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EXERCISE PRESCRIPTION FOR SPECIAL CASES

EXERCISE PRESCRIPTION FOR SPECIAL CASES. 1. Rheumatoid Arthritis Symptoms - pain, swelling, stiffness of small peripheral joints, female preponderance (3:1), progressive course Systemic Disorders - pericarditis, vasculitis, pleuritis, pulmonary fibrosis, neuropathy, episcleritis, amyloidosis

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EXERCISE PRESCRIPTION FOR SPECIAL CASES

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  1. EXERCISE PRESCRIPTION FOR SPECIAL CASES 1. Rheumatoid Arthritis Symptoms - pain, swelling, stiffness of small peripheral joints, female preponderance (3:1), progressive course Systemic Disorders - pericarditis, vasculitis, pleuritis, pulmonary fibrosis, neuropathy, episcleritis, amyloidosis Functional Capacity - class 1-4 (complete ability to carry all duties without handicap, little or no self - care, bedridden)

  2. Muscular Weakness, Low Endurance • Exercise precription • CLASS 1 - any type of exercise - best bicycle • CLASS 2, 3 - in low activity phases - cycling, walking, heated pool exercise, exeptionally jogging) • CLASS 4- few patients perform physical activity (supported - in water). • Effect of Exercise in RA • Beneficial effect on physical, psychologic, social performances.

  3. 2) Osteoporosis • Definition - bone atrophy • Osteoporosis Type I - related to menopause, accelerated trabecular bone loss • Osteoporosis Type II - age related, after age 70 • Other Causes of Osteoporosis • Immobilization, drug related (corticosteroids, anticonvulsants, bone-marrow disorders, connective tissue dis.) • Symptoms Pain (mainly of the spinal column), fractures (spine, wrist, hip, wedge fractures of vertebrae).

  4. Diagnosis • Symptoms, x-ray, densitometric evaluation (dual photon absorptiometry) • Exercise Prescription • 1) Affecting Osteoporosis Risk Factors (20 min., 3 days/week, 40 - 70  of HR reserve) • 2) Reducing Risk of Fractures Water exercise, resistance training, weight bearing, 2 - 3 times/week

  5. 3) Spinal Disorders and Low Back Pain • Incidence - majority of adults, mostly a result of activity - related spinal disorders. Most frequent cause of limitation to activities of daily living including work, housekeeping, school, recreation

  6. Symptoms • ACUTE low back pain - (accidents, inappropiate weight lifting), bed rest, resolve spontaneously. • CHRONIC PAIN - anatomic changes of the spine (discopathies, spondylarthrosis, Bechterev disease)

  7. Exercise for Prevention of Low Back Pain • Isometric endurance of the back muscles. Strengthening abdominal muscles, flexibility hyperextension back exercise • PRECRIBING DIFFERENT EXERCISE PROGRAMS FOR DIFFERENT SUBGROUPS OF PATIENTS! • Emphasis on flexibility, muscle strengthening, endurance conditioning, pain management, education

  8. 4) Bronchial Asthma • Definition - chronic inflammatory disorder of the airways, clinically manifested by dyspnea, dry cough in response to different triggers (allergens, infection, exercise) caused by diffuse narrowing of bronchial tree.

  9. Incidence - 5 of adults, 10 in children • Diagnosis - familial history (presence of atopy - ekzema, rhinitis, conjunctivitis). Symptoms, physical examination, pulmonary function tests (bronchoconstrictor, bronchodilatory), skin prick tests, IgE.

  10. Exercise Induced Asthma (EIA) • Decrease in FEV1  15  following exercise, symptoms of cough, wheezing • More frequent in runners, long - distance ski - runers, cyclists, less frequent in swimming sports

  11. Prevention of EIA SELECTION of the type of exercise, environment, duration and intensity of exercise • Warm-up Period important • Drugs - salbutamol, formoterol - approval for competitive athletes • Olympic Games - 1984 USA - 594 athletes, 67 (11.2 ) suffered EIA, won 41 medals (15 gold, 20 silver, 6 bronze)

  12. 5) Chronic Obstructive Pulmonary Disease • Definition • Chronic inflammatory disorder of the airways, causing obstruction which is progressive not reversible after bronchodilating drugs, clinically manifested by productive cough and dyspnoea • Incidence – 10% of adults over 40, men prevalence (3 - 4:1). • Etiology – 90% cigarette smoke, others (repeated infectious bronchitis, occupation in dusty environment, alfa - 1 antitrypsin deficiency

  13. Diagnosis - history, physical examination ( expiration, adventitious breath sounds, diminished vesicular breathing) pulmonary function tests (irreversible airways obstruction, increased residual volume, decreased diffusing capacity). • Classification into 4 steps (GOLD) mild, moderate, severe, very severe - according to FEV1. • Exercise Prescription part of total approach to patient care (optimal medical care, increased physical and social activity)

  14. Grade 1 Disability (FEV1  60%, VO2 max  25, normal PCO2 , SaO2 )- submaximal exercise, 30 - 60 min. every other day. • Grade 2 Disability - (FEV1  60%, VO2 max  25, SaO2 90%) - 60 – 80% of ventilatory capacity (FEV1 x 35), short time exercise to breathlessness • Grade 3 Disability (FEV1  40%, VO2 max  15, SaO2 90% during exercise) - training of muscle groups (respiratory muscles, pattern of breathing). • Grade 4 Disability (FEV1  40%, VO2 max  7, SaO2 90% at rest) - exercise related to dyspnoea, fatigue, headache, oxygen supplementation • Individualization for each patient

  15. 6) Metabolic Syndrome • Definition • Presence of: obesity, dyslipidemia, hypertension, diabetes, insulin resistance

  16. Importance - high risk factor of cardiovascular disorders (ICHD, heart failure, ischaemic cerebral strokes, renal failure) • Treatment Aggressive multi - factorial intervention. Most important - THERAPEUTIC LIFESTYLE CHANGE, INCORPORATING MODERATE PHYSICAL ACTIVITY PROVED EFFECTS OF EXERCISE: weight loss, decrease of LDL - cholesterol, increased HDL - cholesteral, decrease of blood pressure, decrease of insulin resistance. • Exercise Prescription Regular exercise 3 - 5 days/week, longer duration (30 - 60 minutes), intensity approximately 40 – 60% VO2 max. (not exceeding 7 METs).

