Rehabilitation and Motor Sciences Periodical

Transcription

Autorizzazione Tribunale di Pisa n. 1 del 19-01-2015 - Marzo 2015
Year I ∙ 1 - 2015
Regular physical activity prevents
nitrosative stress caused by ageing
in elderly athletes.
Thyroid dysfunction and physical
activity: clinical and therapeutic
implications
The relationship between internal
and external load in intensive ball
drills in young sportspeople
The interaction between “dry” and
“water” rehabilitation therapies
Energy homeostasis and locomotor
activities: the role of leptin and of
the melanocortin system
Role of proteins in sports activities
Ancient Chinese medicine:
understanding the laws of nature
to understand and treat the human
being
Acute-phase Radial Shock Wave
Therapy (RSWT). New perspectives
and applications in professional
football players
Interview with Antonio Stecco
ISSN 2421-3292
Year I ∙ 1 - 2015
Scientific Director
Eugenio Gaudio
Editorial manager
Marco Gesi
Managing director
Patrizia Alma Pacini
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Pacini Editore SpA
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editorial board
Andersen Per Nymann (Tromsø - Norway)
Bernardi Marco (Roma - Italy)
Boden Nicholas (Kuala Lumpur - Malaysia)
Busoni Francesco (Pisa - Italy)
Capelli Carlo (Verona - Italy)
Castagna Carlo (Ancona - Italy)
Cocco Lucio (Bologna - Italy)
d’Almeida Neto Antonio (Rio de Janeiro - Brasil)
de Labareyre Hervé (Paris - France)
Di Baldassarre Angela (Chieti - Italy)
Fornai Francesco (Pisa - Italy)
Först Andreas (Bamberg - Germany)
Franzoni Ferdinando (Pisa - Italy)
Genty Marc (Yverdon les Bains - Switzerland)
Gerdesmeyer Ludger (Kiel- Germany)
Guido Giulio (Pisa - Italy)
Gulisano Massimo (Firenze - Italy)
Inglese Francesco (Forlì - Italy)
Kertzman Paulo F (Sao Paulo - Brasil)
Magaudda Ludovico (Messina - Italy)
Maier Markus (Starnberg - Germany)
Manetti Paolo (Firenze - Italy)
Mangiarotti Marco (Roma - Italy)
Manzoli Lucia (Bologna - Italy)
Mondardini Paolo (Bologna - Italy)
Montagnani Stefania (Napoli - Italy)
Montella Andrea (Sassari - Italy)
Moxham Bernard (Cardiff - United Kingdom)
Muzio Marisa (Milano - Italy)
Natale Gianfranco (Pisa - Italy)
Nicolini Ida (Pisa - Italy)
Palma Antonio (Palermo - Italy)
Pellegrino Raffaello (Lecce - Italy)
Pöttgen Klaus (Darmstadt - Germany)
Rigardo Sergio (Alessandria - Italy)
Ruffoli Riccardo (Pisa - Italy)
Santoro Gino (Pisa - Italy)
Schmitz Christoph (Munich - Germany)
Soldani Paola (Pisa - Italy)
Stecco Antonio (Padova - Italy)
Stecco Carla (Padova - Italy)
Vitale Marco (Parma - Italy)
Table of Contents
EDITORIAL
1
by M. Gesi
Original article
2
Regular physical activity prevents nitrosative stress caused by ageing in elderly athletes
J. Fusi, E. Guidotti, A. Innocenti, L. Tocchini, E. Ricciardi, M. Rossi, F. Galetta, G. Santoro, F. Franzoni
8
The relationship between internal and external load in intensive ball drills in young sportspeople
A. Nonnato, G. Belli, R. di Michele
Review
14
20
Energy homeostasis and locomotor activities: the role of leptin and of the melanocortin system
G. Ceccarini, A. Basolo, M. Maffei, P. Vitti, F. Santini
Thyroid dysfunction and physical activity: clinical and therapeutic implications
E. Sabini, A. Biagini, E. Molinaro
Insights
25
The interaction between “dry” and “water” rehabilitation therapies
S. Rigardo
28
Role of proteins in sports activities
M. Ceriani
33
understanding the laws of nature to understand and treat the human being
F. Nocchi
38
Acute-phase Radial Shock Wave Therapy (RSWT).
New perspectives and applications in professional football players
C. Schmitz
News
41
“The fascia is the forgotten tissue, but it is essential in the regulation of proprioceptive afferents”
edited by E. Calvani
Year I ∙ 1 - 2015
JSA 2015;1:1
Marco Gesi
In the presence of the highest authorities of the
University of Pisa, of colleagues, students and friends
of “Sport and Anatomy” the official presentation of “The
Journal of Sport and Anatomy “ took place on the 23rd
of January.
The day started in “Palazzo alla Giornata” with the
Rector of the University of Pisa, and continued in the
Great Hall of the Scuola Medica Pisana in the presence
of many passionate people from the sports world.
We wanted to share this important event with some
friends who over the years have believed in our project
and who have shared part of this long journey: Gianni
Rivera, president of the technical sector of the FIGC
(Italian Football Federation), Renzo Ulivieri, President of
AIAC (Italian Football Coaches Association), Giovanni
Bonocore, trainer of Alessandro Del Piero and Salvatore
Sanzo, president of CONI Tuscany Professor Giulio
Guido, director of the Department of Translational
Research and New Technologies in Medicine and
Surgery, the clinical doctor Professor Gino Santoro,
Professor Paolo Mancarella, Didactic Vice Rector at
Pisa University and Dr. Pierfrancesco Pacini, historic
publisher and entrepreneur from Pisa, gave their
welcome.
“The Journal of Sport and Anatomy” continues its
publishing project with the publication of its first 2015
issue, whose articles deal with many issues belonging
to modern sport.
In the foreground, two original studies: the first deals
with the role of physical activity to combat nitrosative
stress caused by ageing; the second is a preliminary
study on the relationship between internal and external
load in young players during technical and tactical
Editorial
exercises involving intense physical effort. Two reviews
follow, the first provides an overview on the influence
of the leptin-melanocortin system on the different
components of physical activity, while the second takes
into account the clinical and therapeutic implications
in sports people with a thyroid dysfunction, a problem
that affects many people practicing sports. The insights
dealt with in this issue are dedicated to particularly
modern themes in the field of rehabilitation and sports
performance: integrating water and dry therapies; the
role of proteins in sports practice and, finally, a nod to
the old traditional Chinese medicine, the most ancient
medical system known.
I hope the topics covered in this issue can bring “ an
extra something “ not only to those who have to manage
sports people as best as they can, but also to those
who want to do sports and be aware of the benefits and
possible damages.
SportandAnatomy | 1
JSA 2015;1:2-7
Jonathan Fusi, Emanuele Guidotti, Augusto Innocenti, Leonardo Tocchini, Emiliano Ricciardi,
Marco Rossi, Fabio Galetta, Gino Santoro, Ferdinando Franzoni
Department of Clinical and Experimental Medicine and Department of Surgical, Medical and Molecular Pathology
and Critical Care at the University of Pisa
Regular physical exercise prevents
nitrosative stress caused
by ageing in elderly athletes
Abstract
Ageing is associated with an increased susceptibility to free radical-induced tissue damage. One of the most important classes of free
radicals generated in living systems is represented by reactive nitrogen species (RNS), responsible for the so-called nitrosative stress.
It has been shown that physical activity is able to induce up-regulation of antioxidant systems contributing to prevent oxidative stress.
The aim of the present study was to assess whether regular physical activity is able to counteract age-induced nitrosative stress.
Thirty male endurance athletes (average age 70.8 ± 6.1 years, VO2max 59.07 ± 8.5 ml/kg/min) and thirty age-sex-matched sedentary
controls ( average age 71.5 ± 4.3 years, VO2max 25.6 ± 8.2 ml/kg/min) were studied. Plasma free radicals antioxidant capacity against
peroxynitrite, one of the most important RNS, was evaluated as Total Oxyradical Scavenging Capacity (TOSC) units. Results. Plasma
TOSC values against peroxynitrite were higher in athletes than in sedentary controls (22.94 ± 1.85 vs 15.41 ± 1.24 units/ml, p < 0.001).
In the athletes group, TOSC values were related to VO2max (r = 0.44, p < 0.05). In conclusion, these results suggest that regular physical activity is associated with increased antioxidant defences in elderly athletes. In athletes, a direct correlation between the scavenger
scavenger of the plasma and the VO2max (r = 0.44, p <0.05) was also observed. These results confirm that regular physical activity
practised for many years can determine the best response to nitrosative stress induced by peroxynitrite.
Key words: physical activity - oxidative stress - free radicals – peroxynitrite
Riassunto
L’invecchiamento è associato a una maggiore suscettibilità al danno tissutale mediato da radicali liberi. Una delle più importanti
classi di radicali generati nei sistemi viventi è rappresentata dai radicali liberi dell’azoto (RNS), responsabili del danno cellulare
definito come stress nitrosativo. È stato dimostrato che l’attività fisica regolare migliori i sistemi antiossidanti dell’organismo,
contribuendo a prevenire e contrastare lo stress ossidativo. L’obiettivo del presente studio è quello di valutare se l’attività fisica
sia in grado di contrastare lo stress nitrosativo indotto dall’invecchiamento. A tale scopo sono stati reclutati 30 atleti master
di sesso maschile (età media 70,8 ± 6,1 anni, VO2max 59,07 ± 8,5 ml/kg/min) e 30 soggetti di controllo (età media 71,5 ± 4,3
anni, VO2max 25,6 ± 8,2 ml/kg/min) sani, ma con stile di vita sedentario. La capacità antiossidante plasmatica nei confronti del
perossinitrito, uno dei principali RNS, è stata valutata mediante tecnica gascromatografica Total Oxyradical Scavenging Capacity Assay (TOSCA). I risultati ottenuti dimostrano che gli atleti anziani presentano una più alta attività scavenger plasmatica nei
confronti del perossinitrito rispetto ai soggetti di controllo (22,94 ± 1,85 vs 15,41 ± 1,24 units/ml, p < 0,001). Negli atleti è stata
inoltre osservata una correlazione diretta tra la capacità scavenger del plasma e il VO2max (r = 0,44, p < 0,05). Tali risultati confermano che l’attività fisica regolare condotta per molti anni è in grado di determinare una miglior risposta allo stress nitrosativo
indotto dal perossinitrito.
Parole chiave: attività fisica - stress ossidativo - radicali liberi - perossinitrito
Introduction
Ageing is one of the most important independent risk factors
for cardiovascular diseases. It is associated with increased
2 | SportandAnatomy
susceptibility to free radical-induced tissue damage caused
by a progressive loss of natural antioxidants capacities,
resulting in increased oxidative stress (1).
ORIGINAL ARTICLE
Free radicals are highly reactive and unstable molecules in
organic systems produced by oxidative phosphorylation
or as a response to inflammations.
Although a multitude of free radicals exists, those
deriving from oxygen or nitrogen, together defined
as RONS (Reactive Oxygen and Nitrogen Species),
represent the largest class of radicals generated in living
systems (2).
Normally, a delicate balance exists between the
production of oxidant factors, represented by reactive
oxygen species (ROS), and their elimination through
an elaborate system of antioxidant defenses, made
of enzymes being responsible for the conversion of
free radicals and by antioxidant molecules able to
neutralize them, the so-called scavengers. When this
balance is altered in favour of free radical expression,
a condition called oxidative stress is established which
alters the structure and function of proteins, lipids and
nucleic acids, thus inducing cell damage (3)(4). Similarly,
reactive nitrogen species (RNS) as well are in equilibrium
with a buffer system made of scavengers and, as is
the case for ROS, when this balance no longer exists
a condition of cell damage emerges which, given the
type of species involved, is described as nitrosative
stress. The alteration of the RNS / scavenger balance in
vivo has been associated with inflammatory processes,
neurotoxicity and ischemia. In addition, nitrosative
stress frequently coexists with oxidative stress and the
two conditions overlap (5). Among the RNS, the radical
being most associated with neurodegenerative and
cardiovascular diseases was identified in peroxynitrite
(ONOO-) (6-8).
It has been shown that although physical activity causes
on one hand an increase in the production of RONS,
especially by increasing the mitochondrial oxidative
processes, on the other hand it stimulates adaptive
phenomena of up-regulation of the body’s antioxidant
systems. This phenomenon contributes to maintaining
the balance between the production of RONS and
scavenger systems by helping to prevent and counteract
oxidative stress (9) (10). The fact that physical activity
can improve the scavenger response of the human body
to oxidative stress has been highlighted in a previous
work against two species of ROS: peroxyl (ROO-) and
hydroxyl (OH-) radicals (11). The aim of this study was
to evaluate how physical activity is able to counteract
nitrosative stress caused by ageing, comparing the
antioxidant activity of plasma to peroxynitrite in a group
of elderly sports amateurs and in an age-matched
sedentary control group.
Materials and Methods
Subjects
Thirty masters runners (males, average age 70.8 ± 6.1)
belonging to the Marathon Club of Pisa and practicing
endurance activities for many years (average age 28.4
Regular physical exercise prevents nitrosative stress caused
± 10.5) were enrolled in the study. They attended at
least 5 training sessions per week for a total of about
7 hours per week, plus a competitive marathon or half
marathon at least one Sunday a month. Thirty sedentary
healthy volunteers (average age 71.5 ± 4.3) were
selected by the cardiology clinic of the Department of
Clinical and Experimental Medicine at the University
of Pisa to form the control group. All subjects were
healthy and free of the main cardiovascular risk factors
on the basis of an accurate medical history, a complete
physical examination as well as a baseline and stress
ECG. They were non-smokers and no one of them
was taking medications or vitamin supplements of any
kind. Athletes and controls showed a maximum oxygen
uptake (VO2max), assessed through a cardiopulmonary
exercise testing (CPET) (QUARK PFT ERGO, Cosmed,
ITALY) respectively higher than 50 ml/kg /min and lower
than 35 ml/kg/min. The study was approved by the
Ethics Committee ‘Comitato Etico di Area Vasta Nord
Ovest’ (CEAVNO) for Clinical Trials, and all the parties
signed a written consent to the study.
Experimental Design
After cannulation of the antecubital vein, the subjects
underwent a blood test (50 ml) under controlled
environmental conditions (temperature 22-24 °C)
at least 48 hours after their last sports activity. The
sample obtained and collected in test tubes containing
dipotassium-ethylenediaminetetraacetic acid (EDTA, 10
l μl/ CC) was immediately centrifuged at 3,000 g for 10
min to obtain plasma samples divided into 500 μl aliquots
and stored in Eppendorf at -80 °C for subsequent
analyses. The evaluation of plasma antioxidant capacity
was performed through TOSCA assay (Total Oxyradical
Scavenging Capacity Assay) (12).
In short, the paper is based on the artificial genesis of
peroxynitrite derivatives at 35 °C from the decomposition
of SIN-1 (3-morpholinosydnonimine N-ethylcarbamide)
in a potassium phosphate buffer 100 mM (pH 7.4) with
0.1 mM of DTPA (diethylene-triamine-pentaacetic acid)
(8). Reactions with KMBA (α-keto-γ- (methylthiol) butyric
acid) 0.2 mM were performed in 10-ml vials sealed with
Mininert® gas tight valves (Supelco, Bellefonte, PA) in
a final volume of 1 ml (16). The plasma analyzed was
diluted 1/100 into potassium phosphate buffer 100 mM
(pH 7.4) in a final volume of 1 ml (10 μl plasma + 990 μl
potassium phosphate buffer). The production of ethylene
was measured by gas chromatography analysis of a
200 μl aliquot taken from the vials’ headspace at regular
time intervals throughout the entire duration of the race.
The analysis was carried out with a Hewlett-Packard
Gas Chromatograph (HP 7820A Series, Andoven, MA)
equipped with a Supelco DB-1 capillary column (30 ×
0.32 × 0.25 mm) and a flame ionization detector (FID).
The temperatures of the oven, of the injector and of the
FID were respectively 35, 160 and 220 °C. Hydrogen was
used as a gas carrier (at a flow of 1 ml/min). The TOSCA
SportandAnatomy | 3
values
were calculated with the equation: TOSCA =
100 - (∫SA / ∫CA × 100), where ∫SA and ∫CA represent
the integrals of the areas for the sample and the control
reaction, respectively. The results were expressed in
TOSCA units per ml of plasma. A TOSCA value of 0
corresponds to a sample without scavenger capacity
(no inhibition of the formation of ethylene compared to
the control reaction, ∫SA / ∫CA = 1), while a TOSCA value
of 100 corresponds to the maximum efficiency of the
sample analyzed.
The linearity of the dose-response curve between the
plasma (in ml) and the antioxidant response (TOSCA
value) was tested, and good correlation coefficients were
obtained (generally greater than 0.9) for the different
doses of plasma which were used to test the validity of
our experiments. Each experiment was performed twice.
The coefficient of variation (CV) of the method is <5%.
Statistical Analysis
The results were expressed as mean ± standard
deviation. The differences between the two populations
were measured using the Student t-test. The differences
were considered statistically significant when p <0.05. To
assess any correlation between variables, the univariate
and multivariate linear regression was used.
Results
The two study groups proved similar in terms of age,
weight, height, BMI, systolic and diastolic blood pressure,
blood sugar, total cholesterol and LDL cholesterol (Tab.
I). As expected, the athletes had a significantly lower
heart rate (53.9 ± 5.2 vs 65.3 ± 9.2, p <0.001) and a
significantly higher VO2max (59.07 ± 8.5 vs 25.6 ± 8.2,
p <0.001) compared to sedentary controls. Furthermore,
it was found that the plasma concentration of HDL
cholesterol in the group of athletes was significantly
higher than that in the control group (59.7 ± 11.3 vs
43.4 ± 8.7, p <0.01) (Tab. I). As shown in Figure 1, the
antioxidant capacity against peroxynitrite measured in
the group of athletes was significantly higher than that in
the control group (TOSCA value: 22.94 ± 1.85 vs 15.41 ±
1.24 units / ml, p <0.001).
