Non-Alcoholic Fatty Liver Disease (NAFLD)

The role of the liver, the body’s largest internal organ, is to convert food into fuel that is stored and released when needed, process fat from blood, clear toxins, and make protein to help with blood clotting.  Keeping a healthy liver, therefore, is important.

You may not be familiar with non-alcoholic fatty liver disease (NAFLD), which, according to the Mayo Clinic, is an umbrella term for a range of liver conditions affecting people who do not drink or drink small amounts of alcohol. It is also called simple fatty liver.  Fat in the liver typically develops when more fat and sugars are consumed than the body can handle. The main characteristic of NAFLD is too much fat stored in liver cells. The Canadian Liver Foundation reports that a fatty liver is having fat that builds up to more than 5 percent of the liver.

Facts about NAFLD

• Prevalence - NAFLD is becoming increasingly common around the world and particularly in the West. Currently, some experts estimate that about 25 percent of adults worldwide have NAFLD. It is the most common liver disease in Canada, affecting about 20 percent of Canadians. The rate is higher in the US, with NAFLD affecting between 30 and 40 percent of Americans.  The Berkeley Wellness Letter calls this condition “a growing threat.”
• Overweight and obesity the most common cause - this is especially the case if a person has fat around the waist (abdominal fat). The Canadian Liver Foundation indicates the waist circumferences putting people at increased health risks - for men, a waist circumference of more than 102 cm or 40 inches, and for women, a waist circumference of more than 88 cm or 35 inches. People who gain weight in the abdomen are at greater risk than those who gain weight around their hips or shoulders. Unfortunately, a 2018 statistic for Canadians is that almost 30 percent of adults 18 years of age and older are considered overweight or obese. Among people who are obese, which increases the risk, as many as nine in 10 have the condition. NAFLD can also develop in people who have a healthy body weight but who consume lots of sugary and fatty foods and have extra fat around the waist
• Gender and age - weight distribution in the abdomen is more common among men, putting them at slightly higher risk for NAFLD compared to women. Harvard Men’s Health Watch indicates that 60 percent of people with NAFLD are men. NAFLD is the most common form of liver disease in children and the cases have more than doubled over the past 20 years.
• Greatest risk factor for people living with NAFLD - cardiovascular disease
• NASH - up to 40 percent of people with NAFLD will develop non-alcoholic steatohepatitis (NASH), an aggressive form of fatty liver disease. NASH develops when NAFLD becomes severe and is more likely to develop in people who are older, have diabetes and body fat located in the abdomen. With NASH, there is inflammation of the liver and this can damage the cells of the liver, therefore impairing its function. NASH can get worse and cause scarring of the liver (fibrosis) which leads to cirrhosis (a late stage of scarring). The outcome is similar to people who have liver damage from excessive alcohol intake. Stanford Health Care, however, points out that NASH  doesn’t always get worse.
• Our understanding of NAFLD - despite the increasing number of people with NAFLD, Wynne Armand, MD, a contributing editor to Harvard Health Blog, indicates that NAFLD’s “causes, consequences, and treatment options are still a work in progress.”

 Causes in addition to obesity

• Nutritional causes - these include starvation, protein malnutrition, long-term use of total parenteral nutrition (infusing nutrients directly into the bloodstream), intestinal bypass surgery for obesity, and rapid weight loss
• Health conditions- health conditions that may contribute include diabetes, hyperlipidemia (elevated lipids in the blood), insulin resistance (cells do not take up sugar in response to the hormone insulin)  and high blood pressure, metabolic syndrome (a disorder when a person has three or more of a cluster of risk factors: high blood pressure; excess abdominal fat; high blood sugar; low HDL, or good cholesterol; and high triglycerides), sleep apnea, underactive thyroid (hypothyroidism) and underactive pituitary gland (hypopituitarism).
• Genetic factors - some people who develop NAFLD are not overweight, do not eat processed foods and high amounts are carbohydrates, and do not live a more sedentary lifestyle.
• Some people develop NAFLD without any risk factors. The Mayo Clinic notes that experts do not know exactly why some people accumulate fat in the liver and other people do not, as well as why some people go on to develop NASH.  

