of OSA.

It is important to point out that 36% of the drivers were overweight, while a further 50% were obese. This leaves only 14% of the drivers in the healthy weight range, which is a worry as we know being overweight is one of the risk factors for OSA.

Studies like this highlight the possibility of mandatory testing for sleep disorders, particulary OSA, in people using a commercial drivers licence.

Jessica

]]> http://www.mansemedical.com.au/?feed=rss2&p=1630 0 http://www.mansemedical.com.au/?p=1623 http://www.mansemedical.com.au/?p=1623#comments Mon, 23 Apr 2012 06:07:17 +0000 Manse Medical http://www.mansemedical.com.au/?p=1623 Full Article]]> As a ‘newbie’ to Manse Medical, I have been asked to write a blog about my background prior to starting at this specialist private practice.

Born in Newcastle, NSW but raised in Sydney, I grew up in a tight knit community on a peninsula between the Lane Cove and Parramatta Rivers. I developed a love of sport, the outdoors and the ocean. After finishing high school, I completed a Bachelor of Science degree majoring in Marine Science, but could not really see myself following a career in this area.

Having participated regularly in ocean swimming races over several summers, along with running for cross training, I was encouraged by a friend to give triathlon a crack by adding cycling as well. Due to my perfectionist nature, this led to an almost obsessive interest in improving my performance across all 3 disciplines (swim, bike & run) and a burning desire to understand more about how the body worked and what happens during exercise. While doing random research on exercise related topics, I discovered exercise physiology degrees (that I never knew existed) and enrolled at Sydney University in an Applied Science degree majoring in Exercise and Sports Science. In my Honours year, I completed a research thesis which required combining exercise physiology with sleep studies to assess the effect that taking caffeine (equiv. 4-5 cups of coffee!) during exercise had on exercise performance and also subsequent sleep.

Since leaving university in 2009, I have worked in a range of exercise physiology related areas, including working with elite athletes (Australian Institute of Sport), junior athletes (South West Academy of Sport) and also in a rehabilitation setting at St John of God Hospital in Warrnambool.

Currently based in Camperdown, I am enjoying the more laid back lifestyle from the hustle and bustle of Sydney where I grew up. I am so far enjoying the respiratory scientist position, which is a slightly new career direction, but involves elements of all the experience I have accumulated and I am looking forward to furthering my career in the health field with Manse Medical.

Ben

The first day was mostly spent at a symposium on interstitial lung disease.  Luca Richeldi, from Modena, was the star attraction at this part of the meeting.  It’s always good to get the perspective of an internationally-recognised expert on some of these more complicated conditions.

There have been some important developments in the classification of these disease, but we are still struggling to find a good treatment for idiopathic pulmonary fibrosis – which is the most prevalent and most deadly.  Unfortunately a recent/current trial looking at combinations of prednisolone/azathioprine/n-acetylcysteine in treatment of this condition has found that low dose prednisolone with azathioprine – ’til now considered the standard treatment of IPF, albeit based on scant evidence – increases the risk of mortality of IPF as much as ten-fold vs placebo.  It should be emphasised that this does not apply to connective-tissue disease associated interstitial lung disease or non-specific interstitial pneumonia or sarcoidosis.  So if you’re a patient reading this and you realise you’re on that combination of medication for interstitial lung disease then you will need to discuss the finding with your own specialist in your own particular situation.  Nevertheless, this finding – which is to be published in the New England Journal of Medicine shortly – is going to cause a number of patients with IPF to have their treatment regime revised. 

He also emphasised – and this is important – that multidisciplinary discussion is now the ‘gold standard’ for diagnosis in interstitial lung disease.  That is, respiratory physicians, radiologists and pathologists need to sit down in the same room to review cases of patients with many of the interstitial lung diseases, and if that is not happening then patients are not receiving best care.  For us in the country this is difficult.  It means that we need to try to participate in such meetings involving other specialists who are city based if we are to look after our patients properly – or else to refer them on.  However, I’ve underlined this point in my notes;  for most of the interstitial lung diseases physicians in the country should think twice before making a diagnosis on our own.

The other point I’ve underlined is this quote:  after talking about idiopathic pulmonary fibrosis, which now is a quite well defined, albeit difficult-to-treat, disease, classification and diagnosis of the other interstitial lung diseases is ‘a bit of a mess’.  Furthermore, even in the best institutions around 10% of the interstitial lung diseases are unclassifiable!

No wonder it’s difficult for patients to understand!

Andrew

A split study is when for the first part of the night the patient undergoes a diagnostic sleep study and then after approximately 1am this becomes a cpap implementation study. A referrals for a split study is normally made on the grounds that there is a high likelihood of OSA and in the circumstance where it is important that the initiation of treatment occurs very quickly. With the vast geographical locations that our patients travel from to undergo an in laboratory sleep study it also reduces travel time and costs.

In the case where a diagnostic sleep study has been requested and one of our experience sleep technicians recognizes that during the initial part of the study (again pre approximately 1am) that the patients has an AHI over 40 then they will contact Dr. Bradbeer for approval to change this study into a split sleep study.

In this circumstance the patients will be woken and explained that a trial of cpap is warranted. If they are in agreement to go ahead with the split study, they will be fitted with an appropriate mask and once they have fallen sleep the cpap pressure will be titrated accordingly. Again this benefits the patient through establishing treatment quicker and reducing travel time, cost and costs associated with an additional sleep study.