The analysis of the correlation between variables also
highlighted a direct correlation in the whole population
studied between the antioxidant capacity against
peroxynitrite and the VO2max (r = 0.44, p <0.05) (Fig. 2).
No correlation was found between the other variables
measured.
Discussion
Our group has previously shown that physical activity
can improve the response of the human body against
oxidative stress induced by ROS, in particular by
peroxyl (ROO-) and hydroxyl (OH-) radicals (11).
However, to our knowledge, there are no data on the
effectiveness of exercise in improving the capacity of
the human body to counteract nitrosative stress. This
paper documents the fact that regular physical activity
is also effective in reducing nitrosative stress induced
by ageing. Peroxynitrite has been linked to various
pathologies of the cardiovascular and central nervous
system (6-8). In the human body it is mainly generated
through a process of controlled diffusion between
nitric oxide (NO) and superoxide (O2-), according to the
following reaction:
O2·⁻ + NO ––––> ONOOThis reaction is one of the fastest known in chemistry,
even faster than the dismutation catalyzed by the enzyme
Table I. Clinical characteristics of the study population (mean ± SD).
Athletes
Controls
Age (anni)
70,8 ± 6,1
71,5 ± 4,3
Height (cm)
172,1 ± 5,8
173,5 ± 6,2
Weight (kg)
75,9 ± 5,4
77,2 ± 6,9
BMI (kg/m )
23,8 ± 2,1
25 ± 1,6
2
HR (bpm)
53,9 ± 5,2*
65,3 ± 9,2
SAP (mmHg)
126,3 ± 4,2
128,2 ± 5,4
DAP (mmHg)
78,2 ± 5,2
79,7 ± 5,8
Blood glucose (mg/dL)
93,0 ± 9,1
92,2 ± 10,0
Total cholesterol (mg/dL)
185,9 ± 21,3
187,4 ± 17,0
HDL cholesterol (mg/dL)
59,7 ± 11,31
43,4 ± 8,7
LDL cholesterol (mg/dL)
111,8 ± 12,8
117,5 ± 10,2
VO2max (ml/kg/min)
59,07 ± 8,5
25,6 ± 8,2
* p < 0.001; 1 p < 0.01 vs sedentary.
4 | SportandAnatomy
J. Fusi et al.
Figure 1. Plasma Antioxidant activity against peroxynitrite in the
group of athletes and sedentary controls. * p < 0.001.
superoxide dismutase, one of the most represented
endogenous antioxidants (13).
For its chemical properties, peroxynitrite is considered
an important biological oxidant and a central mediator
of many pathological processes affecting both the
cardiovascular system and the central nervous system
(14). In fact, given its radical nature, it can interact with
all cellular components, including DNA, thus altering
their structure and consequently their function. At a
cellular level, a major production site of peroxynitrite is
represented by the mitochondrion (15), the main source
of O2··⁻ which combines with NO given the easy diffusion
of the latter from the cytosol to this site (6) (16).
The subsequent reaction of peroxynitrite with mitochondrial components irreversibly alters the activity of complexes I and II of the electron and ATPase transport chain,
thus modifying mitochondrial bioenergetics and calcium
Figure 2. Analysis of the correlation between maximum oxygen
consumption and plasma antioxidant activity against peroxynitrite in
the study population.
homeostasis and ultimately promoting the further formation of O2··⁻ (6) (17)(18).
The data collected in this study showed, for the first time,
that the antioxidant activity of plasma for peroxynitrite
derivatives is significantly higher in a group of elderly
people who have done amateur high level running
activities for many years compared to that in sedentary
controls. Our results can therefore assume that exercise
can counteract the damaging effects caused by the
nitrosative stress associated with ageing. This evidence
is supported by the direct correlation between the
scavenging capacity of plasma against peroxynitrite and
VO2max, and shows that the level of fitness and training
and thus the degree of fitness are the main correlate of
the best response to nitrosative stress.
In fact, physical activity is universally recognized as an
important factor in primary and secondary prevention.
Regular physical exercise, in fact, is not only a
fundamental factor which reduces the risk of onset and
progression of arterial hypertension, dyslipidemias,
diabetes and metabolic disorders in general, but has
proven to be extremely important for the direct impact
on mortality (19-23).
However it is assumed that these effects may be fully
obtained only when RONS are produced in physiological or slightly higher quantities (24). The excessive production of RONS can be the result of a great variety of
stressors ranging from exposure to pollutants to excessive or inappropriate nutrient intake (25). More generally, any situation in which an increase in oxygen consumption is found can lead to an acute state of oxidative
stress. This condition can then also occur during intense
and / or prolonged exercise (26). Thus, on the one hand
exercise causes an increased production of RONS, especially through an increase in mitochondrial oxidative
processes, but on the other hand it stimulates adaptive
phenomena rather than oxidative insults thanks to the
increased production of reactive species. A repeated
exposure of cellular systems to an increasing production
of RONS arising from exercise leads, in fact, to an upregulation of the body antioxidant systems (9) (10). It is
precisely the alteration of the redox balance, associated
to a smaller environment, that may seem to entail a protective adaptation to RONS during sequential training
sessions, as well as in case of exposure to conditions
not associated to exercise. The results obtained with the
present work are therefore in favour of the hypothesis
that regular exercise improves plasma antioxidant capacity and reduces oxidative and nitrosative stress induced by ageing.
Presumably, the increase in antioxidant activity following
physical training is the result of a process of adaptation
according to the principles of hormesis: in response to
a repeated exposure to toxins or stressors of various
origins in limited quantity, the body undergoes a
favourable adaptation which results in an improvement of
physical performance and of general health (27) (28). The
SportandAnatomy | 5
intermediate level of RONS produced, which is therefore
optimal, apparently leads to a state of equilibrium and
advantage for overall health, whereas a production
being too low or too high leads to an alteration of the
body’s defenses, or to extensive oxidative damage and
inflammation. Although the exact understanding of the
relationship between RONS and exercise still remains
open to interpretation and insights, it is now clear that
both aerobic (29) and anaerobic exercise (30) may
potentially cause acute oxidative and nitrosative stress
through various types of biochemical mechanisms.
Different exercise protocols can induce different levels
of production of RONS, since the oxidative damage they
cause has proved to be dependent on the intensity and
duration of the exercise itself (31). It should be taken into
account, however, that also other factors, including age
(32), degree of training (10) and diet (33) play a crucial
role in the possible alteration of the balance between
antioxidant defenses and pro-oxidant elements. From
a molecular point of view, it is worth considering that
the positive effects of regular physical activity may be
mediated in part by the increased bioavailability of NO
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1
6 | SportandAnatomy
resulting from physical exercise and in part by a RONSmediated activation of gene transcription pathways that
ultimately determine a greater production of antioxidant
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an activation signal of a series of molecules that in turn
activate nuclear transcription factors being sensitive to the
redox state, such as Nuclear Factor kB (NF-kB). The gene
regions promoters of several antioxidant enzymes such
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In conclusion, given the demonstration of a correlation between physical activity, mechanisms of gene transcription
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and completeness the molecular mechanisms behind the
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33
CORRESPONDENCE
Ferdinando Franzoni
[email protected]
SportandAnatomy | 7
JSA 2015;1:8-13
Andrea Nonnato1, Guido Belli2, Rocco di Michele3
Trainer of Allievi Biancoscudati, Padova
PhD, Trainer of Allievi Biancoscudati, Padova
3 PhD, Assistant Professor, University of Bologna
1 2 The Relationship between internal
and external load in intensive
ball drills in young sportspeople
Preliminary Study
Abstract
The aim of this preliminary study was to analyse the training load produced by two physically demanding technical-tactical drills
in soccer players of different age groups. Sixteen male players (U16: n = 8, U15: n = 8) performed 2 small-sided games (SSGs)
drills: a 4 vs 4 possession in a “double square” pitch (3 x 4-min), and an “in/out” possession with regular goals and goalkeepers
(20-min total duration, 2 vs 2 to 4 vs 4). The external load was monitored using a GPS device, and the rate of perceived exertion
(RPE) was recorded at the end of each session. The 4 vs 4 possession showed a higher training intensity than the “in/out” drill
as revealed by higher average metabolic power, distance covered per minute, equivalent distance per minute, and RPE. On
thecontrary, the percentage equivalent distance, and high intensity acceleration/deceleration were higher in the “in/out” possession. These differences between examined drills were observed both in the U15 and U16 age group. Finally, in both the drills
and for all examined load variables, the training intensity was overall higher in the U16 than in the U15 group. In conclusion, the
4 vs 4 possession is more physically challenging than the “in/out” possession, being more focused on physical than on technical aspects. U16 players are more capable than U15 to produce the maximum effort in the 4 vs 4, and thus are more ready to
perform optimally that kind of drill.
Key words: soccer - metabolic power - GPS - RPE
Riassunto
Questo studio preliminare ha analizzato il carico di allenamento di due esercitazioni tecnico-tattiche a elevato impegno fisico in
calciatori di età differenti. 8 calciatori Under 16 e 8 Under 15 hanno eseguito 2 SSGs (Small Sided Games) in diverse modalità:
un 4 vs 4 in “doppio quadrato” (3 x 4’) e mini-partite, con la presenza del portiere, in “gabbia” (20’ totali, dal 2 vs 2 al 4 vs 4). Gli
indici di carico esterno sono stati monitorati attraverso un sistema GPS, ed è stata registrata la fatica percepita (RPE). Il 4 vs 4
ha mostrato un’intensità complessivamente maggiore rispetto alla gabbia per potenza metabolica media, distanza al minuto,
distanza equivalente al minuto ed RPE. Al contrario, un’intensità maggiore è emersa nella “gabbia” per percentuale di distanza
equivalente e accelerazione/decelerazione ad alta intensità. Tali differenze tra le esercitazioni sono risultate pressoché simili
negli Under 15 rispetto agli Under 16. Infine, l’intensità delle 2 modalità di SSGs è risultata complessivamente maggiore negli
Under 16 per tutte le variabili esaminate. In conclusione, il 4 vs 4 è più intenso della “gabbia”, essendo un lavoro più focalizzato
su aspetti fisici che tecnici. I calciatori di categoria Under 16 riescono a esprimere un impegno maggiore nel 4 vs 4 e appaiono
quindi più pronti a svolgere in modo ottimale tale esercitazione.
Parole chiave: calcio - potenza metabolica - GPS - RPE
Introduction
This study presents a preliminary research in which two
intensive drills were examined in football players of two
8 | SportandAnatomy
different age groups. As there are no specific data in
literature on the variables examined in the proposed
drills, it is not possible to compare them with previous
ORIGINAL ARTICLE
studies, but only to comment what was observed, on
the basis of general remarks suggested by practical
experience.
As reported by Hill-Haas et al. (1), the Small Sided
Games (SSGs) are usually considered as a means of
specific training for football. They basically refer to drills
in which the size of the field, the number of players and
some rules of the game are modified with respect to the
classic 11 vs. 11, in order to give different training stimuli
to the players, depending on whether the objective is
more focused on physical skills or on technical-tactical
ones. The SSG training has several advantages: first,
it is possible to train at the same time the technicaltactical and physical qualities of the player with drills
that reflect the real game situation; furthermore, the
SSGs are more motivating for players compared to
training without the ball and guarantee good flexibility
for load modulation, thanks to the possibility of varying
their different parameters (number of players, size of the
field, rules, etc.). However, the SSGs also have some
limits, that is the plateau effect being difficult to achieve
for well trained players, the difficulty of replicating the
most intense moments of the competition, the higher
probability of contact injuries and the necessary
presence of multiple coaches to control and keep the
intensity high. When using SSGs in training, however, it
is essential to measure the training load obtained in an
accurate and systematic way, especially with reference
to exercise intensity. Several indexes exist for load
assessment:
1) indexes of internal load, such as heart rate (HR,
usually assessed with respect to HR max), blood
concentration of lactic acid and level of perceived
exertion (Rate of Perceived Exertion, RPE). Moreover,
all the methods currently available to assess intensity
during the SSGs have specific advantages, but also
limitations. This is why it has been suggested that
the SSGs be better monitored through a combination of different measures of intensity of the internal
load (2). By analyzing the previous studies, in which
load intensity in the SSGs has been assessed through the parameters mentioned above (see for example
the Review of Hill-Haas et al. (1)), it may be observed that the increase in field size and the decrease
in the number of players lead to higher Heart Rate
(HR), Lactate and RPE (2). The combined effect of the
two variables is also interesting: the intensity of the
game, in fact, seems to decrease when the number
of players increases and the size of the field decreases. Another factor that can affect the intensity of the
drill is the type of rules adopted and the presence or
absence of goalkeepers. The effects of the latter variable, however, are not yet clear: for example, some
authors have shown that the presence of goalkeepers
involves a decrease in the HR of the players (3), while
other studies show an opposite effect (4). Finally the
intensity of the SSGs is very much influenced by the
relationship between work and recovery and by the
spur by the technical staff (2);
2) indexes of external load have been introduced over
the past few years through a first measurement with
GPS at 1 Hz, and today it is already possible to measure at 20 Hz. One of the aspects arising from these
measurements is the possibility to assess how the variation of the playing surface, when the number of players remains the same (5 vs. 5 plus the goalkeeper),
results in a variation of the distance covered in total,
of the average speed and of other variables measured through GPS systems, including some technicalmotor behaviour (5). In a recent study by Gaudino et
al. (6), it was mainly observed that the total distance,
the distance covered at very high speed, as well as
absolute maximum speed, accelerations and decelerations increase as the size of the field increases (10
vs 10> 7 vs 7> 5 vs 5). Furthermore, the total distance, the distance covered at very high and maximum
speed, absolute maximum speed and absolute maximum acceleration and deceleration were higher in
SSGs with goalkeepers and goals (SSG-G) compared
to the SSGs aimed at ball possession (SSG-P). On
the other hand, the number of accelerations and decelerations of moderate intensity and the total number of speed variations were greater when the size of
the field decreased (5 vs 5> 7 vs 7> 10 vs 10) both in
the SSG-G and in the SSG-P.
Aim of the Study
Even in the youth sector the SSGs are widely used in
modulating load intensity through field size, use of
specific rules, number of players and spur of the coach.
As shown by McMillan et al. (7) the use of SSGs can
lead to very high load intensities (up to 90% and more
of HRmax) being comparable to those of dry resistance
trainings such as interval training, and producing the
same adaptations over time (8). In literature there are still
no studies that have analyzed the same drills in different
age groups, and there is no evidence about them. From
a practical point of view, however, it is crucial to know the
characteristics of the drills which are most appropriate
for the various age groups, in order to propose them in
the most appropriate and specific way. Therefore, in our
research we pursued the following objectives:
1) assess the differences in physiological impact of
two technical-tactical drills (SSGs) entailing a high
metabolic effort, through the measurement of external
and internal load;
2) assess the impact of individual drills in two different
age groups: Under 15 and Under 16.
Materials and methods
After a familiarization in two sessions, 16 players
in categories U15 (n = 8) and U16 (n = 8) (Tab. I)
executed two ball drills, in different sessions and not on
consecutive days, for the development of the metabolic
The Relationship between internal and external load in intensive ball drills
in young sportspeople
SportandAnatomy | 9
Table I. Anthropometric data of the players in the two age groups examined (average and St. dev.).
U 15
U 16
Height (m)
Weight (kg)
BMI
Mean
1,70
57,40
17,13
St. dev.
0,08
7,74
6,08
and technical-tactical components. Load intensity
was monitored through the assessment of perceived
exertion (RPE), as measured by the Borg Scale (CR 10).
The RPE was collected 10 minutes after the end of the
exercise for the in/out and, both after each series and at
the end, for the double square. The external load was
instead measured through a GPS system (K-sport, 10
Hz, software K-fitness). The exercises were:
1 The “double square” (Tab. II), consisting of a 4 vs. 4
in a square of 15 x 15 m for 1’, followed by a change
of square, called by the coach, to go to a 20 x 20
m square placed at a distance of 15 m, for 1 ‘, all
repeated twice (tot. 4 ‘). The rest between repetitions
was 2’. There were three repetitions, each respectively
of 4 ‘, for a total of 16’;
2 in/out (Tab2 in/out (Tab. III) (proposed by Capanna),
which consisted of two teams of 6 players. In turn,
according to the diagram below, 2-3-4 pairs of players
were called to play in the pitch (30 x 20m) and faced
each other in a possession with finalization. In case
of a 2 vs 2, game time was 60”, for 3 vs 3 game time
was 75”, for 4 vs 4 game time was 90”. Exchange
time between players in the pitch was 15”. The overall
work was 20’, while it was 579” for each player in
case of players 2-3-4-5-6, and 495” for player 1.
The following tables show some details about the
features of the drills used. The variables of external load
being analyzed, in accordance with Osgnach et al. (9),
have been:
1 average metabolic power (W / kg);
2 distance per minute (m);
3 equivalent distance per minute (m);
4 percentage of equivalent distance (%);
5 high intensity speed (m)> 5 m / s;
6 high intensity acceleration (m),> 2 m / s * 2;
7 high intensity deceleration (m), <-2 m / s 2 *;
8 intensive metabolic power (m),> 20 w / kg.
The variable which was analyzed, and which represented
internal load, was (10): RPE (points, arbitrary units). To
test the effect of the two drills (4 vs 4 and in/out), of the
age of the players (Under-15 and Under-16) and of their
interaction on various dependent variables observed, 2
x 2 ANOVA were carried out for repeated measures, with
age group as a factor among the subjects and type of
drill as a factor within the subjects. The analyses were
performed with SPSS software, Version 14. The level of
significance was set to p < 0.05.
10 | SportandAnatomy
Height (m)
Weight (kg)
BMI
Media
1,80
69,50
21,35
Dev. st.