How would you know if you have NAFLD?
In general, no symptoms are experienced, so NAFLD and NASH are considered the “silent liver diseases.” Wajahat Mehal, PhD, MD, director of Yale Medicine’s Metabolic Health & Weight Loss Program states, “Most people aren’t even aware fatty liver disease exists. Large numbers of people are affected by this disease, and they don’t realize it.” You would only know if abnormalities show up in blood tests or an imaging test such as an ultrasound.

If symptoms are experienced, they include discomfort in the abdomen at the level of the liver (upper right abdomen), fatigue, general feeling of being unwell, and vague discomfort. The American Liver Foundation adds the following symptoms to the list: weakness, loss of appetite, nausea, spider-like blood vessels, jaundice (yellowing of the skin and eyes), itching, fluid build up and swelling of the legs (edema) and abdomen (ascites), and mental confusion. Harvard Men’s Health Watch also includes weight loss as a symptom.

Getting a diagnosis
The typical profile of someone who would have this condition would be a person who is overweight or obese (especially if they have a large waist circumference), evidence of dyslipidemia, insulin resistance and/or abnormal liver tests.  NAFLD is often discovered when tests are conducted for unrelated reasons. A blood test would show elevated liver enzymes, but other liver diseases are ruled out by using additional tests. Ways to detect whether a person has a fatty liver is through ultrasound or Fibroscan, or by having a liver biopsy, which is the only way to make a definitive diagnosis.  

Complications
The Mayo Clinic indicates that the main complication of NAFLD and NASH is cirrhosis. Scarring (fibrosis) takes place to halt inflammation as the liver attempts to repair itself. If the process is not halted, it can lead to fluid buildup in the abdomen, swelling of the veins in the esophagus, confusion, drowsiness, and slurred speak, liver cancer, and the liver no longer functioning (end-stay liver failure). Between 2000 and 2010, liver cancer associated with NAFLD increased 10 fold in the US.

How to manage and prevent NAFLD
A “medical treatment” is not available yet for NAFLD. The good news is that by following a healthy lifestyle in the early stages, you can reverse liver damage. The goal is to reduce or prevent further build-up of fat in the liver by addressing obesity, diabetes, and elevated blood lipids. For those who do not have NAFLD, following a healthy lifestyle can prevent its development.
If you have NAFLD:

• See your doctor for guidance on ways to improve your liver health
• Make lifestyle changes - the benefits of lifestyle changes were found in a study published this year in the journal Alimentary Pharmacology & Therapeutics. The study included 4,040 adults with NAFLD compared to 7,515 healthy adults in a control group. Participants were assessed on the American Heart Association’s Life’s Simple 7, a list of 7 metrics for a heart-healthy lifestyle or 7 risk factors that people can improve through lifestyle changes. The seven lifestyle changes include not smoking, maintaining a healthy body mass index, exercising most days of the week, eating a healthy diet with a focus on plant-based foods, managing blood pressure, maintaining healthy cholesterol, and managing blood sugar levels. The researchers calculated that if all NAFLD subjects achieved 7 ideal health metrics, 66% of all‐cause deaths and 83% of CV deaths were preventable. Failing to control blood pressure explained 52.8 percent of deaths in people with NAFLD.
• Weight - manage your weight if you are overweight or obese. “If people lose about 10 percent of their weight, that’s probably sufficient to help with fatty liver,” says Dr. Mehal of Yale Medicine. He reports that studies have shown that with a relatively small amount of weight loss, the liver is able to repair itself and regenerate healthy cells. Harvard Men’s Health Watch cites a 2016 study in JAMA finding that people losing 3 to 6 percent of their body weight reduced their liver fat levels by 35 to 40 percent. A 2019 study in JAMA Internal Medicine suggests that participating in a weight loss program is the most effective way for people with NAFLD to lose weight. Dr. Wynne Armand adds that gradual weight loss should be planned since rapid weight loss may worsen inflammation and fibrosis.
• Healthy diet - this is important for both the management and prevention of NAFLD. There is no “healthy liver diet” but the Canadian Liver Foundation suggests watching your intake of added sugars. The World Health Organization recommends added sugars to be less than 10 percent of total energy intake. Focus on fruits, vegetables, whole grains, and healthy fats. In addition to limiting sugar, also limit saturated and trans fats and salt. Added sugar can be identified by reading ingredients on a label – those ending in “ose” are likely added sugars. What about coffee? This is a maybe, according to Dr. Wynne Armand because some research has found that drinking about 2 cups a day decreased the risk of fibrosis, but the negatives of caffeine need to be considered.
• Exercise regularly - a 2016 study in Digestive Diseases and Sciences found that for people with NAFLD, 90 minutes of brisk walking three times a week was beneficial in lowering elevated liver enzyme levels. Check with your doctor if you have been sedentary and you want to start exercising.
• Other health problems - treat other health problems that may affect your liver e.g., diabetes, sleep apnea, underactive thyroid (hypothyroidism), and underactive pituitary gland (hypopituitarism)
• Alcohol - avoid or minimize alcohol consumption. Ideally, Dr. Wynne Armand suggests that is probably best to avoid alcohol completely.
• Vaccinations - ask your doctor about vaccines to protect you against Hepatitis A and B because these viruses can damage the liver.
• Medications - always take medications as prescribed, take only medications needed, and share a list of all the drugs and supplements you take with your doctor and pharmacist to ensure that none of them are toxic to the liver. A website called LiverTox from the National Institutes of Health can let you crosscheck your list. Be aware that acetaminophen can be harmful to the liver if a person takes too much for too long, and that acetaminophen can be an ingredient in cold remedies. 