  17. 7) Cystic Fibrosis • Definition - inherited disorder, transmitted as an autosomal recessive trait. • Gene causing the disease - CFTR (cystic fibrosis transmembrane regulator) • CFTR protein controlles flux of chloride ions into and out of the cells lining airways and other endocrine glands (pancreas, intestine, sweat glands). • Decreased water - in airways - thick secretions - impede breathing, less secretions of digestive enzymes. • Symptoms- cough, wheezing, dyspnoea, frequent, bulky, foul - smelling stools, high lipid content.

  18. Diagnosis - high concentrations of sodium and chloride in the sweat. • EXERCISE TOLERANCE decreased (malnutrition, dyspnoea, increased energy expenditure) • EXERCISE PROGRAM Prescription of aerobic exercise - individualized Type of activity - enjoying for patient Intensity - middle grade (50 - 70% of individual´s maximal capacity - according HR) Exercise should be encouraged as part of the regular routine

  19. 8) End-stage Renal Disease • Definiton Chronic renal failure with diminished renal function, requiring renal replacement therapy such as dialysis or transplantation • Causes - hypertension, diabetes, chronic infection, congenital abnormalities, autoimmune processess

  20. Symptoms- fatigue, anorexia, nausea, malaise, edema, dyspnoea. Physical functioning and performance decreased. • Exercise Prescription - participation in moderate physical activity. Patients who are weak - benefit from strength - training intervention, resistance and aerobic exercise initiated at low intensity, slowly progressed as tolerated. Incorporation of exercise into the dialysis session may increase patient participation and tolerance of exercise.

  21. 9. CHILDREN WITH HEART DISEASE

  22. Congenital heart disease • Left-to-right shunts – atrial septal defect (ASA) ventricular septal defect (VSD), patent ductus arteriosus • Obstructive – aortic stenosis (AS), pulmonary stenosis (PS), coarctation of aorta • Complex lesions –Fallot tetralogy, transpositions of great arteries

  23. Diagnosis • Physical examination, x-ray, echocardiography, catheterization, angiography

  24. Excercise capacity (EC) • in ASD – normal or slightly decreased, until shunt flow exceeds 40 % of pulmonary blood flow • in VSD – small defects (< 3 mm) – normal EC. Large – surgical repair necessary –EC limited – after surgery normal of slightly decreased

  25. In AS and PS • EC directly related to the degree of peak pressure gradient, after surgical of balloon angioplasty no limitation of EC. • In cyanotic lesions – EC very limited, after successful surgery – light exercise recommended

  26. Disorders of cardiac rhythm • Exercise testing – evaluation of heart´s response to physical activity, bring out occult arrhythmias, assistance in diagnosis of arrhythmias in patients with palpitations, syncope, light-headennes, exercise testing in combination with Holter ECG monitoring – complex information of rhythm disorders, mainly in problems with sinus node function and conduction system

  27. Attitude toward exercise and sport • most children with heart disease without or with heart surgery – no restriction to recreational sports activities, physicaleducation.Cardiomyopathy, chronic myocarditis – steered away from all competitive sports and many exercise activities (mainly weight training, strenuous´exercise). Total abstinence from physical activities is not required.

  28. 10. VALVULAR AND CONGENITAL HEART DISEASE IN ADULTS • Valvular heart disease – mitral valve prolaps, mitral valve stenosis and insufficiency, tricuspidal valve stenosis and insufficiency, aortic stenosis and incompetence, pulmonary stenosis and insuficiency

  29. Diagnosis • Symptoms, physical examination, exhocardiography, X-ray, catheterisation functional cassification according to the degree of tolerable physical activity – NYHA I – IV

  30. Exercise programs • AIM– improving working capacity of sceletal muscles. Intensity – 40 – 50 % of VO2max, 4 – 5/week, 20 – 30 min. • Possible adverse effects – arrhythmia, anginal pain, acute heart failure, syncope.

  31. Congenital heart disease in adults • very rare nowadays (ASD more than 50 %) • Exercise testing – help for assessing functional status, cardiac arrhythmias • Physical work capacity is either normal or slightly below normal

  32. 11. LOW FUNCTIONAL CAPACITY • Definition: individuals with functional capacity of 5 METs or less (NYHA class III-IV) due to cardiovascular disease. • Etiology: 80-85 % coronary heart disease (CHD) others – cardiomyopathy, valvular, congenital heart disease • Symptoms: dyspnoea, dizziness, syncope, fatigue during exercise

  33. Low functional capacity • Diagnosis– history, physical examination, x-ray, echo, catheterization, exercise ECG, Holter monitoring • Exercise testing – strict medical supervision during exercise tests! Start exercise at a very low level (1 – 2 METS) • Exercise prescription – lower intensities, greater duration, greater frequency (5 – 10 min several times a day). • Benefit from training – carrying on daily activities without symptoms, psychologic effect.

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