0,04
4,57
0,98
Table II. Features of the “double square” drill (4 vs 4).
1st Possession double square
Pitch 1° (m)
15 x 15
Pitch 1° (m2)
225
Area (m ) x player pitch No. 1
28,1
2
Pitch n° 2 (m)
20 x 20
Pitch n° 2 (m )
400
Area (m2) x player pitch No. 2
50
Distance (m)
15
No. players
16 (2 x 4 vs 4)
2
No. of players (team)
4
Tot. duration (min)
16
Net. duration (min)
12,5
Exercise duration (min)
4
Recovery (min)
2
2nd In/Out possession with regular goals
Pitch (m)
30 x 20
Pitch (m )
600
2
Area (m ) x player field
2
75-100-150
No. of players
12
No. of players
6
Tot. duration (min)
20
Net. duration (min)
17
Exercise duration
1,5-1,25-1
Recovery (min)
0,15
Results
Table IV shows the descriptive statistics for the
different load variables analyzed, divided according to
age group and type of drill. Tables V, VI, and VII show
instead, for each of the variables, the significance
of the main effects and of the interaction, such as
differences in percentage between the two age groups
and between the two types of drill. The results showed
that in drill 4 vs 4 the values of
total intensity of the
drill were higher than in the in/out with regard to the
following variables: average metabolic power, distance
per minute, equivalent distance per minute and RPE
(Tab. V). Conversely, higher values were

observed in
A. Nonnato et al.
Table III. Description of the in/out possession drill (Rec. = Recovery) (Capanna).
Game
Rec.
1
Players
R
1
R
1
R
1
Matches
R
1
1
R
1
R
1
495”
375”
2
R
2
R
2
R
2
R
2
2
R
2
R
2
570”
450”
3
3
R
3
R
3
3
R
3
R
3
R
3
R
570”
450”
4
4
R
4
R
4
R
4
R
4
R
4
4
R
570”
450”
5
5
R
5
R
5
5
R
5
R
5
R
5
R
570”
450”
6
R
6
6
R
6
R
6
R
6
R
6
R
6
570”
450”
75”
75”
90”
60”
90”
90”
60”
90”
90”
60”
90”
75”
75”
Game time
Table IV. Descriptive statistics (mean and St. dev.) of the variables analyzed.
4 vs 4
U15
Average metabolic power (W/kg)
In/Out
U16
U15
U16
7,52 ± 1,38
8,49 ± 0,98
6,6 ± 1,42
7,33 ± 1,04
Distance per minute (m)
79,89 ± 12,21
87,86 ± 8,49
66,83 ± 11,79
73,39 ± 8,94
Equivalent distance per minute (m)
97,06 ± 17,86
109,8 ± 12,49
85,19 ± 18,21
94,89 ± 13,45
Percentage of equival. dist. (%)
20,82 ± 4,92
24,88 ± 3,8
26,92 ± 4,38
29,07 ± 3,52
Speed to HI (m)
117,41 ± 82,67
146 ± 74,46
128,4 ± 108,3
165,3 ± 87,76
Acceleration to HI (m)
78,24 ± 32,2
98,84 ± 21,69
104,6 ± 35,5
118 ± 24,13
Deceleration to HI (m)
79,24 ± 29,99
99,17 ± 22,89
104,6 ± 36,8
120,2 ± 24,9
Metabolic power to HI (m)
261,06 ± 103,9
317,7 ± 60,36
279,5 ± 121,7
340,1 ± 93,07
4 vs 4
RPE (points)
In/Out possession
U15
U16
U15
U16
3,95 ± 0,52
6,44 ± 1,09
3,68 ± 0,74
5,34 ± 0,77
the in/out drill” compared to 4 vs 4 for the percentage
of equivalent distance and high intensity acceleration
and deceleration. There were no significant differences,
instead, between the two types of drill (p> 0.05) with
regard to metabolic power and high intensity speed.
These differences between drills were overall similar in
the Under 15 and the Under-16, because no variable
(except RPE) showed a significant interaction between
age group and type of drill. In the case of RPE, the
level of perceived exertion was similar between the two
drills in the Under-15, while Under-16 perceived the 4
vs. 4 as more challenging with respect to the in/out. As
for the effect attributable to age (regardless of the type
of drill) intensity was found to be higher in the Under 16
in reference to all the load variables examined.
Variables of external load
See Tables V, VI and VII.
Variable representative of internal load
See Tables VIII, IX and X.
Discussion and conclusions
This study has presented a preliminary inquiry in which
two high-intensity drills have been examined in players
of two age groups (U15 and U16).
As there are no specific data in literature on the variables
examined in the proposed drills, it is not possible to
compare them with previous studies, but only to comment
what was observed, on the basis of general remarks
suggested by practical experience, and comparisons can
be made with the studies conducted so far. What chiefly
emerges is that a drill such as the 4 vs. 4, where there is
a 4 minute-workout without pause, is more demanding
from all points of view with respect to the in/out: the work
is therefore more focused on technical aspects than on
physical ones, and is probably less motivating for the
players as it does not include finalizing. However, high
intensity accelerations (> 2 m / s2) and decelerations
(<-2 m / s2) have showed higher values in the in/out than
in the 4 vs 4. It can be assumed that this is due to the
presence of goalkeepers and thus of the goal, as well
as to the size of the pitch and to the fact that not only
ball possession, but also attacking and defending were
SportandAnatomy | 11
Table V. Percentage differences between drills for external load
variables. The value is specified in the column which refers to the
type of drill with the highest value.
Table VIII. Percentage differences between drills for variable of
internal load. The value is specified in the column For the type of drill
that showed the highest value.
For training
4 vs 4
> in/out
For training
In/out
> 4 vs 4
p
14%
p = 0,000
18%
p = 0,000
14%
p = 0,000
Percentage of equival. Dist. (%)
24,2%
p = 0,000
Speed to HI (m)
2,4%
p = 905
24,9%
p = 0,001
24%
p = 0,002
2,6%
p = 0,732
Table VI. Percentage differences between age groups for the
different variables of external load.
RPE (points)
U16 > U15
p
16%
p = 0,000
13,3%
p = 0,000
16,3%
p = 0,000
14,1%
p = 0,005
Speed to HI (m)
43,2%
p = 0,000
24%
p = 0,004
25%
p = 0,003
27,7%
p = 0,002
Table VII. Significance of the interactions between age group
and drill type for the different variables of external load analyzed.
Interaction
p
p = 0,630
p = 0,518
p = 0,621
p = 0,444
Speed to HI (m)
p = 0,354
p = 0,857
p = 0,717
p = 0,500
necessary. For both types of drill the intensity expressed
was greater in the U16 than in the U15. The U16 are
probably more ready to endure a certain type of request
p
14%
p = 0,001
By age
RPE (points)
U16 > U15
p
50,4%
p = 0,000
Table X. significance of the interaction between age group and
Drill type for the variable of internal load.
Interaction
In/out
> 4 vs 4
Table IX. Percentage differences between age groups for the
variable of internal load.
By age
4 vs 4
> in/out
p
RPE (points)
p = 0,008
than the U15, as certainly they have got more used to a
certain type of intensity, given the diversity of proposals
from team coaches used in this study. As for the RPE,
the U15 perceived less exertion in both drills. Therefore,
the proposal of 4 vs 4 in this age group did not result
in obtaining the expected intensity level. This is probably
linked to a limit of this preliminary study, that is, to the
fact that the U15 involved in this study were not used to
performing a drill such as the 4 vs. 4 and as a result failed
to express the maximum physical effort.
In reference to the studies conducted to date, it can
be noted that there are more similarities with the in/out
possession (Capanna), because many drills have used
a space of 30 x 20 m in the execution of the SSGs,
although with different game time, number of players
and repetitions. These studies have shown that the
higher the number of players in a predefined space, the
lower the intensity, although in our proposal the different
ages of the participants influenced the response to
stress. In both drills there were no limits to ball touch,
another factor that affects the increase of individual
internal load. A spur also influences the increase in
intensity, as shown by Coutts (10) and Rampinini (2), and
the two proposed drills included this kind of stimulus.
As for the parameters of external load, the number and
intensity of accelerations and decelerations in the two
different fields of “double square” drill and even in the in
/out were not analyzed.
A. Nonnato et al.
The difference in RPE may however suggest that these
drills are in line with what has been observed by Gaudino
et al. (6). Another interesting topic to be developed
concerns the analysis of internal and external load in ball
drills with game themes and specific rules suitable for
the different age groups of the youth sector. Moreover,
future studies shall be geared towards an attempt of
planning and preparation with respect to ball drills.
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Special thanks go to Duccio Ferrari Bravo, PhD,
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CORRESPONDENCE
Andrea Nonnato
[email protected]
JSA 2015;1:14-19
Giovanni Ceccarini, Alessio Basolo, Margherita Maffei, Paolo Vitti, Ferruccio Santini
Obesity Center - Endocrinology Unit, Pisa University Hospital
Energy homeostasis and locomotor
activity: the role of leptin
and of the melanocortin system
Abstract
For the purposes of proper control of body weight, nutritional intake and physical activity are integrated through a common
regulatory system in which the leptin-melanocortin system plays a major role. This system is responsible for controlling the
caloric balance through a feedback mechanism, that signals to the central nervous system the amount of stocks contained in
the adipose tissue, so as to optimize dietary intake and energy expenditure. In rodents, the decrease in leptin levels that occurs
following food deprivation or fat mass reduction is associated to an appetite stimulus, to a decrease in overall locomotor activity and to a simultaneous increase in food anticipatory activity, a specific motor activity that reflects the inclination to search for
nutritional resources. This activity can be modulated through the administration of leptin and is mediated, at least partially, by
the neurons of the melanocortin system. In humans, the studies on twins have attributed to genetic factors at least 50% of the
variability in the propensity for physical activity. In particular, some polymorphisms of the melanocortin and leptin 4 receptor are
associated with variations in the levels of motor activity. Clarifying the complex mechanisms involved in the regulation of physical
activity and the connections between the different pathways involved in energy homeostasis could help to understand the nature of the differences existing between individuals in terms of inclination for physical activity and energy expenditure associated
with it. Given the historic difficulties in the development of anti-obesity drugs that are both safe and effective, the exploitation
of the multiple beneficial effects produced by physical activity is an essential component in the context of a multidimensional
behavioural strategy aimed at tackling obesity and its related diseases.
Key words: locomotor activity - leptin - physical activity - obesity - melanocortin system - anorexia nervosa
Riassunto
Ai fini di un adeguato controllo del peso corporeo, l’apporto nutrizionale e l’attività fisica sono integrate attraverso un sistema
regolatorio comune all’interno del quale il sistema leptina-melanocortina riveste un ruolo di grande rilievo. Questo sistema è
deputato a controllare l’equilibrio calorico attraverso un meccanismo a feed-back che segnala al sistema nervoso centrale
l’entità delle scorte contenute nel tessuto adiposo al fine di ottimizzare l’introito alimentare e la spesa energetica. Nei roditori, la
riduzione dei livelli di leptina che si verifica in seguito alla deprivazione di cibo o alla riduzione della massa grassa è associata a
uno stimolo sull’appetito, a una diminuzione dell’attività locomotoria complessiva e a un simultaneo aumento dell’attività anticipatoria del pasto, una specifica attività motoria che riflette l’attitudine alla ricerca di risorse nutrizionali. Questa attività può essere
modulata dalla somministrazione di leptina ed è almeno in parte mediata dai neuroni del sistema melanocortinico. Nell’uomo, gli
studi sui gemelli hanno attribuito a fattori genetici almeno il 50% della variabilità nella propensione all’attività fisica. In particolare,
alcuni polimorfismi del recettore 4 della melanocortina e della leptina sono associati a variazioni dei livelli di attività motoria.
Chiarire la complessità dei meccanismi che intervengono nella regolazione dell’attività fisica e le connessioni tra le diverse vie
coinvolte nell’omeostasi dell’energia potrebbe consentire di comprendere la natura delle differenze che esistono tra individuo
e individuo in termini di propensione all’attività fisica e di dispendio energetico a essa associato. In considerazione delle storiche difficoltà incontrate nello sviluppo di farmaci contro l’obesità che siano nel contempo sicuri ed efficaci, lo sfruttamento dei
molteplici effetti favorevoli prodotti dall’attività fisica rappresenta una componente imprescindibile nel contesto di una strategia
comportamentale multidimensionale finalizzata al contrasto dell’obesità e delle malattie ad essa associate.
Parole chiave: attività locomotoria - leptina - attività fisica - obesità - sistema melanocortinico - anoressia nervosa
REVIEW
Introduction
Under natural conditions, energy homeostasis and body
weight are regulated through the harmonization of caloric
intake and consumption. The latter is mainly determined
by resting energy expenditure, motor activity not linked
to physical exercise and voluntary physical activity (1).
Appetite and metabolism are variables regulated by very
efficient neurobiological mechanisms. The mutations of
individual genes at the basis of this homeostatic system
are responsible for about 5% of the causes of early
obesity (2). These mutations affect proteins which are
mainly expressed in the central nervous system.
Studies conducted on adopted twins and their families,
both biological and adoptive, have established that in
50-70% of cases the body mass index is genetically
determined (3) (4). But it is still not clear to what extent
genetics influences the caloric intake and the energy
expended through physical activity. In particular, the
fact that motor behaviour and the inclination for physical
activity are modulated by neurohormonal regulators is
very often underestimated.
Locomotor activity is a complex behavior influenced
by social, demographic and environmental factors (5).
Experimental data obtained both in animals and in
humans also show that locomotor activity can also vary
on a genetic basis. The recognition of these regulatory
mechanisms is becoming increasingly important in
the face of a real obesity epidemic. When it comes to
physical activity, two components are usually referred
to: voluntary exercise and spontaneous physical activity.
Voluntary exercise is defined as a locomotor activity not
directly required for survival and not directly motivated
by external events (6): in other words, voluntary exercise
consists in sport and similar activities.
Spontaneous physical activity consists of all the
remaining activities in everyday life (e.g. maintenance of
posture, gesticulation) (6) (7). It is also true that many
physical activities fall into a grey area between voluntary
activities and spontaneous activities. In mammals,
complex regulatory mechanisms have developed
that allow for an optimal integration of physical
activity with the maintenance energy homeostasis.
A short-term caloric restriction and fasting decrease
overall locomotor activity, while a modest caloric but
prolonged restriction increases such activity, both in
mice and non-human primates (8) (9). The variants
of certain genes (peroxisome proliferator-activated
receptor-γ, hypocretin, beta-2 adrenergic receptors,
uncoupling protein 3, fat mass and obesity (FTO) gene)
are associated with different levels of physical activity
(10) (11). In addition, several hormonal gastrointestinal
peptides, such as ghrelin, PYY, cholecystokinin, incretin
and insulin appear to contribute significantly to the
regulation of locomotor behavior. Certain components
of the ‘reward’ system,such as dopamine receptors,
endogenous opioids and endocannabinoids may
significantly affect voluntary exercise. The main purpose
Energy homeostasis and locomotor activity:
the role of leptin and of the melanocortin system
of this article is to provide an overview on the influence
of the melanocortin-leptin system on the different
components of locomotor activity.
Rodent studies
Natural selection has led to continuous evolutionary
adaptations to facilitate the acquisition of the necessary
nutrients for reproduction and survival. Several studies
have shown that it is possible to select mouse lines
characterized by high or low levels of locomotor activity
(12) (13). Rodent models have also allowed the analysis of
the major factors involved in the regulation of locomotor
activity, thanks to methods of objective evaluation of the
activity and to the absence of confounding factors that
are inevitably present in studies conducted on humans.
Mouse models have provided important information
through the study of knockout mice, knockdown mice or
through the assessment of gene over-expression, thus
allowing the successful study of the neurobiological
mechanisms underlying locomotor behavior. The
voluntary locomotor activity is usually measured by the
number of rotations of the wheel in the cage (“running
wheel activity”, RWA) and expresses a rewarding
activity and a self-motivated behaviour similar to
voluntary physical activity in human beings. The “home
cage activity” (HCA) describes spontaneous locomotor
activity (7) and can be measured by infrared rays or
through video-recording. In this respect, it is worth
noting that the resistance to the exercise (influenced by
the quality of the components of muscle fibers) and the
total levels of physical activity did not probably develop
synergistically and are not correlated (14).
The effect of leptin and of the melanocortin system
on locomotor activity
Leptin is a hormone secreted by adipocytes in amounts
proportional to their mass and regulates body weight
homeostasis by inhibiting food intake and increasing
energy expenditure (15) (16). Leptin-deficient (ob / ob)
mice are obese and hypoactive (17); administration of
leptin normalizes their body weight and physical activity
levels (18). This finding would seem in line with the
prevailing idea that hypoactivity is secondary to obesity.
However, experimental results exist which indicate
that low doses of leptin can increase both RWA and
HCA during the first day of treatment, i.e. before the
weight loss occurs, thus demonstrating the fact that the
action of leptin on motor activity is not a minor effect
with respect to weight loss (19)(20). It is worth noting
that in a normal mouse, peripheral administration of
over-physiological doses of leptin does not increase
locomotor activity (18) (19). In line with this effect of
leptin, lean mice that overexpress transgenic leptin do
not show variations in motor activity; this is however
reduced when the hormone secretion is interrupted (20).
In mice exposed to a low-calorie diet in which serum
concentrations of leptin are kept normal through the
continuous administration of the hormone, the sudden
interruption of the infusion causes a 50% reduction
in motor activity. Such decrease in the activity is not
observed when leptin levels are restored through free
access to food (21). Taken together, these data indicate
that a reduction of the physiological concentrations of
leptin, like the one occurring during fasting, can be one of
the mechanisms that mediate the reduction of physical
activity observed in subjects showing a marked weight
loss. Restoring the physiological levels of leptin means
encouraging an increase in locomotor activity, while
over-physiological levels of leptin do not have additional
effects. The lack of leptin, reflecting a negative energy
balance, is therefore responsible for a reduction of total
motor activity that seems to be aimed at energy saving
and body weight maintenance. However, this effect of
reduction in motor activity could be counterproductive
in case it causes an inhibition in the search for food.