Another new happening in our sleep laboratories is the arrival of the Provent cannula’s to enable validation of Provent as a treatment for patients trialing this therapy. The process will involve patients initially using a 10 days trial pack of Provent. If they feel they are able to tolerate the treatment and would like to keep trialling it they will then be booked to have a sleep study while using Provent.

It is important to assess how successfully Provent is managing a patients OSA, as it will not be successful for every patient.

Irene and Lisa have been busy making temporary MAS for patients wishing to trial this therapy. This is important as the temporary MAS is a low cost way to determine if a MAS will be successful in treating the patients OSA, as it is not always an effective mode of treatment. It also gives the patients an opportunity to see if the can tolerate a MAS.

These new procedures and devices in the sleep laboratories will enable patients quicker access to treatment, potentially reduce out of pocket costs and provide an alternative to cpap in the circumstance that this has not been successful or appropriate for the patient.

Jessica

The centre has been operating since March 2012 and will be officially opened on April 23^rd, 2012 by the Australian Minister for Human Services, Senator Kim Carr.

Dr Margaret Garde has relocated her practice to Active Health to take up the role of clinical director. Along with additional general practitioners the centre is expected to offer podiatry, diabetes education, dietitian services, an exercise physiologist, mental health services, physiotherapy, adolescent health education, rehabilitation services and a full-time practice nurse. Linda Thompson has been appointed as the practice manager.

Active Health is the result of a 6-year vision to develop a new centre of excellence to ensure the health needs of the region’s patients are met. The project was announced in August 2009 when the Federal government allocated $4.9 million to Portland District Hospital to lead a consortium including Deakin University of Medicine, Otway Division of General Practice and Greater Green Triangle GP Education and Training to construct a new GP super clinic. Active Health is the only super clinic in Western Victoria and one of 11 in Victoria.

The clinic name was chosen to reflect the holistic nature of the centre which aims to motivate people to take an active role in their health and wellbeing.

Vanessa

In normal sleep structure wake is usually followed by stage 1 sleep, then stage 2, stage 3, stage 2 then REM. The transition from wake to REM is rare but it does occur in narcolepsy. It is normal to wake 4 times a night which we often do not remember.

Hypnagogic hallucinations usually occur at sleep onset and can last from seconds to minutes all the while the subject usually remains aware of the true nature of the image, this may be related to narcolepsy.

Most of Stage 3 sleep (slow wave) occurs in the first ½ of the night and it is during this stage where most parasomniacs like to sleep walk and where night terrors and teeth grinding occur.

When subjects sleepwalk they arise from a slow wave sleep stage in a stage of low consciousness and perform activities that are usually performed during a state of full consciousness. These activities can be as benign as sitting up in bed or walking to the bathroom or as hazardous as cooking or driving! Sleepwalkers often have little or no memory of the incident which may last as little as 30 seconds or as long as 30 minutes. There are many theories as to the why subjects sleepwalk i.e. sleep deprivation, fever and delayed development of the central nervous system. Sleepwalking is clustered in families with a 45% chance of childhood sleepwalking if one parent is affected.

Night terrors usually occur earlier in the night associated with slow wave sleep and there is little or no recall. Children between the ages of 4 -12 years are most prone to night terrors where they bolt upright with their eyes open with a look of fear on their face. They are usually inconsolable and will not always recognise others. Laboratory findings suggest that being overtired or having a fever can increase the likelihood of an episode occurring.

It is much harder to wake people from stage 3 sleep. That is why smart alarm clock aps do not wake people in stage 3 sleep they wait until another stage. Stage 3 sleep seems important and the body will always get enough stage 3 at the expense of REM or other stages of sleep.

During REM sleep the brain sends a message to our spinal cord to switch off. This results in temporary paralysis and prevents us from acting out our dreams. REM sleep occurs periodically through the night, usually with an interval of 90 minutes and most of the time spent in REM is in the second ½ of the night.

Nightmares usually occur during the second ½ of the night associated with terrifying dreams, dream recall & difficulty returning to sleep most commonly in teenagers and occurring on average once a month. The unpleasant dream in 75% of cases can cause a strong negative emotional response from the mind, typically fear or horror, but also despair, anxiety and great sadness. Nightmares have been attributed to physical causes such as sleeping in an uncomfortable or awkward position, fever or psychological causes such as stress and anxiety. Eating before going to sleep is a potential stimulus for nightmares.

I will finish with a bit of trivia about animal sleep. Apparently large animals require less sleep then small animals and humans require about the same amount of sleep as a pig or guinea pig (8 hours) but not as much as a chimpanzee or gorilla (12 hours). Dog sleep is similar to ours and they experience REM and slow wave sleep but wake more often than us. A rescue dog requires less sleep than a house pet, a giraffe only requires 2 hours of sleep, a cow 3 hours while a bat sleeps for 20 hours.

The more danger for the animal the less REM sleep an animal will have. Fish do not experience REM sleep nor do dolphins who are thought to be highly intelligent, which blows the theory that only mammals seeming to be more advanced in thinking than others dream during REM sleep. Not all animals that experience REM sleep dream……. (Now this is getting weird) All sorts of animals dream, cats, dogs, chimps, horses, cows, elephants, giraffes, and sheep. A horse needs to lie down to experience REM sleep due to paralysis. I could go on and on and on………………

Vanessa