Prevention
To prevent NAFLD, follow a healthy lifestyle by eating a healthy diet, exercising regularly, limiting alcohol, and getting adequate sleep. The Canadian Liver Foundation sees sleep as being just as important as healthy eating and regular exercise. Lack of sleep has been linked to an increased risk of developing a fatty liver as it may affect the way the liver converts nutrients from foods. As well, lack of sleep interferes with the ability to stay active. The recommended amount of sleep per night is between 7 to 9 hours for adults.

Resources

• Canadian Liver Foundation - includes a National Help Line call 1-800-563-5483 from 9 am to 5 pm EST and provides information on the disease and resources, as well as the Peer Support Network, a national network of people living with liver disease provides an opportunity for sharing of experiences. If you would like to be connected with a peer supporter in your area or would like to join the peer support network, please call 1 (800) 563-5483 Monday to Friday from 9 AM to 5 PM EST or email them. The website has a video on NAFLD. 
• American Liver Foundation - website includes a video on NAFLD and NASH
• American Heart Association's Life's Simple 7 webpage

Sources: Canadian Liver Foundation website, Stanford Health Care website, Berkeley Wellness Newsletter website, Yale Medicine website, WebMD website, Harvard Health Blog website, Harvard Men's Health Watch website, Mayo Clinic website
 

---

Hemp Seeds 

Plant-based diets are a food trend, and the Berkeley Wellness Letter named seeds, including hemp seeds, as one of the top ten trendiest foods for 2019. Hemp seeds are gaining popularity in Western society but are a staple in many societies outside the West. Hemp is an ancient crop that has been cultivated in Asia for about 10,000 years. In the West, hemp was grown for animal or bird feed. From a sustainability point of view, hemp grows quickly. Canada is second to China for growing hemp. Unlike tall and leafy marijuana plants, hemp plants are grown low and bushy to get the most seeds.   

What's the difference between hemp and marijuana?
According to Matt Shipman, science writer and public information officer at North Carolina State University, hemp, and marijuana are, taxonomically speaking, the same plant and just different names for the same genus (Cannabis) and species (Cannabis sativa L.). Registered Dietitian Sylvia Moe describes hemp as the “sober, non-hallucinogenic first-degree cousin of marijuana.”  Hemp is used as a food source and in industry, while marijuana is used medically and recreationally. Hemp is the edible plant seeds from industrial hemp or hemp used for food or material. Hemp seeds are about the size of a popcorn kernel with a pale beige to dark brown colour and a mild nutty and buttery flavour - described as a cross between a sunflower seed and a pine nut.

While hemp and marijuana look and smell the same, they differ in the amount of THC (tetrahydrocannabinol), the psychoactive substance with intoxicating effects. The hemp plant contains trace amounts of THC (no more than 0.3 percent) if they are cleaned and processed properly, while marijuana usually contains 5 to 20 percent THC. Registered Dietitian Leslie Beck states that the low level of THC “makes it impossible to ‘get high’ off hemp.”

Hemp seeds and hemp hearts
Hemp hearts are the soft inner part of hemp seeds after they have been shelled or hulled, eliminating three-fourths of the fibre content. On the plus side, hemp hearts are easier to eat and may be better in recipes since the seeds are harder and crunchier, explains Registered Dietitian Andy De Santis.