It is worth noting, in this regard, that when the animal
is accustomed to receiving a meal at fixed times, the
levels of RWA increase immediately before this event.
Such phenomenon is commonly referred to as a food
anticipatory activity (22). The behaviour of rodents in
which the availability of food is reduced and limited
to certain hours of the day is characterized by weight
loss, hypothermia and increased anticipatory activity
(23). The way the administration of leptin influences
food anticipatory activity has been the object of specific
studies which have shown an inhibitory effect (24). In
accordance with this action of leptin, ob / ob mice in
which the hormone is completely absent show, despite
a reduced total motor activity, a marked anticipatory
activity that is abolished by the administration of the
hormone (19). All the actions of leptin on physical
activities can be reproduced when this is administered
at low doses directly into cerebral ventricles, and this
suggests that the effects of leptin on motor activity are
mediated at the level of the central nervous system
(19) (25). The melanocortin system includes various
effectors: neuropeptide Y (NPY), agouti gene-related
protein (AgRP), proopiomelanocortin (POMC) and
α-melanocyte stimulating hormone (αMSH) with its
specific receptors (MC3R and MC4R). Leptin receptors
(LepR) are widely expressed in the central nervous
system, particularly in the hypothalamus, where leptin
regulates feeding and energy expenditure. In the arcuate
nucleus, leptin stimulates the POMC neurons which
perform an αMSH-mediated anorectic action. At the
same time, leptin inhibits the neurons that express the
powerful anorectic peptides NPY and AgRP. Alpha-MSH
is an agonist of MC4R and MC3R, while AgRP is a high
affinity antagonist for both receptors (26). In the mouse
model obesity can be caused by a faulty POMC gene,
by AgRP over-expression or by a reduced function of
MC4R (27). The restoration of the leptin-receptor signal
transduction in the arcuate nucleus of db / db mice,
genetically lacking LePR and therefore obese as ob / ob
mice, normalizes their locomotor activity before effects
on weight appear (28). The same action is obtained
when the signal from the leptin receptor is restored only
in the arcuate nucleus of POMC neurons. This indicates
that such neurons are major mediators of the effects of
leptin on locomotor behaviour (29). The STAT-3 signal
transducer is one of the major intracellular effectors of the
action of leptin. Mice that show a constitutive activation
of STAT-3 in AgRP neurons are lean and hyperactive
(30). By contrast, mice with inactivation of the STAT3 signal in LePR neurons show a reduced locomotor
activity (31). The administration of NPY during a food
restriction period increases the food anticipatory activity
(32) but does not modify the total activity in normal
mice. These data emphasize the behavioural effects
of NPY, which are modulated by changes in energy,
and identify the NPY as a possible mediator of leptin
activity in food anticipatory activity. It is unclear which
additional downstream centers regulate locomotor
responses to leptin, but probably the signal converges
on neural networks such as those of the mesolimbicdopamine system, which is involved in the processes of
reward and motivation (33) and those of the sympathetic
nervous system (34). Male MC4R knockout mice have
lower locomotor activity in the dark phase than normal
mice (35). The administration of MC4R antagonists
decreases locomotor activity in rats (36). It is interesting
to notice that MC4R knockout mice have less total
activity and increased fat mass compared to normal
mice (37). The POMC neurons are estrogen targets (38)
and provide synaptic inputs to neurons that express the
hormone stimulating gonadotropins (GnRH). This could
be an explanation of the effect that estrogens have on
locomotor activity and of the dimorphism between sexes
which is sometimes observed in mouse models. MC3R
knockout mice show an attenuated food anticipatory
activity associated with reduced expression of AgRP
and NPY in the arcuate nucleus (39). These observations
reinforce the impression that AgRP and NPY influence
the anticipatory activity. In this regard, it is interesting
to observe how NHLH-2 transcription factor knockout
mice (nescient helix loop helix 2) present a late-onset
obesity due to a reduction in spontaneous physical
activity.
These animals further reduce their activity after
caloric restriction, an effect which is not reversible
even after restoration of normal access to food (40). If
documented in humans, this phenomenon could be one
of the mechanisms that contribute to regain weight after
discontinuation of a diet (41). It is interesting to notice
that the human homolog of NHLH-2 is implicated in the
transcriptional control of MC4R. It is also assumed that
the BDNF factor (brain derived neurotrophic factor), one
of the major regulators of neuronal plasticity, is one of the
effectors of the leptin / melanocortin system (42). Mice
exposed to environmental enrichment through special
cages that encourage physical activity and increase
G. Ceccarini et al.
sensory stimulation, cognitive and social activities,
show increased sensitivity to leptin and an increased
expression of hypothalamic BDNF, increased stimulation
of POMC anorectic neurons and inhibition of NPY
orexigenic neurons (43) (44). In other words, it seems that
when the animal is exposed to a more natural lifestyle,
its hypothalamus is affected by modifications which
produce a lowering of the leptin set point and promote
a restructuring of synaptic connections, arranged by
BDNF, with a consequent strengthening of the systems
inhibiting appetite and of those promoting motor activity.
In a natural environment, therefore, the system would
be geared to limit an excessive accumulation of body
fat, which would hinder the animals in the exercise of
their natural functions (competition for food, escape,
territorial expansion). It is conceivable that environmental
enrichment, translated into human physiology, may
have an important role in promoting spontaneous motor
activity and represents an additional means to tackle the
obesity epidemic. In conclusion, the reduction in leptin
levels that follows the deprivation of food or a reduction
in fat mass is associated with a decrease in total motor
activity and an increase in total food anticipatory activity.
When food availability is limited, such actions would be
aimed at minimizing energy waste, while stimulating the
motor behaviour related to the search for food and to
the acquisition of the necessary resources to survive
(Fig. 1). These aspects are mediated, at least in part, by
the melanocortin system.
Possible mechanisms of regulation
of physical activity in humans
In humans, the assessment of voluntary exercise can be
carried out through tools such as accelerometers, selfreports, questionnaires, direct observation, continuous
assessment of cardiac activity, calorie counters. A
study in which multisensory devices were used for
the monitoring of motor activity (45) has shown that,
compared to normal weight controls, moderately obese
subjects were spending an average of two hours more
per day in a sitting position and consequently two
hours less in the upright position or walking. This motor
behaviour did not change when obese volunteers lost
weight or lean subjects gained weight. Based on these
observations it is therefore conceivable that a reduced
spontaneous motor activity precedes the onset of obesity
and represents a predisposing factor. Other studies
have shown that acute overeating causes a reduction
in locomotor activity (46). This effect would be more
pronounced in individuals predisposed to obesity (47).
In humans, hyperactivity can be associated with caloric
restriction in some extreme conditions, such as anorexia
nervosa (48). It is conceivable that this phenomenon
involves mechanisms implicated in food anticipation. In
some situations, the stimulatory effect produced by the
reduction in leptin levels on food anticipation may be
dominant with respect to the inhibitory effect produced
Figure 1. In a state of caloric restriction, the circulating levels of
leptin are reduced in order to signal to the hypothalamus a condition
of negative energy balance, resulting in the activation of the AgRP /
NPY neurons and inhibition of POMC neurons. These effects leads to
reduced locomotor activity and increased food anticipatory activity,
in order to counter the effects of energy deprivation in famine situations. From [1], as amended.
on total motor activity. A study using the Swedish
registry of twins showed that within couples, the levels
of physical activity are much more similar when it comes
to monozygotic twins compared with heterozygotic
ones (49), showing an influence of genetic factors on
motor activity. It is estimated that the variability of motor
activity attributable to genetic factors is between 50%
and 78% (49-51).
Numerous studies have assessed the genetic bases
of physical activity (intended as intensity and duration)
using different approaches: linkage studies, association
studies and wide genome scan studies (52). In the
Quebec Family Study (53), a polymorphism (C-2745T)
located near the MC4R gene was associated to the
intensity of physical activity. A limit of these studies
consists in an impossibility to establish a causal link
between the variables examined, and in the tools used to
assess the nature and intensity of physical activity; many
of them are in fact based on questionnaires completed
independently. Two genetic linkage studies have also
confirmed a correlation between physical activity and
loci that are localized in MC4R 54 55. Another study
identified a polymorphism at position 1704 in the 3
‘region of MC4R, which interferes with a connection
site binding a micro-RNA with marked effect on motor
activity evaluated through the use of accelerometers
(56). The Pima Indians, homozygous for the Arg223
polymorphism of the leptin receptor, show low levels of
physical activity, calculated as ratio between total energy
expenditure and baseline metabolism, using a metabolic
chamber (57) (58). The levels of leptin explain 37% of
the variation of motor activity in patients suffering from
anorexia nervosa (59). It is interesting to observe how
physical exercise affects in turn the secretion of leptin,
leading to an acute decrease in circulating levels (60),
even in the absence of changes in body weight (61). In
humans, the candidate genes to explain the marked
inter-individual variability in the levels of physical activity
are the ones that control the systems of reward and
motivation, as the dopamine receptor D2 gene (62). In
conclusion, to clarify the complexity of the mechanisms
involved in the regulation of physical activity and the
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CORRESPONDENCE
Giovanni Ceccarini
[email protected]
JSA 2015;1:20-24
Elena Sabini, Agnese Biagini, Eleonora Molinaro
Endocrinology Devision , Department of Clinical and Experimental Medicine, University of Pisa
Thyroid dysfunction and physical
activity: clinical and therapeutic
implications
Abstract
Thyroid dysfunctions and, in particular, hypothyroidism are complex diseases characterized by signs and symptoms that may
have a significant negative impact on quality of life and performance in the course of physical activity. The exercise intolerance
in conditions of untreated hypothyroidism is multifactorial and is dependent on the functional limitations of the various system
organ class. Thyroid hormones preserving the functions of cardiovascular, respiratory and muscle systems during relaxation and
during exercise and they are responsible for the limitation of exercise tolerance in conditions of hypothyroidism.
Adequate hormone replacement therapy in conditions of hypothyroidism, in addition to improving the quality of life, helps to
achieve good results during physical activity. However, exercise intolerance in patients with overt hypothyroidism and in patients
with subclinical hypothyroidism, is not always reversible following an appropriate hormone replacement therapy.
In fact, in these patients there is a loss of tolerance to physical activity, consequently they perform a lower physical activity resulting deterioration in the quality of life. These patients do not enjoy the psychophysical benefits who instead are available to
individuals who practice regular physical activity. In general an active lifestyle based on regular physical activity of aerobic type
is recommended in all subjects, in particular in patients with hypothyroidism as it can improve the quality of life regardless of the
condition of hypothyroidism
Key words: thyroid - physical activity - hypothyroidism
Riassunto
Le disfunzioni tiroidee e, in particolare, l’ipotiroidismo sono malattie complesse caratterizzate da segni e sintomi che possono aver un impatto notevolmente negativo sulla qualità della vita e sulla performance in corso di attività fisica. L’intolleranza
all’esercizio fisico in condizioni di ipotiroidismo non trattato è multifattoriale e dipende dall’insieme di limitazioni funzionali dei
diversi apparati. Gli ormoni tiroidei preservando le funzioni cardiovascolari, respiratorie e muscolari a riposo e durante l’esercizio rappresentano il fattore limitante per la tolleranza all’esercizio in condizioni di ipotiroidismo. Un’adeguata terapia ormonale
sostitutiva in condizioni di ipotiroidismo, oltre a migliorare la qualità della vita concorre a garantire buoni risultati sportivi durante
l’attività fisica. Tuttavia, l’intolleranza all’esercizio nei pazienti con ipotiroidismo conclamato e, in misura minore, in pazienti con
ipotiroidismo subclinico, non è sempre reversibile in seguito ad una adeguata terapia ormonale sostitutiva. Infatti, in tali pazienti
si assiste ad una minor tolleranza all’attività fisica che porta a sua volta ad una minor attività fisica praticata con conseguente
peggioramento della qualità della vita in tali pazienti in quanto viene meno il beneficio psico-fisico di cui si giovano i soggetti
che praticano un’attività fisica regolare. In generale uno stile di vita attivo basato su una regolare attività fisica di tipo aerobio è
raccomandata in tutti i soggetti ed in particolare in pazienti con ipotiroidismo in quanto in grado di migliorare la qualità della vita
indipendentemente dalla condizione di ipotiroidismo.
Parole chiave: tiroide – attività fisica – ormoni tiroidei
REVIEW
Introduction
The thyroid is an endocrine gland, located in the anterior
region of the neck, that through the synthesis and
secretion in the circulation of 2 hormones, triiodothyronine
(T3) and thyroxine (T4), plays an extremely important
physiological role: it directly influences skeletal and
brain development, participates in the regulation of body
metabolism and in the development of skin, hair system
and genital organs. Thyroid hormones are produced by
the thyroid follicular cells in response to the pituitary
hormone TSH, whose production is in turn regulated by
the hypothalamic hormone TRH. The secretion of thyroid
hormones is pulsatile and follows a circadian rhythm; the
highest levels of T3 and T4 are reached during the night
and early morning, while the lowest levels are reached
between 12 am and 9 pm.
Action of thyroid hormones
Thyroid hormones in the foetus and infant are
indispensable for the normal growth and for the
maturation of various organs, while in the adult they
condition the function of each organ and tissue through
a generalized increase in metabolic processes. In
particular, thyroid hormones:
• - directly regulate the basal metabolic rate through
the increase in oxygen consumption at rest, of the
production of heat and of energy expenditure (as
a result of the increase in mitochondrial oxidative
metabolism and respiratory enzymes). In fact, in
normal conditions, O2 consumption is about 250 ml
/ min, in conditions of hypothyroidism it drops to 150
ml / min and increases to 400 ml / min in conditions
of hyperthyroidism;
• - promote glycogenolysis and gluconeogenesis
(through an increase in hepatic glucose production
and the synthesis of the enzymes involved in its
oxidation);
• - stimulate lipolysis (using fat as energy) and
lipogenesis (adipose tissue synthesis), with a
predominant effect on lipolysis and a consequent
increase in the availability of fatty acids, whose
oxidation generates ATP, used for thermogenesis;
• - increase protein synthesis and therefore have a
trophic effect on the muscle;
• - regulate the growth and differentiation of the central
nervous system during foetal life and during the first
weeks of life;
• - increase myocardial contractility (inotropic positive
effect), heart rate (positive chronotropic effect) and
venous return to the heart; they are therefore essential
for the functioning of the heart;
• - have a key role in skeletal development, in fact:
they stimulate endochondral ossification, linear
growth and maturation of the epiphyseal centers,
promote maturation and activity of chondrocytes in
the cartilage of foil growth, in adults, accelerate bone
remodeling with major effect on reabsorption.
Thyroid hormones also have other various metabolic
effects: they increase intestinal motility, promote the
absorption of cyanocobalamin (vit. B12) and iron,
increase the synthesis of erythropoietin, renal blood
flow and glomerular filtration, stimulate the endogenous
production of other hormones (GH), have a permissive
role in reproductive functions and regulate the trophism
of skin and skin adnexa. A dysfunction of the thyroid
gland results in two well-defined clinical syndromes:
• hypothyroidism: clinical syndrome deriving from a
deficiency of thyroid hormones in tissues that leads
to a general reduction of all the body’s metabolic
processes;
• hyperthyroidism: morbid condition deriving from
increased serum concentrations of the free fractions
of thyroid hormones which leads to a general increase
in metabolic processes.
Effects of thyroid hormones
on the osteomuscular apparatus
The action of thyroid hormones at muscular level
Thyroid hormones control the production of energy and
many aspects of neuromuscular physiology through
the modulation of contractile protein synthesis and the
regulation of transmembrane ion fluxes.
In particular:
• hey regulate the synthesis of myosin heavy chains
(through the increase of the alpha-isoenzyme and
the reduction of the beta-isoenzyme, resulting in a
prevalence of type II fibers, with high ATPase activity
and contractile efficiency);
• they increase Ca-ATPase (enhancement of the
uptake of calcium in the sarcoplasmic reticulum with
increased plasma contractility);
• they increase Na / K-ATPase (increased sodium efflux
with enhancement of contraction and increased
consumption of O2 and thermogenesis).
In general, the effects of thyroid dysfunctions on the
osteomuscular apparatus result in a reduced effort
tolerance. In hypothyroidism this is due to a reduced
cardio-vascular reserve (reduction of VO2 max, reduced
cardiac output, increased lactate), to a reduced
pulmonary reserve, to an altered distribution of blood
flow and a reduction in substrate oxidative capacity. The
mechanisms underlying the reduced muscular efficiency
are attributable to the increase in slow fibers (type I),
to an altered oxidative function with a consequent
reduction of ATP and phosphocreatine, to the decrease
of intracellular pH and to the early glycogen depletion.
In hyperthyroidism, instead, the decrease in effort
tolerance depends on an increase in the rate of blood
flow and cardiac output at rest and on a decreased
efficient use of O2, of the anaerobic threshold, of the
contractile reserve and of work capacity.
These effects are the consequence of an increase in
cardiac frequency and output. These metabolic effects
translate clinically in weakness, asthenia, exertional
dyspnea and exercise intolerance in hypothyroid
patients. In hyperthyroid patients, instead, physical
activity leads to events like: resting tachycardia, reduced
effort tolerance, muscle weakness (especially of proximal
muscles and extensors), reduction of muscle mass.
Effects of exercise on the thyroid function
In addition to determining a number of beneficial effects
on the cardiovascular system, physical exercise also
influences a wide range of endocrine and metabolic
functions. Because of the known influence of thyroid
hormones on the cardiovascular system, various studies
have been conducted to examine the variations of the
thyroid function and other endocrine glands during
exercise. The lack of consistency of these studies
resides in different aspects: wide variety of types of
exercise put in relation to the thyroid function, individual
variability and non-homogeneity of the conditions of the
initial thyroid function.
