锻炼和慢性病.ppt

ExerciseandChronicDisease,MarkA.Patterson,M.Ed.,RCEPClinicalExercisePhysiologistKaiserPermanentePresident-ElectRockyMountainACSM,Hippocrates,“Eatingalonewillnotkeepamanwell;hemustalsotakeexercise.Forfoodandexercise,whilepossessingoppositequalities,yetworktogethertoproducehealth.”Hippocrates,Regimen,5thCenturyB.C.SlideborrowedfromRussPateandRobertSalis,,CommonChronicDiseases,CardiovasculardiseaseHeartAttack,Stroke,PADPulmonarydiseaseAsthma,COPD,EmphysemaDiabetesNeuropathies,CADNeuromusculardisordersMultipleSclerosis,ParkinsonsMusculoskeletalconditionsArthritisCancerBreast,Prostate,LeukemiaRenaldiseaseKidneyFailure,CADImmunologicalAIDSObesityAlloftheabove?,Cardiovasculardisease79million(2019CDCWebsite)Pulmonarydisease35million(2019AmericanLungAssociation),Diabetes14.6Million(2019CDCWebsite)Neuromusculardisorders(MS,2.5millionnationalmssociety/Parkinsons1.5million+,NationalParkinsonFoundation)Musculoskeletalconditions(Rheumatoid2.1million,osteo21million,juvenile300,000,nationalarthritisfoundation)Obesity99Million(BasedoffCDCandCensusBureauSites)Cancer10.1Million2019(AmericanCancerSocietyWebsite)Renaldisease20+million(AmericanKidneyFund)Immunological(AIDS36.1MillionAIDS.org,ChronicDiseases,BenefitsofExercise,IncreasedVO2ImprovedBPControlIncreasedHDLDecreasedBodyFatImprovedWeightControlImprovedBSControlImprovedStrengthLessFatigueImprovedBalance,HeartDiseaseLungDiseaseDiabetesNeuromuscularMusculoskeletalObesityCancerKidneyDiseaseAIDs,WhoisBesttoCareforThesePeople?,Me!InanIdealWorldClinicalExercisePhysiologistsPhysicalTherapistsRespiratoryTherapistsRegisteredNursesPhysiciansPersonalTrainersMassageTherapistsAccupunctureChiropractors,WhatisClinicalExercisePhysiology?,TheRegisteredClinicalExercisePhysiologistisanalliedhealthprofessionalwhoworkswithapparentlyhealthypeopleandpatientswithchronicdiseasesandconditionswhereexercisehasbeenproventoprovidetherapeuticbenefit.TheRCEPperformsexerciseassessmentsandprescribesexerciseandphysicalactivity,primarilyinhospitals,clinicsorotherhealth-careprovidersettings.TheRCEPassistsindividualsindevelopingself-managementskillstopromotegoodhealth.TheRCEPisanintegralpartofthehealthcareteamandworkscloselywithotherhealthprofessionalsincluding:Physicians,Nurses,NursePractitioners,PhysicianAssistants,RespiratoryTherapists,PhysicalTherapistsandRegisteredDietitians.RCEPsaretrainedtoworkwithpatientswithchronicdiseasessuchas:Cardiovasculardisease,pulmonarydisease,diabetes,neuromusculardisorders,musculoskeletalconditions,obesity,cancer,endstagerenaldisease,neoplastic/immunological/hematologicaldisorders,CEPorPT?,Physicaltherapy,whichislimitedtothecareandservicesprovidedbyorunderthedirectionandsupervisionofaphysicaltherapist,includes:,Aerobiccapacity/endurance,anthropometriccharacteristics,arousal,attention,andcognition,assistiveandadaptivedevices,circulation(arterial,venous,lymphatic),cranialandperipheralnerveintegrity,environmental,home,andwork(job/school/play)barriers,ergonomicsandbodymechanics,gait,locomotion,andbalance,integumentaryintegrity,jointintegrityandmobility,motorfunction(motorcontrolandmotorlearning),muscleperformance(includingstrength,power,andendurance),neuromotordevelopmentandsensoryintegration,orthotic,protective,andsupportivedevices,pain,posture,prostheticrequirements,rangeofmotion(includingmusclelength),reflexintegrity,self-careandhomemanagement(includingactivitiesofdailylivingandinstrumentalactivitiesofdailyliving),sensoryintegrity,ventilation,andrespiration/gasexchange,work(job/school/play),community,leisureintegrationorreintegration(includinginstrumentalactivitiesofdailyliving),2.Alleviatingimpairmentandfunctionallimitationbydesigning,implementing,andmodifyingtherapeuticinterventionsthatinclude,butarenotlimitedto,Coordination,communicationanddocumentation,patient/client-relatedinstruction,therapeuticexercise,functionaltraininginself-careandhomemanagement(includingactivitiesofdailylivingandinstrumentalactivitiesofdailyliving),functionaltraininginwork(job/school/play)andcommunityandleisureintegrationorreintegrationactivities(includinginstrumentalactivitiesofdailyliving,workhardening,andworkconditioning),manualtherapytechniques(includingmobilization/manipulation)prescription,application,and,asappropriate,fabricationofdevicesandequipment(assistive,adaptive,orthotic,protective,supportive,andprosthetic),airwayclearancetechniques,integumentaryrepairandprotectiontechniques,electrotherapeuticmodalities,physicalagentsandmechanicalmodalities,3.Preventinginjury,impairment,functionallimitation,anddisability,includingthepromotionandmaintenanceofhealth,wellness,fitness,andqualityoflifeinallagepopulations,4.Engaginginconsultation,education,andresearch,ExerciseandDeath(Men),ExerciseandDeath(Women),WhatistheBestWaytoIncreasePhysicalActivity?,Monitoredrehab?Personaltraining?Casemanagement?DoctorsAdvice/Guidance?PhysicalTherapy?CommunityResources?SupportGroups?RecreationCenterMemberships?,ComprehensiveRiskFactorModificationKaiserPermanenteColoradoCardiacRehabilitationModelofIntegratedDeliveryofHealthCare,MI/ACS/PCI/CABGCaseManagerMonitoredCRCEPCPCRSDieticianCardiologistPCPOtherResources,ClinicalExercisePhysiologistRoleKaiserPermanenteColoradoCardiacRehabilitationModelofIntegratedDeliveryofHealthCare,ClinicalExercisePhysiologistExerciseRx/Consult(One-on-One)MonitoredSub-MaxExerciseTestingROM/FlexibilityEvaluationStrengthEvaluationBehaviorChangeCounselingMonitoredRehabCardiologistPCPOtherResources,FunctionalExercises,Whatisafunctionalexercise?Exercisethatisspecifictoandcloselymimicstasktobecompleted.Walkinglungebettertostrengthenmusclestoassistinincreasingefficiencyofwalking/runningthanlegextensions.,INDIVIDUALIZE!,Eachpatientisadelicatesnowflake!Makesuretogetdetailedhistoryofdisease,co-morbidities,checkthatriskfactorsareincontrol,priorexercisehistory,checkforcurrentsymptomsandreviewsupportteamandresourcesforexercise,WhatistheRiskofExercise?,ExercisePrescriptionTips,CardiovascularMedications(HRandBP)Symptoms(CAD,CHF,PAD)F.I.T.PrincipleConsiderationsImportanceofWarmUpandCoolDownDonotholdyourbreath!,Whencantheystart?,AssumingPatientisMedicallyStable:*Allpatientsshouldstartwithslowprogressionofwalking,stationarybike,etc.PCIwithoutMIexercisetestingandmoremoderateexerciseafterabout4weeksofconsistentlowintensityaerobicexercise.MIwithorwithoutPCIexercisetestingandmoremoderateexerciseafterabout4-6weeksofconsistentlowintensityaerobicexercise.CABGexercisetestingandmoremoderateaerobicexerciseabout4weekspostsurgery,moderatestrengthtrainingabout12weekspostsurgery.CHFAsymptomaticpatientsincreaseaerobicexerciseveryconservativelyascantolerate,ifEFisbelow30%strengthtrainingmaybecontraindicated.,ExercisePrescriptionTipsPeripheralVascularDisease,ClaudicationWalkingisamustSpecificity2MostImportantMeasures1.Onsetofsymptoms2.MaximumwalktimeIntermittentWalkingtoModeratePainHighRiskofHeartDisease(CAD)AddothermodesofaerobicexercisetoincreasetotalconditioningtimeRoleofStrengthTraining,Non-ClaudicantCanprescribeexerciselikepeoplewithheartdisease/orathighriskforheartdisease,ClaudicationandStrengthTraining,HiattWR,etal,PeripheralArterialandAorticDiseases:SuperiorityofTreadmillWalkingExerciseVersusStrengthTrainingforPatientswithPeripheralArterialDisease:ImplicationsfortheMechanismoftheTrainingResponse.Circulation;90(4);October1994;1866-1874,ExercisePrescriptionTipsLungDisease,PerceivedExertionvs.ShortnessofBreathReliabilityofHR?AerobicWalkingPartofmostactivitiesofdailyliving.StationaryBikeArmErgometerImportanceofStrengthConditioning1.Improveefficiencyofmuscles/conservationofenergy,ExercisePrescriptionTipsDiabetes,MonitorBloodSugarBeforeandAfter*250withKetones,60%VigorousTime150minutes/weekmoderate90minutes/weekvigorousResistanceTrainingFrequency3daysperweekIntensity8-10repetitionsVolumeofExercise8exercisesUpto3setsperexercise,AerobicExerciseModesChooseexercisessuchasstationarybikeandelipticaltrainers-helpwithbalance-lesschanceoffallingWalkingalsoagoodchoiceasinvolvedinmostactivitiesofdailylivingspecificityResistanceTrainingModesMachineweightsarepreferredatstartsincetheycanhelpwithbalance,ExercisePrescriptionTipsMultipleSclerosis,AerobicExercise1.PerceptualScalebetterforExerciseIntensity2.Adjustdailyaccordingtosymptomsandenergylevels3.Avoidexerciseinheat,exerciseearlyindaybetterforsymptomsoffatigue4.BladderissuescancausepatientstonothydrateproperlyStrengthTraining1.Optimizeinunaffectedmusclegroups2.Functionalexercisesbest,Emphasizecoregroups3.Increaserestperiodtime4.Duringtimesincreasedsymptomsfocusstretching,ROM5.Weightmachinespreferred.,ExercisePrescriptionTipsParkinsonsDisease,AerobicSafetywalkingispreferred,butmayneedtousebikeergometer,eliptical,armergometerorothersifsymptomswarrant.Balancedevicesharness,walkingpolesStrengthWarmupimportantFocusonexercisesthatextendthetrunkFunctionalexercisesbestAuditorycuesmaybeneededtohelpwithtimingofrepetitionsEnsuregoodposture,ExercisePrescriptionTipsOsteoarthritis,“WeightBearing”AerobicExerciseContinuousweightbearingaerobicexercisecanbedifficultCarefulwiththosewhohavesevereosteoporosisWaterWalkingagainstcurrentmaybeagoodoptionExercisestoimprovebalanceMinimizeforwardflexionandtwistingmovementsCanstartwithstrengthtrainingCandocombinationofshortboutsofaerobictrainingwithstrengthtrainingdoneduringrestperiods.,ExercisePrescriptionTipsRheumatoidArthritis,CanfollowsamebasicguidelinesaswithosteoarthritisAvoidexerciseduring“inflamatoryphase”,ExercisePrescriptionTipsFibromyalgia,MustcustomizetoindividualCarefultoavoidoverexertionProgressslowly(watertolandwalking),ExercisePrescriptionTipsObesity,*WalkingimportantasisinvolvedinmostaspectsofactivitiesofdailylivingIfbalanceisanissuethenstationarybikesandelipticaltrainersaregoodoptionWaterwalkingandwateraerobicsidealforthosewithproblematicjointsWatchcarefullyforsignsofcardiopulmonaryandmetabolicdisease.,ExercisePrescriptionTipsObesity,StrengthTrainingMachineweightsmayhelpwithbalanceandhelptoensureproperformLightweightsrecommendedwithmoderatetohighrepetitionsMaybebestoptiontoconcentrateonearlyasde-conditioningandjointissuemaylimitabilitytoperformaerobicexerciseatonsetofnewprogram,ExercisePrescriptionTipsAIDS,HIVExerciseRxmustbeadaptedperstageofdiseaseAsymptomaticusualgeneralACSMguidelinesarefineSymptomaticneedtoadjustdaytoday,shouldnotexercisewithfeverabove100,orifhavingnausea,vomiting,uncontrolleddiarrheaordehydration,ExercisePrescriptionTipsAIDS,Moderatebetter,overtrainingincreaseslikelihoodofinfectionsEnvironmentAbrasions,tissueinjuriesCrossinfection,sharingofwaterbottlesOverseastravel,ExercisePrescriptionTipsAIDS,ExerciseandSicknessCommoncoldMildtomoderateexerciseOKIntenseexerciseOKafewdaysaftersymptomsresolveFever,extremefatigue,muscleachesbesttowait2-4weeksbeforeresumingintenseexercise,ExerciseandDialysis,EffectsofKidneyDiseaseandLongTermDialysisbonedisease,fatigue,coronaryarterydiseaseandrhythmdisturbances,ExerciseandDialysis,“Becauseofthereductionincardiovascularriskfactorsthatresultsfromexercisetraining,andbecauseoftheneedtopreventprogressivedeconditioning,dialysispatientsmayactuallybeplacedatagreaterriskforcardiaceventsandadversemusculoskeletaloutcomesinthearenotparticipatinginregularphysicalactivity”AdvRenReplTher,Vol6,No2,2019:pp165-171,ExerciseandDialysis,ExerciseandDialysis,ExerciseTipsBreathingisatconversationallevelFeelcompleter