Nutritional profile
Hemp seeds have been called “super seeds” with excellent nutritional value. They can be sprinkled on foods, pressed for oil, ground into protein powder or flour, and made into milk, with the seeds providing the broadest spectrum of nutritional benefits per serving.

The main healthy features of hemp seeds are their protein, fibre, and healthy fats (both the hearts and seeds are high in omega-3 fatty acids). As noted above, the hemp hearts have the fibre-rich shell removed and thus have much less fibre than the seeds. 

• Protein - The Dietitians of Canada Unlockfood website reports that 2 tablespoons of shelled hemp seeds have between 7 to 11 grams of protein. This is considered relatively high, beating out chia seeds and flaxseeds, according to Registered Dietitian Adda Bjarnadottir. Registered Dietitian Leslie Beck reports that with regards to the protein quality of plants, hemp is only second to soy. Today’s Dietitian Registered Dietitian Ginger Hultin points out that hemp protein may be superior to soybean because it doesn’t contain the trypsin inhibitors that reduce protein absorption. For a protein comparison, 3 tablespoons of hemp is equivalent to almost 2 eggs. Like quinoa, hemp seeds are a complete protein, meaning they provide all of the essential amino acids that the body cannot produce, and therefore, must be obtained through the foods we eat. The seeds are more digestible than many grains, nuts, and legumes. Hemp can be used as a protein boost.  
• Fatty acids - they are exceptionally rich in two essential fatty acids, linoleic acid (omega-6) and alpha-linolenic acid (omega-3) with a 3 to 1 ratio, considered the ideal ratio required for good health. It is important to ensure a good balance of these two for maximum utilization of omega-3s. Many people get their dietary omega-3 fatty acids from cold-water fish e.g., salmon and halibut, so for people who do not choose fish, hemp is an alternative. In a gram to gram comparison of omega-3 content, hemp comes second to flaxseed. Hemp seed oil from pressed hemp seeds is number one for essential fatty acid content in nut or seed oils. Approximately four teaspoons (20 ml) of hemp seed will provide the recommended daily intake of 1.1 grams of omega-3 polyunsaturated fatty acids.
• Calories - they are relatively high in calories but low in carbohydrates. A serving of hemp hearts, which is 3 tablespoons, has 166 calories and 2.6 grams of carbohydrates.  
• Vitamins and minerals - they are a great source of vitamin E and minerals, such as phosphorus, potassium, sodium, magnesium (a mineral that 75 percent of the population is not getting enough of), sulfur, calcium, iron, and zinc.
• Fibre - whole hemp seeds are a good source of fibre (20 percent soluble fibre and 80 percent insoluble fibre, both important components for overall digestive health). 
• Antioxidants - hemp seeds are high in antioxidants, also known as “free radical scavengers,” which are substances that may protect cells against free radicals. Free radicals are unstable molecules produced by the body as a reaction to environmental and other pressures, and they may play a role in the development of diseases such as cancer and heart disease.  
• Gluten, cholesterol, and sodium-free choice - Registered Dietitian Kelly Plowe, however, points out that hemp seeds can be cross-contaminated at processing facilities and therefore ensure you buy a product stating that it is certified gluten-free.
• Health benefits - claims that hemp seeds can improve your immune system, increase your energy, improve digestion or help with weight loss are not backed by scientific evidence, according to the Unlockfood website. The Very Well Fit website comments that while many research studies have been conducted on the benefits of hemp with animals, more research is needed with humans.

Who should not consume hemp seeds
For most people, hemp seeds and oil are healthful and safe products to add to their diet. Individuals taking certain medications, including estrogen, ACE inhibitors, or antihypertensive drugs, should speak with their healthcare providers before choosing to consume hemp seeds. Some people have an allergy to hemp products.  
 