In particular Smallridge et al. presented a study in which
three different conditions of exercise were evaluated
(sedentary, amateur runners and marathon runners); in
these categories no significant differences of thyroid
function in baseline conditions and after TRH stimulation
(TRH test) were detected. The only significant difference
concerned, in fact, prolactin baseline levels dosed in
the immediate post-exercise phase and one hour after
the end of the exercise, which were lower in sedentary
subjects than in those who carried out regular physical
activity, while no significant differences were found
among amateur runners and athletes, because also the
peak of prolactin after TRH stimulation resulted higher in
this second group. This study seems to show that, while
the effects of physical activity on thyroid hormones are
Signs and symptoms of hypothyroidism
Central Nervous System: loss of memory,
Thyroid
hormones
poor concentration and deafness
Pharynx: hoarseness
Heart: bradycardia and pericardial
effusion
Musculature: delayed relaxation of
reflex
Extremities: feeling of cold
Lungs: shortness of breath and
pleural effusion
Intestine: constipation and ascites
Reproductive system: menorrhagia
Skin: paresthesia and myxedema
Hair Loss
negligible, exercise would, however, influence other
hormones, in particular prolactin, whose values
are
modified by physical activity, without any modulation due
to the intensity of physical activity. Some authors have
in fact suggested that intermittent hyperprolactinemia
produced by exercise can play a role in the amenorrhea
often found in young female athletes (1). Also according
to other authors, a short duration exercise would only
have a modest influence on the hypothalamic-pituitarythyroid axis: it has been demonstrated, in fact, that low
workloads do not determine changes in TSH nor during
exercise or during the subsequent 24 hours (2); while in
case of submaximal prolonged exercise, other studies
show a continuous increase in TSH levels both during
the exercise and in the 15 minutes after its end. The
significant increase in TSH, which can be observed after
prolonged physical stress, is most likely due to the minor
peripheral level of thyroid hormones, widely used at
tissue level, with a consequent stimulation (through the
physiological feedback pathways) of the TRH synthesis
at the hypothalamic level and consequently of the TSH
at the pituitary level. This has been demonstrated in a
study conducted in Norway in which high plasma levels
of T3, T4, TSH and of the protein that binds thyroid
hormones (TBG) have been highlighted in cross-country
skiing athletes immediately after a performance: the
plasma levels of T3, T4 and TSH went back within the
initial limits only several days after the end of the exercise
session (2). Therefore, while an intense but short physical
activity is not able to determine significant modifications
of plasma levels of thyroid hormones, prolonged training
sessions lead to a marked increase in the levels of T3
and T4 as a result of the action of the positive feedback
on the hypothalamic-pituitary-thyroid axis. Prolonged
physical activity can therefore influence the biosynthetic
activity of the thyroid gland and increase the levels of
T3 and T4 without however producing the toxic effects
that occur in case of hyperthyroidism. Some studies,
however, have demonstrated a reduction in circulating
T3, probably as a result of the increased peripheral
conversion in reverse T3 (3).
It should also be considered that physical activity, does
not directly condition the thyroid activity, but indirectly
affects the synthesis and the production of thyroid
hormones by modifying the nutritional status. Since it
regulates energy metabolism, the thyroid function is in
fact affected greatly by the nutritional status: its activity
is reduced in conditions of negative energy balance,
such as during fasting, in which the production of thyroid
hormones and tissue sensitivity to these hormones
decrease. This represents a defense mechanism that
reduces tissue metabolism in order to limit energy
consumption. In fact, according to Uribe et al. (4) the
activity of the hypothalamic-pituitary-thyroid axis is
reduced in conditions of negative energy balance, but
the effect of chronic exercise on the axis is controversial
and not well-known at the hypothalamic level.
E. Sabini et al.
Hypothyroidism and physical activity
Hypothyroidism is a complex disease characterized
by signs and symptoms that may have a considerably
negative impact on quality of life and performance (5)
during physical activity. Exercise, in fact, requires the
coordinated functioning of heart, lungs, peripheral
circulation and muscles. Since they preserve
cardiovascular, respiratory and muscle functions at rest
and during exercise (6), thyroid hormones represent
the limiting factor for exercise tolerance in conditions
of hypothyroidism. In general, a proper replacement
therapy in conditions of hypothyroidism, in addition to
improving the quality of life helps to guarantee good
results in sports during physical activity. However, a
significant number of patients continues to experience
reduced physical performance even during adequate
hormone replacement therapy (3); however, there are no
randomized clinical studies that have assessed reduced
exercise tolerance in hypothyroid patients adequately
treated with levo-thyroxine. In a recent review of the
literature (3) it has been shown that exercise intolerance
in conditions of untreated hypothyroidism is multifactorial
and dependent on the functional limitations of the
different apparatuses (cardiovascular, cardiopulmonary,
pulmonary, musculoskeletal, neuromuscular). In
addition, exercise intolerance in patients with overt
hypothyroidism and, to a lesser extent, in patients with
subclinical hypothyroidism, is not always reversible
following an adequate hormone replacement therapy
(7). This analysis showed that the condition of
hypothyroidism can lead to significant negative effects
on physical well-being, both in untreated patients and in
Endocrine thyroid system
Hypothalamus
Adenohypophysis
Releasing factor of
Thyrotropin
(Trh)
Negative
feedback
Thyrotropin
(tsh)
Thyroid
those adequately treated with Levo-thyroxine, making
them more intolerant to exercise than healthy subjects.
According to this review, there are contradictory data
on the effects of physical activity in patients with
primary hypothyroidism and what emerges is that
hypothyroidism is associated with a worse quality of life
and consequently with less physical well-being, both in
treated patients and in those not adequately treated with
Levo-thyroxine. In particular, these patients have a lower
exercise tolerance that, in a vicious circle, leads to less
physical activity and to the loss of the benefits which
instead are observed in all those who do regular exercise.
In general, an active lifestyle based on regular physical
aerobic activity is recommended for all subjects, even in
patients with hypothyroidism who nonetheless benefit
from regular physical activity. The potential physical
limitations that are observed in hypothyroid patients
and in those treated with replacement therapy do not
represent an impediment to a regular physical activity. It
is important that sports physicians and endocrinologists
work together to limit the negative effects of thyroid
dysfunction, without excluding regular physical activity
and promoting an active lifestyle with all the benefits
that it entails.
Conclusions
Regular physical activity proved to be one of the main
factors that can reduce mortality and cardiovascular
comorbidities. Limited exercise sessions on a regular
basis represent the best non-pharmacological therapy
to prevent and reduce complications of cardiovascular
diseases. Subjects with thyroid dysfunction represent a
particular subgroup that despite the known limitations
(asthenia, easy fatigue etc.) benefit from regular physical
activity in terms of quality of life and psychophysical
well-being.
Important messages: reassure patients that there are
no contraindications to regular physical activity in case
of a worse performance with respect to subjects with a
normal function; involve sports physicians in therapeutic
decisions; promote physical activity as one would do
among subjects without thyroid dysfunction.
However, there are still significant gaps in the knowledge
of the metabolic mechanisms in subjects with thyroid
dysfunction who do exercise. Research in this area
must provide answers through controlled studies linking
physical performance to thyroid hormone status.
Thyroid hormones
(T3 and t4)
References
1
2
Smallridge RC, Goldman MH, Raines K,
et al. Rest and exercise left ventricular
ejection fraction before and after therapy in young adults with hyperthyroidism and hypothyroidism. Am J Cardiol
1987;60:929-31.
Refsum HE, Stromme SB. Serum thyroxine, triiodothyronine and thyroid
stimulating hormone after prolonged
heavy exercise. Scand J Clin Lab Invest
1979;39:455-9.
3
4
5
Lankhaar JA, de Vries WR, Jansens JA,
et al. Impact of overt and subclinical
hypothyroidism on exercise tolerance:
a systematic review. Res Q Exerc Sport
2014;85:365-89.
Uribe RM, Jaimes-Hoy L, et al., Voluntary exercise adapts the hypothalamuspituitary-thyroid axis in male rats. Endocrinology 2014;155:2020-30.
McMillan CV, Bradley C, Woodcock A,
et al. Design of new questionnaires to
measure quality of life and treatment
6
7
satisfaction in hypothyroidism. Thyroid
2004;14:916-25.
Mainenti, MR, Vigario PS, Teixwira PF,
et al. Effect of levothyroxine replacement on exercise performance in subclinical hypothyroidism. J Endocrinol
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Biondi B, Cooper DS. The clinical significance of subclinical thyroid dysfunction. Endocr Rev 2008;29:76-131.
CORRESPONDENCE
Eleonora Molinaro
[email protected]
E. Sabini et al.
JSA 2015;1:25-27
Sergio Rigardo
Physiatrist, Master Teacher “Sports Physiotherapy “, University of Pisa
Director Physiokinesitherapy - LARC Group, Turin
The interaction between “Water”
and “Dry Land” rehabilitation therapies
The interaction between water and dry land therapies
represents the added value in the development of a
rehabilitation plan for pathologies of different origins.
Only by adjusting water rehabilitation programs to dry
ones is it possible to achieve a “complete treatment”,
and this is often the weak point of the project, which
risks to fail if the integration is not well studied.
Mmany pathologies exist that can benefit from the
combination of kinesi-hydrokinesitherapy (KT + IKT),
and the association between the various therapies can
boost the effectiveness of each of them. If we consider
that the treatment in water is administered only to
patients with specific clinical conditions and that only
a few specialized centers have a rehabilitation pool,
then it is necessary to include hydrokinesitherapy in
the rehabilitation project with well-codified methods
and timings. When the rehabilitation program evolves
slowly and obstacles become increasingly difficult to
overcome, and if the patient is suitable for treatment in
water, then a method needs to be studied in order to
arrange over time the dry treatment and that in water.
It is then important to know not only “what to do” but
“how” and “when to do it”. What needs to be exploited
in water are the physical characteristics of the fluid
that facilitate tissue relaxation, lymphatic and vascular
drainage, articular decongestion and gravity drain, but
also the specific antalgic effects (Fig. 1).
Rehabilitation protocols in water as well as on dry land
are currently available, but they do not consider the
integration of the two operating modes. Rehabilitation
proposals can vary greatly, depending on the patient’s
conditions and according to the objectives set for the
short and medium / long-term.
In ideal conditions, the program is agreed between the
physiatrist and therapist in accordance with the patient
and does not follow rigid schemes, but is subject to
daily variations. Too often, the modes of treatment
being created are fixed, so they are comfortable but
Insights
not forward-looking, and are therefore inadequate
to keep up with the evolution of the techniques of
orthopedic surgery. Water allows to reset most of the
information received by the body through the variation
of gravity action, the contact with water, the flotation,
the temperature etc. Water allows to explore a three
dimensional space through movements that some
disabled people cannot perform on the ground. Water
activates a massive “bombardment” of stimuli for the
training of proprioceptive, visual, auditory perceptions;
skin receptors are overstimulated, both by the effects
of turbulence and heat and by hydrostatic pressure; an
improvement in breathing and balance is also achieved,
and this is an aspect of rehabilitation not to be neglected
(Fig. 2). Sometimes, during the rehabilitation treatment,
postural adaptations, misalignments and / or functional
compensations, developed by the patient during the
evolution of the rehabilitation process need to be
faced. If these adaptations go against the rehabilitation
objectives, it is then necessary to reset them, thus
nullifying and confusing the expectations of the
patient, by providing a set of additional stimuli, whose
Figure 1.
Figure 2.
elaboration will allow for the reconstruction of the correct
motor sequences. As terrestrial creatures, we develop
subconscious adaptations to the effects of gravity on
earth that are practically useless in water and vice versa,
but if these adaptations are structured in a KT / IKT
integrated rehabilitation protocol, they can decisively
influence the evolution of the rehabilitation process
and shorten recovery times. In fact the reconstruction
of specific motor sequences, the improvement of
deep sensitivities, etc., undergo a substantial increase
both for an abundance of different stimuli and for
the possibility of experimentation in environments
with different gravity (Fig. 3). The hydrokinesitherapy
session can be shortened or prolonged depending on
the desired effect, and can also be held before or after
work in the gym. In case of stiff joints, for example,
it is preferable to hold it before KT, in order to exploit
water to “relax” the tissues and prepare them to work
in the gym also through better vascularization. When
the rehabilitation program draws to a close, workloads
become challenging: this is when working in the pool
can be useful to decongest the joint, relax muscles and
allow the patient to close the treatment with a positive
Figure 3.
condition of freedom. Hydrokinetics allows to prepare the
joint to the work of the therapist in the gym; immersion
in fact produces an automatic vascular and lymphatic
drainage. The periarticular tissues relax and stretch, so
that manual maneuvers can work in depth. Even muscle
injuries benefit significantly from work in the pool. After
remaining in hot water, even for a fairly short time (20/30
minutes), the muscle-tendon apparatus is in a condition
of hypotonia, being therefore more prepared to receive
a massage or do some stretching. The pool is in this
case a preparation for work in the gym or on the table.
When instead the progression in the return to loadbearing activities and to walking needs to be dosed,
water allows to perform the first exercises with reduced
body weight, by varying the depth level of the pool and
the degree of immersion of the body. The concession of
the load is then decidedly anticipated in patients who,
for example, would have had to refrain for much longer
from it because of fractures or cartilage lesions. In this
respect, instead, water is the fundamental part of the
rehabilitation program. Separate considerations should
be made for the shoulder. Here, the increase in the
articular range of motion in the first few weeks is almost
always higher in the pool, both with passive exercises
and with “active” ones controlled by the very presence
of water, compared to the dry kinesitherapic maneuvers
administered by the therapist. For shoulder pathologies,
in the initial stages, water is once again the fulcrum of
the rehabilitation program, while dry therapy allows to
monitor the progresses obtained and to integrate them
with specific exercises. One can also choose to divide
the exercises, by allocating a group of proposals only to
work in the gym and another one only to work in water.
In tendon diseases, for example, it is advisable to first
carry out load-bearing activities in water, in order to
protect the muscle-tendon apparatus from dangerous
overloads. For the same reason, in pathologies that
involve a very long rehabilitation program (ligament
reconstructions, severe fractures), the first dynamic
activities can be facilitated and anticipated in water. This
can be useful, even more so, every time an athlete has to
get used again to the rhythm of training and competition.
The abilities to stand upright, walk in all directions, jump
and rotate in water must be acquired as a fundamental
basis to achieve autonomy and to prepare the person
to swimming. All activities should start with the stable
“curled up” position and, progressively, with the
improvement of control, the ‘”opening” of the body in a
“stretched” position can be encouraged (Fig. 4).
Flotation can be used as a force in water to help movement
and act against gravitational effects. To understand
flotation, the patient may be asked to push objects less
dense than water itself underwater and to observe their
return to the surface as soon as they are released. When
the patient has learned to breathe out into the water and
to control rotation, underwater activities integrated with
dry activities may be introduced. These activities will
S. Rigardo
Figure 4.
still require a good breath control and breathing should
never be held. Also, in order to look for objects in water,
patients have to keep their eyes open under water, and
this is another very important skill for every swimmer. It is
only after reaching the so-called “integrated aquatics”,
that is, the ability to develop specific motor sequences
References
Arms W, Pope MH, Johnson RJ, et al. The
biomechanics of anterior cruciate ligament rehabilitation and reconstruction.
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Davis BC, Harrison RA. Hydrotherapy in
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Franchimont P, Juchmes J, Lecomte J. Hydrotherapy-mechanism and indications.
Pharmacol Ther 1983;20:79-93.
Gasco P, et al. Analisi della dinamica del
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SIMFER 1988, vol. I, Chianciano Terme.
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benefici effetti per diminuire la resistenza dei tessuti molli. La Riabilitazione
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Harrison RA. A quantitative approach to
strengthening exercises in the hydrother-
resulting from the integration of dry and water activities,
that the patient can begin to use those same sequences
to reconstruct complex actions like walking in water and
swimming within the limits of his abilities. There is no
limit to the activities that can be devised in the pool to
achieve integration between KT and FKT, the important
thing is to respect the principle that the rehabilitation
program must be clear, known, shared and evolving,
so that every water activity of the patient is aimed at
achieving the objective and has a specific therapeutic
content. Another favourable aspect is that of a group
therapy, both dry and in water, because the patient
takes further advantage of the socialization, emulation
and competition that derive from it, and is also often
called to work longer and to focus more. In short, a
true interaction between dry and water therapies must,
in any case, provide for a mutual coordination and
completion of rehabilitation proposals. The inclusion
and the continuation of aquatic therapies should not
follow strict protocols, but should answer our needs
of outcome and especially those of the patient. To do
this, maximum cooperation is necessary between the
various professionals who interact in the rehabilitation
process.
apy pool. Physiotherapy 1980;66:2-60.
Iannilli M, Dalla Corte G, Ballotta M, et al.
Nostra esperienza di trattamento riabilitativo in piscina terapeutica. In: Atti del
Convegno triveneto della Società Italiana di Medicina Fisica e Riabilitativa.
Lamon 26/9/1998:1-444.
Marenzi R. Effetti dell’acqua in riabilitazione. In: Zorzi GA, ed. Riabilitazione
2000: l’era dell’acqua. Pordenone 2000,
pp. 21-29.
Mazzaro E, Armani S, Boccardo S. Ruolo della acquaticità in idrochinesiterapia. Giorn
Ital Med Riab 1996;10:7-9.
Mercanton G, Padey A. L’expérience de
3000 épaules en balneothérapie. Kinesithérapie Scientifique 1997;368:7-12.
Messina B, Grossi T. Elementi di idrologia
medica. Roma: Universo Ed. 1983.
Napletan JC. Water on the knee. Rehab
Manag 1993;6:80-2.
Ortolani M, Atzori B, Cardani R. Elementi di
biomeccanica del gesto terapeutico in
idrochinesiterapia. Giorn Ital Med Riab
1993;1:4-14.
Phyonen T, Keskinen KL, Hautala A, et al.
Human isometric force production and
electromiogram activity of knee extensor muscles in water and on dry land.
Eur J Appl Physiol 1999;80:52-6.
Rigardo S, Matti A, Lesina MR. Idrochinesiterapia degli esiti di meniscectomia. Il
Fisioterapista 1996;1:7-9.
Skinner AT, Thomson AM. La rieducazione
in acqua. Roma: Marrapese Ed. 1985.
Speer FP, Cavanaugh JT, Warren RF, et
al. A role for hydrotherapy in shoulder rehabilitation. Am J Sport Med
1993;21:850-3.
Tovin BJ, Wolf SL, Greenfield BH, et al.
Comparison of the effects of exercise in
water and on land on the rehabilitation
of patients with intra-articular anterior
cruciate ligament reconstructions. Phys
Ther 1994;74:710-19.
Walk EE, Himel HN, Batra EK, et al. Aquatic access for the disabled. J Brun Care
Rehabil 1992;13:356-63.
Webels A. La ginnastica in acqua. Roma:
Ed. Marrapese Ed. 1995.
CORRESPONDENCE
Sergio Rigardo
[email protected]
The interaction between “Water” and “Dry Land” rehabilitation therapies
JSA 2015;1:28-32
Marco Ceriani
Expert in Food Science and Technology, Scientific Advisor GENSAN
The role of proteins in sports
Protein-based food supplements are included into
Italian law in the categories listed in Annex 1 of
Legislative Decree 111/92 (already covered in the article
“Definition of dietary supplements and their use in
sport” in Sport & Anatomy 2014; 00: 38-42) concerning
“special physiological conditions of foods suitable for
intense muscular effort especially for sportpeople”.
The body of sports people, in fact, is mainly anabolic,
and this causes a significant physiological increase in
overall nutritional requirements to support the plastic
requirements and the intense metabolic effort. For
this reason, in the labelling of food supplements the
following words have been proposed in the list of health
claims (EU Regulation 432/2012) “proteins contribute
to the maintenance and growth of muscle mass and
to the maintenance of normal bones”. Proteins, amino
acid compounds and their derivatives (such as creatine,
beta hydroxy methyl butyrate) are certainly molecules
of great importance in the diet of the sportsperson.
Physical activity is in fact, first of all, a muscular
expression, and although depending on the presence
of energy substrates, it requires maximal muscle
efficiency (endurance, power and physical strength). An
insufficient amount of protein nutrients in the diet can
reduce the capacities of defense of the body (the lack of
nitrogen compounds, as is known, weakens the immune
system). The main role of proteins is therefore to provide
the amino acid bases for the synthesis of new cells and
tissues. On a chemical level, the proteins are composed
of amino acids linked together by peptide bonds,
forming polypeptides with high molecular weight, which
make the molecular configuration of proteins particularly
complex (primary, secondary, tertiary and quaternary). A
linear configuration composed of up to 100 amino acids
is defined with the term “polypeptide”, while longer
molecules are referred to as “proteins”.
The role of proteins in sport
Physical performance is not highly dependent on
protein intake. The known factors that can affect muscle
energy metabolism are in fact due to the metabolic
energy pathway whose limiting factors are, in brief,
made up of availability of energy substrates, efficiency
of the cardiovascular and respiratory function, muscle
fibers and enzymatic activity. But there is no doubt
that the percentage of lean body mass, the functional
characteristics of the different types of muscle fibers
(slow and fast) used in physical activity, and muscle
metabolism prove essential to produce maximum and
winning performances. The exact knowledge and correct
interpretation of the bioenergetic metabolic pathways
followed in different types of sports performances
(short maximal efforts, endurance and aerobic activities)
allow to assess the extent of use of macronutrients,
carbohydrates, fats and proteins. Within the human body,
proteins have mainly a plastic function, as they are the
main component of lean mass (about 20% of the body
component). They are also constituents of enzymes and
vitamins. In sports, the most popular proteins are those
with the highest intake of essential amino acids. The
amino acids, as is known, are classified into essential
(the human organism is unable to synthesize them and
they must therefore be introduced through nutrition) and
non-essential (a definition that must not reduce their
importance, but convey the concept that they can be
produced, at a metabolic level, from other precursors).
The essential amino acids are: isoleucine, leucine,
lysine, histidine, methionine, phenylalanine, threonine,
tryptophan and valine (in addition to arginine, essential
to children, and cysteine and tyrosine in the absence of
methionine and phenylalanine).
In sport, glutamine is considered an essential or
“conditionally essential” amino acid, given its significant
presence in muscle groups. Proteins with high biological
value (present in common foods such as eggs, milk,
meat and fish) contain all the essential amino acids in
optimal quantities to maintain nitrogen balance and
enable tissue repair and growth. In special diets linked
to lifestyles like the vegan diet, whose only prevailing
protein sources are cereals and legumes, qualitative and
Insights
quantitative deficiencies may occur in essential amino
acids (1). In a vegetarian diet, instead, animal by-products
(milk and eggs) are included, so the probabilities of a
shortage of essential amino acids are very low, provided
that the diet is varied and normocaloric. In particular, a
“lacto vegetarian” diet doesn’t involve any risk of protein
deficiencies and is able to guarantee an adequate intake
of minerals (calcium and phosphorus) and vitamins (in
particular vitamin B12) (Tab. I).
Table I. Main functions of proteins.
Making up hormonal and enzymatic structures (metabolic regulators)
Maintaining the muscle structure and promoting protein anabolism
Preventing inflammations and infections (Antibody immune action)
Neutralizing many toxic substances (detoxicating enzyme systems)
Representing a primary source of organic nitrogen
Performing plastic and adjustment functions
Promoting the growth, maintenance and repair of cells and tissues
Performing energy functions during exercise (glucose-alanine cycle)
Protein Quality Indexes
The methods used for the evaluation of protein
requirements can be summed up in two types: nitrogen
balance (Protein Efficiency Ratio, PER, Net Protein
Utilization, NPU) and factorial method. While the latter
determines all the losses of nitrogen compounds after a
period of protein-free diet, the analytical methods linked
to nitrogen balance determine the minimum amount of
food proteins which can maintain the nitrogen balance in
a person of medium build (excluding specific metabolic
situations such as pregnancy and lactation).
The nitrogen balance can be determined in several
ways, such as:
• Protein Efficiency Ratio (PER, efficiency rate of the
protein), an indicator used to evaluate the quality of
food proteins and representing the ratio between
weight gain (in animals) and amount of protein (in
grams) administered;
• NPU (net protein utilization), represented by the ratio
between the nitrogen retained by the body and the
one introduced through the diet multiplied by a factor
of 100.
The PDCAAS is instead a method of evaluation of
protein digestibility assessed in terms of the amino acid
score corrected by an index of protein digestibility. The
casein derived from milk, egg white powder, the isolated
proteins of soy are all protein compounds characterized
by a high index of PDCAAS (1.00), contrary to wheat
proteins (gluten) that have a score of 0.25 (2).
Absorption and digestion of proteins
Food proteins are digested and absorbed by the
intestine in large daily quantities. They are not all of
food origin; some are of endogenous origin (serum
albumin, mucoproteins, digestive enzymes), are
secreted in the gastrointestinal tract and spilled in the
intestine as enteric juices. Considering 100 grams of
ingested proteins, about 170 grams is the total amount
absorbed and about 10 grams are excreted (fecal loss)
(3). Between 50 and 70 g of endogenous proteins are
therefore digested daily, which is roughly equivalent
to the average amount of protein ingested (4). Protein
digestion occurs in the stomach, where acid secretion
denatures the proteins, exposing them to the attack of
pepsins (endopeptidase: trypsin, pepsin, chymotrypsin,
elastase), carboxy and aminopeptidase that split the
polypeptide chains into fragments of small size (amino
acids), which are absorbed by the cells of the intestinal
mucosa. The digestion (hydrolysis) of proteins occurs in
three phases, gastric, pancreatic and intestinal, through
mechanical, chemical and enzymatic disintegration
leading to obtain simpler molecules (peptides and amino
acids). In the gastric phase, hydrochloric acid contained
in the gastric juices of the stomach and specific
enzymes (pepsins, trypsin, elastase and chymotrypsins)
denature proteins (the process involves only 10-15%
of the ingested proteins that are broken down, at this
stage, into polypeptides). In the pancreatic phase,
which occurs in the duodenum, protein hydrolysis takes
place (approximately 50-60%), due to some proteases
contained in the pancreatic juice: endopeptidases
(trypsin and chymotrypsin), being active on the peptide
bonds inside the protein molecule, and exopeptidases
(carboxypeptidase), which lead to the release of amino
acids. The intestinal phase covers virtually all protein
hydrolysis (80-90%) and completes the denaturation of
proteins through the action of specific peptidases that
release amino acids. This phase leads to the hydrolysis
of both the proteins ingested and the endogenous ones
(digestive enzymes, desquamated epithelial cells and
others).
As for the absorption of proteins, it is important not to
neglect the fact that traditional protein foods (meat and
fish), once cooked, can present a more or less marked
denaturation of protein structures. While on the one hand
thermal heating may degrade the quality of the proteins
contained in meat, on the other hand some plant foods
(cereals, legumes and tubers) can improve the intake
as a function of a decrease in anti-nutritional factors.
Establishing the actual extent of the positive or negative
effect of cooking food on the bioavailability of proteins
is a complex task, full of variables, being closely related
to the type of food and the heat treatment it undergoes
(grilling, frying, boiling, microwaving...).
Branched Chain Amino Acids (BCAA)
Amino acids are complex molecules that differ in
their chemical-physical properties (solubility, pH and
molecular structure) and metabolic fate (glucogenic and
ketogenic). Amino acids are not only the constituents
of proteins, but also play a valuable role as precursors
of fundamental biological molecules such as hormones,
pigments, purines and co-enzymes. Of all known
amino acids, five (leucine, isoleucine, valine, lysine
and histidine) cover alone 75% of the needs of human
organism. However, these amino acids are present in
small concentrations in food (less than 20% in proteins
with a high biological value). This factor is of great
importance in the athlete’s food supplementation, and
should lead to reducing the presence of the other amino
acids in favor of leucine, isoleucine, valine, lysine and
histidine, thus promoting a reduced accumulation of
synthesized urea in blood. The definition of “essential”
amino acids, as already explained, is not univocal since
they can be “essential” not only for the whole body but,
in a more selective way, only for some organs (only the
liver, for example, has a specific hydroxylase, which is
absent in the cells of other organs, and is able to operate
the synthesis of phenylalanine into tyrosine) (5). The
three branched amino acids (also known as “neutral” or
BCAA) L-Leucine, L-Isoleucine and L-Valine, represent
the group of molecules being most studied at the level
of clinical and sport integration. In terms of performance,
the utilization rationale of branched amino acids is
due to their oxidation which takes place, preferably, in
skeletal muscles rather than in the liver, thus decreasing
the time of assimilation. Amino acids allow for the
intake of active molecules in muscle construction /
reconstruction, without producing metabolic waste and
without providing a caloric surplus (Tab.II).
Protein requirement
The protein requirement is dependent on several factors
such as age, sex, professional and sport activity, and
on special physiological conditions (growth, pregnancy,
old age). It is usually defined in relation to physiological
body weight (in the athlete it is always known as ideal
weight), age, sex and workload during training. In
order to correctly define the daily protein requirement
of an athlete (which must obviously always be equal to
nitrogen balance), it is essential to evaluate the weight,
the level of hydration and the individual constituents of
body mass (lean and fat), and obviously the duration
and intensity of the daily physical activity. It is also worth
assessing the percentage of essential amino acids
ingested with the diet, that should be equal to 36% of
the total amino acid intake (6) (Tabb. III-IV). In athletes it
is therefore particularly important to maintain a sufficient
energy intake to support muscle activity. In case of
insufficient energy intake in the diet, body proteins are in
fact metabolized to make up for the energy deficit. With
the reduction of energy reserves in the body (low-calorie
diet or fasting), glycogen is less available, and glucose is
therefore synthesized from protein compounds and fatty
acids (gluconeogenesis). The problem of the correct
determination of protein requirement is given by the fact
that the response of the nitrogen balance to increasing
Table II.
The branched amino acids (also referred to by the initials “BCCA”:
Branched Chain Amino Acids) are the three essential amino acids Lisoleucine, L-Leucine and L-Valine
They are especially used in conditions of stress, injury, intense physical
exercise
L-Leucine, which is used twice more than the other two branched amino
acids (the amino acid being more oxidized during endurance performances), acts as a stimulator of protein synthesis in the phase of plastic
recovery, at the end of intense muscular exercises. It is one of the promoters of the release of growth hormone (GH) and insulin
BCAAs are not metabolized in the liver (the liver unlike, the muscle, does
not have the specific transaminases needed to obtain the corresponding
alpha-keto acids)
The branched amino acids compete with phenylalanine and tryptophan
for the same conveyor at the level of the blood brain barrier. As a consequence, during exercise they tend to deplete branched chain amino acids
in plasma before the other amino acids, tryptophan and tyrosine are conveyed in the brain with greater efficiency, with beneficial effects on the
serotonergic and adrenergic systems controlling sleep, mood and fatigue
They are used as supplements for power and endurance sports and
power endurance and in low-calorie diets
amounts of proteins of good nutritional quality is not
linear.
In case of poor protein intake, the improvement is
proportional to the amount of protein introduced with
food, but for the amount of protein being capable of
maintaining the body balance, the efficiency of protein
decreases. Protein requirements, therefore, appear
higher than those shown in the case of low protein
intakes (Ardent, p. 118) (3).
Protein supplements and production
technology
Today, in sports, integrating nutrition with concentrated
protein powder from different food sources is common
practice. The most widespread protein sources are those
of milk, that are produced through technological processes
(drying and concentration). While drying occurs typically
through the “spray-dried” technique (nebulization in hot
air chambers), concentration processes occur through
ion exchange (resins which separate proteins according
to their electrical charge) or ultrafiltration (through
membrane filters).
Dietary protein in the form of supplements (concentrated)
are often the result of two or more different protein
constituents and produce non-homogeneous nutritional
responses according to the resultant of the amino acid
profile. Four situations can be defined (8):
1) no complementary effect (in the case of identical
amino acids missing or deficient);
2) poor complementary effect (same deficiency of limiting
amino acids but in a quantitatively different measure);
M. Ceriani
Table III. Sports at risk of poor diet.
Criteria
Sport
Low weight
Chronically low energy input to maintain weight
and muscle definition
Gymnastics, ballet dance, fitness and aerobics
Fast competition weight
Rapid and drastic weight loss to access competition categories
Ring sports and tatami
Increase in lean body mass
Accentuated muscle definition (drastic loss of fat and body water)
lack of liposoluble vit./ cramps
Body building, boxing
Vegetarian diet
(strictly vegetarian or vegan athletes)
Endurance and weight lifting
Table IV. Daily protein levels (average requirement expressed
in g/kg/day).
Adults
0,8 g
Active people
1,0 g
Endurance athletes
1,0-1,6 g
Team sports (football)
1,4-1,7 g
Strength sports
1,6-2,0 g
Sources: International Society of Sports Nutrition (2) ISSN (7).
Note: the values shown are referred to body weight intended as ideal weight.
3) limited complementary effect (protein sources with
common deficiency of an amino acid, where the
protein source with the highest intake of the deficient
aminoacid prevails);
4) high complementary effect (synergy of the components
of the protein mixture where the resulting protein
quality exceeds that of each individual component).
Milk proteins (whey and casein)
Serum proteins (also defined by the term “whey protein”)
are proteins with a high biological value of high quality,
soluble in liquids and readily digestible. The protein
fraction is composed of albumins (75%) and globulins
(15%). Whey proteins are considered as fast proteins
(2), contain a high percentage of branched chain amino
acids and sulfur amino acids (cystine and methionine).
The current trend is to produce delactosed proteins
(more compatible with the needs of many consumers
with problems of lactose absorption). Casein is instead
the main constituent (about 80% of milk proteins).
Chemically, it is a phosphoprotein which, together with
phosphoric acid and citric acid, binds calcium and
favours its assimilation (it is for this reason that milk
turns out to be an essential food for the absorption of
calcium). Casein is considered as a slow-release protein
(2) since it creates a gel in the intestine that slows down
the intestinal transit, thus favouring protein absorption.
On the market there are protein compounds from whey
proteins and casein in different proportions:
• isolated milk protein: a mixture of whey proteins and
casein in a variable ratio, characterized by specific
release time and absorption (the formula is often
protected by the exclusivity of the manufacturer);
• total milk proteins: they represent the fraction of milk
protein as it is (80% conjugated caseins and 20%
whey proteins);
• protein concentrate: the protein fraction is made with
customized protein ratios by the manufacturer (which
may include multiple sources such as, for example,
egg white, soya and legumes) according to specific
needs of absorption or intolerances to one or more
components provided by traditional milk proteins. In
addition to proteins derived from milk, other protein
sources are produced, such as:
• egg proteins: obtained from egg white (ovalbumin).
Despite being characterized by an optimal amino
acid profile, they are not particularly pleasing to
consumers because of their aroma and flavour which
is considered as a bit, or completely, unpleasant;
• soy proteins: mainly required by those who are
intolerant to milk protein or do not want to eat
proteins derived from animals (vegetarians and
vegans). Recently, thanks to the improvement of the
processes of extraction and concentration, this type
of protein has improved in terms of palatability and
this has contributed to a better acceptance;
• hydrolyzed wheat proteins: they are not very common
because of their lower biological value (even if, in terms
of amino acids, they can bring about 40% of glutamine),
but also of a taste poorly appreciated by consumers and
of a low solubility in liquids that make them unsuitable
for the preparation of drinks with a high protein content;
• proteins from legumes: proteins that can provide
a good protein percentage (and a relative share of
amino acids); they are suitable in cases of intolerance
to milk (lactose) and may provide a basis for a protein
mixture (e.g. concentrated proteins from egg whites,
soya and peas).