How to use
Hemp seeds do not need to be soaked, crushed or cooked. They can be eaten raw, cooked, or roasted. Ideas on how to incorporate hemp include:

• Sprinkle on salads, vegetables or rice
• Use instead of breadcrumbs as they are gluten free
• Make seed butter or pesto
• Use in homemade energy and protein balls or bars
• Use hemp seeds to make a pie crust. Pulse them in a food processor first to get the right consistency, then press into a pie pan.
• Add to muffins/cookies, smoothies, cereal, oatmeal, granola, stir fries or lasagna
• Use hemp oil for low-heat cooking or in salad dressings, or can be drizzled over pasta, grilled veggies, or popcorn
• Make hemp milk by blending hemp hearts with water, then straining with a cheesecloth

Storage
Hemp seeds can spoil fairly easily. Buying them in small amounts is cost saving as they expire quickly.  Check the “packaged on” or “best before date” and buy the newest product you can find to prolong freshness. Once opened, store them in the fridge or freeze them in an airtight container for about 12 months. A package stored in a pantry will only have a shelf life of 3 to 4 months or by the “best before date.” Hemp hearts that have gone bad will have a rancid smell. Hemp seed oil should be stored in dark coloured, refrigerated containers as light, oxygen, and heat can damage the essential fatty acids.

Densie Webb, PhD, RD, author for Today’s Dietitian, concludes that nuts and seeds are healthy additions to a diet and may reduce the risk of several chronic health conditions. Another benefit is that, like processed foods, they are easy to eat, but unlike processed foods, they are nutrient-rich.  

Resource: Video from the Foodful Life website 

Sources: Today's Dietitian website, Today's Dietitian website, Healthline website, Unlockfood website, PhysOrg website, AndytheRD website, Bon Appetit website, Leslie Beck RD website, Medical News Today website, VeryWellFit website, Livestrong website, WebMD website, The Conscious Dietitian website, Foodful Life website, Huffington Post website, Comprehensive Reviews in Food Science and Food Safety website, Berkeley Wellness Letter website 
 

---

Nonpharmacological Treatment for Chronic Pain

 
The Canadian Psychological Association defines chronic pain as pain “lasting longer than 3 or 6 months, or beyond the usual time of recovery.” In Canada, it is estimated that between 10 and 30 percent of adults are living with chronic pain. Chronic pain affects slightly more women than men and is more common in people of middle age, but it can affect anyone of any age. The potential impacts of living with chronic pain include depression, anxiety and social isolation. Chronic pain is the leading cause of disability in Canada. Unfortunately, for many people living with chronic pain, obtaining a diagnosis and finding pain-relieving treatments can prove to be difficult.  
A 2020 systematic review by the Agency for Healthcare Research and Quality (AHRQ) looked at conservative noninvasive non-pharmacological treatment for the most common chronic pain conditions. These treatments included psychological therapy, exercise, mind-body practices, multidisciplinary rehabilitation, mindfulness practices, manual therapies, physical modalities, and acupuncture. The reviewers focused on musculoskeletal pain, as this pain represents the most common type of chronic pain. Five of the most common causes of musculoskeletal pain include chronic low back pain, chronic neck pain, osteoarthritis, fibromyalgia, and chronic tension headache. 

A total of 233 randomized controlled trials were reviewed, an addition of 31 trials from the previous review. The findings included:

• Many studies had small sample sizes (less than 70 participants) and follow up of less than 12 months
• For function and pain, the effect sizes were generally small.
• No evidence that participants had an increased risk for serious harms from these interventions
• Interventions that improved function and/or pain for 1 month or more included:
  • Low back pain: exercise, psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehabilitation.
  • Neck pain: exercise, low-level laser, mind-body practices, massage, and acupuncture.
  • Knee osteoarthritis: exercise and cognitive behavioural therapy.
  • Hip osteoarthritis: exercise and manual therapies
  • Fibromyalgia: exercise, cognitive behavioural therapy, myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, and multidisciplinary rehabilitation
  • Tension headache: spinal manipulation

Some interventions did not improve function or pain.

The conclusion was that exercise, multidisciplinary rehabilitation, acupuncture, cognitive behavioural therapy, mindfulness practices, massage and mind-body practices were identified as the treatments that most consistently improve function and/or pain following therapy for specific chronic pain conditions.