• protein gainers: the “Weight Gainers” represent a
type of supplement aimed at increasing body weight
and improving the overall calorie intake of the daily
diet. They are powder products with a base of
carbohydrates and medium release fat(MCT fats),
proteins from different sources and their derivatives
(creatine, glutamine, branched amino acids), vitamins
and minerals depending on the timing of use (before,
during or after the workout).
Conclusion
Proteins and their derivatives (BCAA) are a dietary
source of great nutritional value also recognized by
the Italian legislation governing the production and
marketing of food supplements (food suitable for intense
muscular effort especially for sportspeople). Like other
macronutrients, carbohydrates and fats, proteins require
a minimum daily intake (estimated at 0.8 to 1 gram
per kilogram of body weight, defined as ideal weight)
for people of “medium build” who do not do physical
References
Nieman D. Vegetarian dietary practices
and endurance performance. Am J Clin
Nutr 1988;48:754.
2
Campbell B, Kreider RB, Ziegenfuss
T, et al. International Society of Sports
Nutrition position stand: protein and
exercise. J Int Soc Sports Nutr 2007;4:8.
3
Ardenti G. Le basi molecolari della
nutrizione, Padova: Piccin 1996, p. 122.
1
activity. Athletes therefore represent a segment of the
population being particularly attentive and sensitive
to the increased needs in terms of daily intake. The
recommended intake varies in consideration of the body
weight and physical activity practised. Short-duration
and intense sports closely related to muscle power and
strength require a higher protein requirement (up to 2 g
/ kg / day). Diet represents the basis for guaranteeing
a sufficient protein intake (from different protein
sources), and, in the sports field, it is often integrated
with the use of specially formulated products (food
supplements) based on milk proteins and its derivatives
(whey and casein), eggs or legumes. Apart from this,
protein molecules such as branched amino acids are
a significant source of anabolic nutrients to the athlete
(increased muscle mass) when adequately combined, of
course, to exercise. The athlete and the active person
in the end represent a segment of the population with
higher protein and energy requirements than sedentary
and inactive population.
Pasquale M. Amino acids and proteins
for the athlete. The anabolic edge.
Florida: CRC Press Inc 1997.
5
Dioguardi FS. Gli aminoacidi: lettere
di un alfabeto più antico della vita.
Bologna: Lombar Key 2008.
6
Siani V. Sport Energia Alimenti. Bologna:
Zanichelli 1993, p. 125.
7
Kreider RB, Wilborn CD, Taylor L, et al.
ISSN exercise & sport nutrition review:
4
research & recommendations. J Int Soc
Sports Nutr 2010;7:7.
8
Bressani R, Elias LG, Gomez Brenes RA.
Improvement of protein quality by amino
acid and protein supplementation. In:
Bigwood EJ, editor. Protein and amino
acid functions. Vol. 11. Oxford UK:
Pergamon Press 1972, pp. 475-540.
CORRESPONDENCE
Marco Ceriani
[email protected]
M. Ceriani
JSA 2015;1:33-37
Franco Nocchi
Contract Professor, University of Pisa and Florence
understanding the laws of nature
to understand and treat man
Introduction to Chinese medicine
Chinese medicine, recognized by the World Health
Organization and included among non-conventional
medicines, is considered the oldest known medical
system. It is a complex medical system, whose most
popular version (that, in fact, recognized by the WHO)
is the model of traditional Chinese medicine, also
known by the acronym TCM, whose foundation and
systematization, however, dates back only to the era of
Mao Tse-Tung (more precisely in the decade between
1950 and 1960). Ancient Chinese Medicine (ACM),
instead, refers to older medical models. The first work
about ACM dates back to 2600 BC and is the Huang Ti
Nei Ching Su Wen. It consists of inscriptions on tortoise
shells and shoulder blades of bovines, about a form of
massage practiced by shamans. When the body is in
an agitated state, channels or meridians are hindered;
consequently the body loses sensitivity and has to be
treated with massage (Chap. V: Vital energy, blood,
physical and mental constitution of the work mentioned
above). The ACM, first an expression of Taoism and
then of Chan Buddhism, was born as a system based
on massage, acupressure and “osteopathic-like
maneuvers”. The use of needles, moxa, cupping was,
and still should be, an integration and never a complete
replacement of the direct contact of the hands and
fingers of the operator with the body of the “yin” (that is,
the person who benefits from the treatment). Since each
AMC treatment is aimed at harmonizing the energies of
a person, no system or equipment can be more suitable
for this purpose than the direct source of vital energy:
the operator’s hands. The ancient masters have always
invited to be very cautious in the use of acupuncture
needles, a practice which is unfortunately highly inflated
by modern acupuncturists. The practice of medical arts
in ancient times was necessarily carried out in parallel
Insights
to the practice of the so-called “martial arts”, in full
compliance with the necessary complementarity of
opposites, expressed in the law of yin and yang. The
names of the first massage therapists known in China,
who lived, according to Chinese tradition, between 2600
and 2100 BC, are Chi Bo, Dai Ji, Yu Fu. Since then,
the Chinese massage has been increasingly used and
systematized. In the fifth century BC the doctor Hua To
codified the techniques, transmitted until the present
day, of the 5 therapeutic animals (monkey, bear, snake,
tiger, heron).
Such techniques are energy postural exercises inspired
by the movements of the 5 animals mentioned above,
performed at the “rhythm” of functional breathing
(a breathing performed with the movement of the
diaphragm, which must anticipate the movement of the
chest both in the breathe-in phase and the breath-out
phase) and aimed at obtaining well-being and longevity.
Pao Pu Tzu Nei Pian (The Master who embraces the
simplicity of the child) by Ge Hong (281-341 AC), is a
precious handbook of inner alchemy to optimize the
consumption of vital energy and a manual of prescriptions
for emergencies. It is also worth remembering Chang
San Feng (Wudang, 1296 AC) and his Long Lun Nei
Ching (Canon of Internal Medicine of the dragon and the
phoenix). It is to this Treaty that I refer for the subject
I teach in the Master Course of Sports Physiotherapy,
namely the Protocol “Long Lun Shu Lao Tuina” (the
massage of the ancient stream of the Dragon and the
Phoenix). During the Ming Dynasty (1368-1644), the “tui
na” and Chinese medicine were introduced as a core
examination subject at the Imperial School of Medicine.
In this period, by Imperial will, tui na became very
popular and the pediatric techniques of tui na (massage
and acupressure) developed enormously. During the
subsequent Ching dynasty (1644-1911) tui na was
considered unsuitable for the refined tastes of the imperial
family and was therefore removed from the court and from
the Imperial School of Medicine. Any form of prohibition,
however, always causes a physiological rebound, so the
people secretly continued the practice, and developed
its practical-applicative aspects associated with the
popular diffusion of martial arts, which always took place
in secret at that time: a medical encyclopaedia of the
time, by various authors, mentions “the 8 methods to
treat bone fractures” (“duànliè gu pa fa”). In the twentieth
century, the technical inferiority that the Celestial
Empire experienced in the encounter with the West (the
Opium Wars, the Boxer Rebellion) undermined the selfconfidence of the Chinese people. Thus began, on the
part of the Chinese people, the collapse of confidence
in their own culture (including AMC). Then, in 1949, with
the advent of the Republic of China of Mao Tse-Tung, the
period of the “cultural revolution” began, and in its diverse
aspects, also started a real process of purging of every
aspect of the ancient Taoist arts. Just like the practice
of “martial arts” was immediately banned, thousands of
texts of ancient medicine were destroyed and their use
by the people was banned. Only in the late ‘50s, following
the position taken by China with respect to the “cold
war “(an event that came to define the opposing blocks
east / west), the need arose to repropose the products
of the ancient Chinese culture to give to the world the
image of the power of the”middle country” through
autochthonous expressions. In a few years the practice
of martial arts was recodified and re-systematized (and
became what we see today, that is, spectacular practices
having however no link with the original ancient practice)
just like the protocols of the modern traditional Chinese
medicine (anything belonging to the ancients and saved
from the destruction of cultural purge was reconstructed
and rearranged), and ancient medicine was therefore
presented in a “diluted” version, deprived of most of its
therapeutic efficacy. My master Huang Wan De witnessed
and painfully described that time. Indeed, he was forced
to flee China in 1950 at the age of 42 to avoid being killed
by the weapons of the Maoist army, which was at the
time in “full swing” and aimed at completing that dreary
example of human carnage that took precisely the name
of “cultural purge”. The father of the great master was
not so lucky, and died shot, “guilty” only of being one of
the masters of ancient arts. those ancient arts (medicine
and combat) represented precisely one of the deepest
roots of the millennial culture of China, and because
of that had to be - and actually were - eradicated with
inhuman violence. As a form of respect for the master
and for this sad historic watershed, I willingly adopt
the terms of Wade Giles transliteration, and not those
of pinyin, the transcription system introduced by the
People’s Republic of China and still in use today (I will
talk about “chi” and not of “qi”, of “tai chi chuan” and not
of “tai ji quan”, etc.). The World Health Organization has
recognized, however, the traditional Chinese medicine as
part of non-conventional medicines. CTM is considered
as composed of “five pillars”: tui na, acupuncture, drug
therapy, dietetics, movement therapies (tai chi chuan,
chi kung). Deep differences remain in any case between
CTM and ancient medicine.
Modern society and oriental disciplines
The western society of the third millennium has become,
over the past three decades, extremely permeable
to all kinds of conception resulting from the so-called
ancient oriental disciplines. In a society plagued by
growing problems such as rampant petty crime, on
the one hand, and imploding stress on the other, we
increasingly tend to import the cultural components of
the ancient East in an attempt to integrate them in the
western mentality and lifestyles to benefit from them and
obtain help, and often succeeding in operating only an
adaptation process that degrades and impoverishes the
original essence of such components. The concept of
oriental disciplines includes the whole range of activities
focused on finding a deep psycho-physical-emotional
connection, and forming a continuum that starts with
those practices being mainly focused on the acquisition
of practical skills in combat techniques (kung fu, karate,
ju jitsu, etc.) to get to more introspective practices aimed
at finding the equilibrium and calm of inner dialogue (chi
kung, yoga, meditation, etc.). Along this continuum,
other activities can be found that complement the two
dichotomous aspects (e.g., tai chi chuan) and some
practices being more focused on medical-therapeutic
aspects (tui na, shiatsu, acupuncture, etc.).
It is precisely in the importation of the medicaltherapeutic aspects, especially in the application of
traditional Chinese medicine, that the impoverishment
of the essence of the ancient arts appears more
paradoxical. Many aspects would be worthy of
attention and study but, to be concise, any reference
to the historical aspects, to the methods of application
and especially to the relationship between modern
science and ancient medicine will be omitted for the
moment, so as to focus on a fundamental but forgotten
F. Nocchi
concept, which now little or nothing is known about: the
subjective energy biotype. It is a concept that stems from
(and at the same time demonstrates...) a fundamental
postulate: every individual possesses unique and
different energetic and organic characteristics; as a
consequence, each therapeutic practice is only partially
effective (or even harmful ...), if it does not take into
account the subjective characteristics of the patient
mentioned above. This concept is defined starting from
the Huang Dao, the Chinese calendar.
The basic postulates of ancient Chinese
medicine
Let us look briefly at some of the assumptions that
formed the very foundations of the entire theoretical and
practical system of ancient Chinese medicine:
• all is one, a basic concept that starts from one’s
awareness that nothing in nature is considered
antithetical to something else, but is only
complementary and integral to it; the concept is
expressed by the law of yin / yang;
• the human being is an OLOS composed of 4
spheres being independent and at the same time
interdependent from each other. These four spheres
are: the corporeal sphere, the energy sphere, the
psycho-emotional sphere and the spiritual sphere.
Any intervention on one of the four spheres can have
direct effects on the other 3;
• every human being is a microcosm and represents
an integral and essential part of the macrocosm of
nature;
• every human being lives in relation to the energy flows
of nature and is governed by the rhythms of the laws
that govern nature itself. Just as nature is changing,
despite the repetitive cyclical rhythms that regulate it,
the human being too has some characteristics which
vary cyclically and are governed by the laws of the
cosmos;
• knowing the laws that govern nature allows to better
understand the laws that sustain the human being in
his life in the world;
• the strong link between the human being and nature,
the fact that the human being himself is powered
by the same energy that powers nature: the chi
(pronounced “cì”), the vital energy;
• every human being is born with some sort of
preconceived tank of chi (the yuan chi, the chi of
the origin, which comes from the encounter of the
energies of parents strengthened or weakened by
the natural energies of the day – or of the period of
conception. No one can increase, but only optimize,
the consumption of the yuan chi, which, once
finished, marks the end of earthly life. To optimize the
use of the yuan chi, the ancient masters used special
psycho-corporeal techniques (meditation, chi kung,
tai chi chuan, etc.) and adopted healthy eating and
correct breathing, based mainly on the use of the
diaphragm and on the full awareness while breathing.
The circulation of the chi in the human being is
continuous and guaranteed by a system of 12 meridians
(or ordinary channels and 8 extraordinary channels) (for
ancient medicine, any disease is only an imbalance of
the flow of chi which can be restored by the therapist
with suitable interventions on the points of access
to energy, acupuncture points). The chi flows, in the
circadian cycle, in all ordinary meridians simultaneously
but reaches its energy peak for about 2 hours in each of
the 12 meridians according to Table I below.
Table I. Meridians and maximum energy peak circadian circulation.
Circadian circulation
Time of max energy peak
Lung
03-05
Large intestine
05-07
Stomach
07-09
Spleen
09-11
Heart
11-13
Small intestine
13-15
Bladder
15-17
Kidney
17-19
Heart
19-21
Triple heater
21-23
Gallbladder
23-01
Liver
01-03
Rhythms of nature, rhythms of humans
February 19th was the first day of 2015 (the year of the
sheep) as calculated by the ancient Chinese calendar.
Therefore, while the western new year is conventionally
set each year on the same day (January 1st), the
Chinese New Year varies according to the years. This
is because the first day of our Gregorian calendar was
conventionally established in relation to the date of
Christ’s birth (a week after the nativity, the people of
Israel used to circumcise children), the one of the ancient
Chinese calendar instead is related to the energy flows
of nature, as it was established in the aftermath of the
new moon being closest to the date of February 4th.
The Chinese New Year marks the first day of spring and
the other seasons depend on that date: May 19th, 2015
will be the first day of summer, August 19th of autumn
and November 19th of winter (a short winter, because
in 2016 the New Year, and therefore spring, will start on
February 8th, in the year of the monkey).
Understanding this step is essential from a therapeutic
point of view. Any intervention should be set in close
connection with the law of the 5 changes (Tab. II), which
becomes applicable just because of its connection with
the season and with the relevant organs and viscera.
Ancient Chinese medicine: understanding the laws of nature to understand and treat man
Table II. Some of the most significant correspondences associated with the 5 changes
Wood
Fire
Earth
Metal
Water
Organ
Liver
Heart
Spleen
Lungs
Kidneys
Viscera
Gallbladder
Small intestine
Stomach
Large intestine
Bladder
Season
Spring
Summer
5th season
Autumn
Winter
Muscles
Tendons,
Cardiocirc. system
Connective tissue
Skin
Bone marrow
Emotions
Anger
Joy
Worry
Pain
Fear
Senses
Sight
Touch
Taste
Smell
Hearing
Life stages
Birth
Growth
Transformation
Decline
Death
Body
Just think, for example, that August 20th, 2010, which
was for us in the middle of summer, from the point of
view of natural energy flows was already in autumn, with
the result that the organs had to be stimulated by the
therapist in a completely different way (summer = heart
/ small intestine / blood vessels / etc .; while autumn =
lung / large intestine / skin / etc.). The Chinese calendar
had been built by ancient masters to understand the
energies of nature and had been structured referring
to the rhythmic interactions between the energies of
heaven and those on earth, interactions that are based
on the knowledge of the 10 Celestial Stems and 12
Earthly Branches. In particular, the 12 Earthly Branches
express both the division of the day in two-hourly cycles
which are the so-called 6 fundamental energies of nature
(wind, damp, dryness, cold, ministerial fire, imperial fire)
which are to connect directly to the 12 energy meridians
of humans: each of the 12 Earthly Branches combined
with a human energy meridian expresses its energy
in the circadian cycle which was previously flowing in
humans every 2 hours in a continuous flow. Each of the
12 Earthly Branches is connected to only one of the
12 animals of the Chinese calendar (Tab. III). 10 is the
number of Celestial Stems because they correspond
to the 5 changes (and therefore to the organs and
viscera and to the correlated changes, see again Tab.
II), in correspondence and in combination with the 12
Earthly Branches in the ancient calendar, and determine
the energy status of each year. Since the least common
multiple of 12 and 10 is 60, after 60 years it is clearly
possible to repeat the combination of a branch / stem
couple with identical energy characteristics (Tab. IV). It
is worth noting that the rat, for example, returns every
13 years, but since the stem / branch combination is
different, two people-mouse receive completely different
energy characteristics (jia / zi and bing zi). A mouse can
potentially have the same characteristics as the person
mouse of 1924 in 1984, the year in which the rat / jia-zi
recur.
It is worth remembering that the 10 celestial stems allow
to calculate the energies that change daily: the first day
of the new year will be jia, the second yi, the eleventh
Table III. Meridians and energy circulation in relation to the animals of the ancient calendar and to Earthly Branches.
Meridian
Time of max energy peak
Corresponding Animal
Earthly Branch
Lungs
03-05
Tiger
Yin
large intestine
05-07
Rabbit
Mao
stomach
07-09
Dragon
Chen
spleen
09-11
Snake
Si
heart
11-13
Horse
Wu
small intestine
13-15
Sheep
Wei
bladder
15-17
Monkey
Shen
kidney
17-19
Cock
You
heart
19-21
Dog
Xu
triple heater
21-23
Pig
Hai
gallbladder
23-01
Mouse
Zi
liver
01-03
Ox
Chou
F. Nocchi
Table IV.
Year
New Year
Animal
Element
Stems
Branches
1924
5 February
Mouse
Wood
Jia
Zi
1925
24 January
Ox
Wood
Yi
Chou
1926
13 February
Tiger
Fire
Bing
Yin
1927
2 February
Rabbit
Fire
Ding
Mao
1928
23 January
Dragon
Earth
Wu
Chen
1929
10 February
Snake
Earth
Ji
Si
1930
30 January
Horse
Metal
Geng
Wu
1931
17 February
Sheep
Metal
Xin
Wei
1932
6 February
Monkey
Water
Ren
Shen
1933
26 January
Cock
Water
Gui
You
1934
14 February
Dog
Wood
Jia
Xu
1935
4 February
Pig
Wood
Yi
Hai
1936
24 January
Mouse
Fire
Bing
Zi
1937
11 February
Ox
Fire
Ding
Chou
1938
31 January
Tiger
Earth
Wu
Yin
again jia, and so on during all the year. As a result, at
least in theory, it is clear that:
1) from the moment he sees the light, every Human being acquires a personal energy biotype that makes
him unique and unrepeatable. This unique energy
biotype is the result of the energy biotypes of parents,
of the natural energy being dominant on the day of
conception, of the natural energy being dominant in
the year, on the day and in the minute of birth of the
subject in question;
2) Energy biotype represents the fundamental motivation, beyond any other purely theoretical / philosophical aspect, for the fact that the therapeutic approach
and the attention of ancient medicine are constantly
focused on the patient and never on the illness: not
only does a single disease have different causes in
different patients, but the same symptoms in the
same patient may have different causes if appearing
in different seasons and even in different daily cycles;
3) Once calculated, energy biotype is an essential reference value for each therapeutic intervention intending
to be really effective. Depending on the type of energy
balance shown by the subject, and in relation to the
time of year (season) in which the imbalance occurs,
it will be necessary to act in the times of the day being most appropriate to support and meet the energy
needs of the patient. Every therapist should therefore
be willing to design a plan of action being based not
on their agenda (that is, defined on the commitments
of the therapist), but rather on what can be called
«the bioenergy agenda of the patient» (defined on the
real energy needs of the patient) which cannot take
into account neither public holidays, nor inconvenient
hours (I have had to give appointments on the morning of Easter Sunday at 06.00!). In ancient medicine
only one treatment is transmitted and can be applied
to any person, notwithstanding the subjective energy
characteristics: it is the «Long Lun Shu Lao Tuina»
(«the massage of the ancient stream of the Dragon
and the Phoenix»). It is an intervention of general energy harmonization that the traditional Chinese medicine based on a «Maoist conception» has totally lost.
The great master Huang Wan De used to say:
“One cannot consider any bodily treatment without
involving the energy sphere and the psychoemotional sphere of the person: only the path traced
by the Shu Lao has no risks ...
Correspondence
Franco Nocchi
[email protected]
Ancient Chinese medicine: understanding the laws of nature to understand and treat man
JSA 2015;1:38-40
Christoph Schmitz
Department of Neuroanatomy, Ludwig-Maximilians University, Munich, Germany
Acute- Phase Radial Shock Wave
Therapy (RSWT). New perspectives
and applications in professional
football players
Acute- Phase Radial Shock
Wave Therapy (RSWT)
is used also for the players
of ACF Fiorentina
Medical care and physiotherapy in professional football
players, during the agonistic season, is a huge challenge
for all the subjects involved. The majority of the players
want to recover and be fit as soon as possible after an
injury because they want to return to play in order to keep
their place in the team. In the same way it is important
that players return to full fitness as quickly as possible
even during a game, for example in the interval between
the first and the second half. Acute - phase radial shock
wave therapy (RSWT) is an interesting and innovative
method to help achieve this goal. This article aims at
being a sort of introduction to this new perspective.
As a skilled and qualified anatomist, and also as a
physician, I have cultivated for many years a scientific
Insights
interest in extracorporeal shock waves. It became my
daily job when I worked as International Head of Business
Development at EMS - Electro Medical Systems from
2008 to 2009. During my time at the EMS, I worked
with clinicians and physiotherapists of professional
football clubs on the development of new approaches
for the use of RSWT in the treatment of players during
the agonistic season, which should have diverged
greatly from the normal practices of RSWT published
in orthopedic literature, for example, for heel pain or
tennis elbow. The key elements of acute-phase RSWT,
in addition to daily treatments with RSWT, focus on the
primary objective of improving the player’s performance
without resorting to doping and on the disappearance
of pain without aiming at a speedy recovery, as well as
on the use of RSWT within a few days, or even hours, of
an injury. These new practices are being used with great
success by top-level clubs in the United States, Brazil,
Ecuador, England, Italy and Norway, and more recently
in German Bundesliga.
N.B. The purpose of this practice is not the speedy
recovery but the possibility of allowing the player to
continue to play, ideally without any interruption. For
this reason, acute-phase RSWT is applied both during
the game, between the first and the second half, and
immediately after the game, as well as during daily
training sessions.
What follows does not describe any specific treatment,
but rather some important aspects in order to create
the conditions for the use of acute-phase RSWT in
professional football players.
1) Trust
The first step is always a personal interview to overcome
many justified doubts and some mistrusts. The most
common questions are: “Does it really work?”, “Isn’t
it doping in disguise?”, “Does the treatment involve
any unpredictable collateral risk for the player?”, “How
do I explain to the player that some RSWT treatments
have to be uncomfortable in order to be effective? “,
“What kind of therapies might be effectively combined
with RSWT treatment?” and “ What are the limits of
RSWT treatment?”. The answers to all these questions
are primarily based on our current knowledge of the
molecular and cellular mechanisms of action of shock
waves on the musculoskeletal system (see below).
2) Infrastructures
When we started using acute-phase RSWT on the
players of the Italian Serie A team ACF Fiorentina, about
a year ago, the question of the need for medical imaging
was raised. My experiences at the Olympic Games in
Athens 2004, Beijing 2008 and particularly London 2012
(see also Henne M, Schmitz C. Stoßwellentherapie
– Mythos oder Evidenz? Medicalsportsnetwork,
Acute- Phase Radial Shock Wave Therapy (RSWT).
New perspectives and applications in professional football players
Steffen Tröster, physiotherapist at the German Bundesliga club FSV
Mainz 05, treating players with acute-phase RSWT.
Ausgabe
5.11;
http://www.medicalsportsnetwork.
com/archive/110338/Stosswellentherapie.html), taught
me just how important a clear diagnosis is, especially
for elite athletes, and that the greatest caution is
needed especially with partial ruptures of tendons and
ligaments. Therefore, in the case of ACF Fiorentina,
almost every application of RSWT was preceded by
an ultrasound scan. Of course, this does not replace
the use of magnetic resonance imaging (MRI), of other
imaging techniques or of further diagnostic procedures
when appropriate.
3) Experience
Once confidence in the possibilities of acute-phase
RSWT has been established, the most important aspects
have been explained and a diagnostic ultrasound unit and
shock wave therapy device has been installed, the team
of physicians and physiotherapists need to gradually
gain experience and reinforce their expertise. During this
time, they are always available via email, phone, SMS or
WhatsApp to give immediate answers to any questions,
for example during the half-time. This is probably the
most important phase when implementing acute-phase
RSWT, and it is virtually impossible to generalize on it.
Each club has developed its own medical/physiotherapy
infrastructure, each clinician or physiotherapist has his/
her own background, experience and therapeutic paths.
As a consequence, any club using acute-phase RSWT
will tend to create its own, highly individual approach.
4) Mechanisms of Action
Usually, many questions arise during the phase of skill
acquisition and consolidation of experiences with regard
to treatment method and duration. Straight answers
rarely exist for these questions, due to the practical
impossibility of a scientific validation of acute-phase
RSWT in accordance with the criteria of evidencebased medicine (see information box). Actually, many
assumptions can be based on our current knowledge of
molecular and cellular mechanisms of action of shock
waves on the musculoskeletal system and I like to refer
to that. Some courses organized by the Swiss DolorClast Academy (www.swissdolorclastacademy. com)
are a reliable source for the elaboration and diffusion
of current knowledge, and are open to all interested
parties. All trainers at the Academy have received
extensive training.
5) Establishing and developing concepts
and notions
Certain conditions and injuries that are particularly
common in footballers can be treated quickly and
effectively with acute-phase RSWT, and even prevented
altogether in some cases. It is extremely stimulating to
see players, who should have interrupted their season
due to chronic achillodynia or patellar tendinopathy,
continue playing until the end of the season, thanks
to acute-phase RSWT. The initial investment in acutephase RSWT certainly pays off for the clubs, even in
case they are forced to reduce their team by just one
player, simply because of faster rehabilitation and of a
better prevention of injuries.
Conclusion
Acute-phase RSWT opens up entirely new perspectives
for the treatment of professional footballers, both for
post-injury rehabilitation and for injury prevention,
benefiting all stakeholders, i.e. players, managers
and clubs. The therapeutic approach of acute-phase
RSWT considerably differs from the “normal” treatment
concepts with RSWT, which are primarily concerned
with a speedy recovery, whereas the primary target
of acute-phase RSWT is that of enhancing players’
performance and keeping them free from pain.
The traditional treatment concepts with RSWT of the
musculoskeletal system have been documented in a
variety of scientific publications. If you want to pick a
selection of the best and most significant clinical studies
conducted by a truly independent body (comparable
to a consumer advice organisation) from this plethora
of publications, it is worth having a look at the PEDro
database of the Centre for Evidence Based Physiotherapy
of the George Institute for Global Health at the University
of Sydney (www.pedro.org.au). To date, the PEDro
database contained a total of about 20 publications on
RSWT. Fifteen of these studies were conducted with the
Swiss DolorClast® device by Electro Medical Systems,
based in Nyon, Switzerland. (A German-language
compilation of the PEDro content is available from the
author.) Many of these 15 publications come courtesy
of the colleagues Prof. Jan-Dirk Rompe (Alzey), Prof.
Ludger Gerdesmeyer (Kiel) and Prof. Markus Maier
(Starnberg). The author was involved in two of these 15
studies. The publications have the following underlying
treatment concepts in common: (i) a randomized and
controlled approach, i.e. comparison to an alternative
therapy or placebo treatment, (ii) the use of RSWT
only after a waiting period of several weeks or months
of unsuccessful conventional conservative therapy,
(iii) the systematic use of imaging techniques such as
ultrasounds and MRI before treatment with RSWT, (iv)
applying RSWT three times at weekly intervals, (v) use
of other types of treatment in addition to RSWT and (vi)
resting of the patient during the treatment period.
In practice, such a treatment concept is out of the
question for professional footballers during the ongoing
season. Numerous discussions with clinicians and
physiotherapists of professional football clubs have
shown that conducting randomised and controlled
studies for new treatment approaches is virtually
impossible in professional football. This is also the reason
why it is quite complex to add these new concepts to
excellence databases such as PEDro. Moreover, it is
rare to have only one single type of therapy used when
treating injuries in football professionals.
Images: © www.violachannel.tv; © Steffen Tröster
* A collection of contents from the PEDro database is available
from the author
C. Schmitz
JSA 2015;1:41-42
“The fascia is the forgotten tissue,
but is essential in the regulation
of proprioceptive afferents”
Xby
X Erika Calvani
The fascia is a membrane structure composed of
connective tissue, extended over the entire body below
the skin. It connects the various parts of the body, lines
the muscles and invaginates between the muscle fibers,
coordinating an articulation with the other, correlating
each part of the body with the whole body and
synchronizing the action of each part with the totality.
Luigi Stecco, physiotherapist since 1975, after a 30-year
work experience has highlighted the importance of the
fascia in the treatment of musculoskeletal disorders,
developing the technical foundations of Fascial
Manipulation. The fasciatherapist does not focus his
attention on the area of symptomatic

manifestation
or on the joint, but on particular areas of the fascia
defined as coordination centers. The treatment of pain
is performed through the manipulative intervention on
the fascial densifications situated on the respective
Coordination Centres responsible for the dysfunction
or pain. We will now analyze the method of fascial
manipulation with Antonio Stecco, current President of
the Fascial Manipulation Association (AMF).
What is the primary concept underpinning
the method of fascial manipulation?
The basic principle of fascial manipulation is to restore
the normal flow both at the intrafascial level and between
fascia and epimysium, in specific points of the body that
have been encoded. The advantage of this method are the
long-lasting results. This is possible thanks to a specific
assessment of the patient by completing an electronic file,
which orders and guides the therapist in the choice of the
areas to be addressed. The electronic file is appreciated in
all the forty countries in which we are still teaching fascial
manipulation. All participants are surprised about the MF
methodology and the clear guidelines that are provided to
help the therapist gather the necessary information and
decide on the treatment plan.
news
What is the densification of the fascia and
how can it cause structural alterations until
the onset of pain?
The densification is an increase in the viscosity of the lax
collagen substance present in different compartments of
the body. An increase in intrafascial viscosity, between
the fascia and the epimysium, generates a decrease in
flow, reducing the articular range and hyper-activating
mechanoreceptors, which will send incorrect information
to the CNS (typical symptoms related to the syndrome
of non-specific musculoskeletal pain).
How can the manipulative maneuver
restore the tensional balance of the fascial
system?
We have published two papers showing ultrasound
modification of fascial tissue pre- and post-treatment
of the fascia. In an article we highlighted the thickening
of the fascia due to an intrafascial increase in the lax
collagen substance. In post-treatment and follow-up
controls, a normalization of the thickness of the fascia
was noticed, which was higher than in the control group.
In the second article we showed how, with FM, we were
able to decrease the “stiffness” of the fascia through an
elastosonographic assessment. This assessment, using
a special ultrasound software, evaluates the stiffness of
tissues.
For years, AMF has studied the therapeutic potential
of fascial manipulation. What is the latest scientific
evidence about the anatomical function of the fascia?
Last year we published the effectiveness
of fascial manipulation for the carpal tunnel
and for functional adolescent kyphosis.
In the first article we confirmed how the entrapment
of the median nerve can occur at different levels,
not just the carpal ligament. For this reason, fascial
manipulation, acting in more body segments, is able to
decrease the entrapment which is generated between
nerve and epineurium (the fascial tissue that surrounds
the nerve). This study confirms the role of the fascia in
nerve entrapment and supports fascial manipulation as
a method of diagnosis and treatment. The result that
excites us the most is the duration of the same results,
which are maintained in the long term.
What about the latest studies on the
fascia in the treatment of musculoskeletal
disorders?
We are now completing work on chronic low back pain
with the University of Bologna. It will be published later
this year. This is a randomized clinical trial that shows the
superiority of Fascial Manipulation compared to another
treatment, with results that are maintained over time.
With the University of New York NYU first a preclinical
study, and now a clinical one, were carried out on the
treatment of the fascia in patients with muscle stiffness.
The preclinical study has already been published. I
cannot deny the enthusiasm among my colleagues
in the Motor Recovery Lab at the Rusk Institute. We
generated a patent that will allow us to further investigate
this new scope of fascial manipulation. We have already
introduced a number of applications in the third level
of the course of fascial manipulation, but our aim is to
further improve the guidelines in the 2016 edition .
How does the fascia therapist do for
musculoskeletal pain?
Whoever uses FM should evaluate the patient by our
guidelines, involving the use of the FM file. This file (now
also in electronic format) helps the therapist to gather
the information needed for proper treatment. Of course
clinical reasoning cannot be dictated by the software.
For further information
Luomala T, Pihlman M, Heiskanen J, et al. Case study: could
ultrasound and elastography visualized densified areas inside
the deep fascia? J Bodyw Mov Ther 2014;18:462-8.
Stecco A, Meneghini A, Stern R, et al. Ultrasonography in
myofascial neck pain: randomized clinical trial for diagnosis and
follow-up. Surg Radiol Anat 2014;36:243-53.
When is fascial manipulation recommended?
In sports, in which algic-dysfunctional
circumstances does it have more results?
We have trained several physiotherapists who work in
the sports sector,
not least the team following Juventus, Diamonds baseball
team in the USA, Worcester Rugby Team in the UK, Net
basketball team in NYC and many others. The application
of FM is the most diverse. It is indicated in painful symptoms
as in those related to the lack of proprioception.
What is the relationship between fascial
manipulation and prevention?
With several team sports a pre-season evaluation
protocol is applied to decrease major trauma. We are
collecting very encouraging preliminary results.
What can be said on the relationship
between fascial manipulation and
rehabilitation?
Several international organizations, such as ISPRM
(International Society of Physical Medicine), are
supporting the application of FM in rehabilitation as a
valuable tool for this branch of medicine.
How important is it for a professional in
sports and rehabilitation to know about the
physiology of the fascia while performing
their daily work?
Unfortunately the fascia is “the forgotten tissue”. Ignoring
the anatomy and physiology of the fascia is like having
a lacuna in the bases of scientific theories that support
the entire clinical work. In all international conferences
more and more attention is given to this tissue, but this
new information will not be available to all until they are
included in the professional training curriculum.
Pratelli E, Pintucci M, Cultrera P, et al. Conservative treatment of
carpal tunnel syndrome: comparison between laser therapy
and fascial manipulation(®). J Bodyw Mov Ther 2015;19:113-8.
Ćosić V, Day JA, Iogna P, et al. Fascial Manipulation(®) method
applied to pubescent postural hyperkyphosis: a pilot study. J
Bodyw Mov Ther. 2014;18:608-15.
E. Calvani