Resources for pain management

• Pain BC™ is a collaborative non-profit organization comprised of people in pain, clinicians, researchers, and other supporters. Founded in 2008, its mission is to improve the lives of people in pain through empowerment, education, and innovation.  Persistent pain is defined as pain that lasts longer than 3 months, the time it typically takes for an injury to heal. They provide a number of resources for people with persistent pain, caregivers, and health care providers. For more information, visit their website at www.painbc.ca.
• Canadian Agency for Drugs and Technologies in Health (CADTH) is an independent, not-for-profit Canadian organization created in 1989 by provincial, territorial, and federal governments. It is responsible for providing health care decision-makers with objective evidence to help make informed decisions about the optimal use of health technologies. CADTH has conducted a series of evidence reviews to evaluate the research on effectiveness of non-drug methods for the treatment of chronic, non-cancer pain. The key messages drawn from the review were that non-pharmacological interventions for chronic pain management are supported by evidence and a Canadian guideline (2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain) recommends first trying non-opioid and non-pharmacological methods for chronic pain before other methods. The CADTH provides evidence summaries on their website. 
• National Center for Complementary and Integrative Health - Pain: Considering Complementary Approaches e-book (2019) - outlines complementary health approaches for pain 

Source: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update Evidence Summary 
 

---

Psychological Therapies for Adults with Chronic Pain - Benefits and Risks 

The goal of psychological treatments such as talking and behaviour therapies is to help people change the way they manage pain and reduce disability and distress. These kinds of treatments have been available for half a century and many trials have evaluated their impact. The aim of a Cochrane Review was to examine the research evidence for the effectiveness of psychologist delivered treatments and potential adverse side effects. The review, an update from 2012, included people living with chronic pain, excluding cancer pain and headaches.

In all, 75 studies were reviewed with a total number of participants of 9,401. Diagnoses included low back pain, rheumatoid arthritis, and a mixture of chronic pain conditions. The average age of the participants was 50 and the average length of time living with chronic pain was 9 years. Follow up after treatment was done up to three years later.

The psychological treatments included cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), behavioural therapy (BT), or another psychological therapy. CBT made up the majority of the studies (59) and is defined as an approach focusing on thoughts, feelings, and actions with the aim to help people think and behave in more adaptive ways. The findings included:

• On average, people who received CBT probably experienced slightly less pain and distress at the completion of treatment and six to 12 months later (evidence was considered of moderate quality) and slightly less disability (evidence was considered of low quality) when compared to people who did not receive treatment for their pain
• When comparing psychological treatment against non-psychological treatment (exercise program or pain management education program) on average, people treated with CBT probably experienced very slightly less pain, disability, and distress by the end of the treatment (evidence considered moderate‐quality), very slightly less pain and distress at six to 12 months later (evidence considered moderate quality).
• Levels of disability may be similar when comparing psychological to non-psychological treatments (evidence considered low quality).
• The authors could not comment on the adverse effects of CBT because of the very low quality of the evidence.  

Amanda C de C Williams, lead author, concludes, “Our evidence supports the use of CBT to reduce disability and distress associated with chronic pain, when delivered by trained psychologists.” She adds that the outcomes are uncertain for BT and ACT so effects of these treatments (both positive and negative) should be monitored and reported.

Sources: Canadian Psychological Association "Psychology Works" Fact Sheet: Chronic Pain, Cochrane Library abstract
 

---

Participants Wanted for an Online UBC Study

Help UBC research (PI Hoppmann) better understand how recruiting support from family or friends can promote everyday health behaviours and well-being during the current circumstances.

Who can take part? Anyone who lives in Canada and is over the age of 18 plus a study partner over the age of 65.

What's involved? Online interview sessions and brief morning and evening questionnaires for a period of 10 days. Questions related to COVID-19, which are optional, but would help them to better understand the current context. Participate in this study and receive a $50 Amazon gift card as a token of appreciation.

Please email or call them if you are interested in participating.  
Website: https://blogs.ubc.ca/alliesinhealthstudy/
Email: allies@psych.ubc.ca
Phone: 604-822-3549 
 

---

 

Get in Motion - Physical Activity Coaching for People with Physical Disability

Get the support you need to be active at home during the COVID-19 pandemic. Get in Motion is a free, telephone-based Physical Activity Coaching for Canadian adults with a physical disability such as spinal cord injury, multiple sclerosis, stroke, cerebral palsy, fibromyalgia, rheumatoid arthritis, osteoarthritis, post-polio syndrome, or an amputation.  
 
For more information, visit the website, or to sign up: 

• Click here; or
• Send an e-mail to CDPPprojects@queensu.ca; or
• Call (613)533-6000 x 78841.  The phone number is for Kingston Revved Up.  This is the correct number.  Please leave your name and contact information.