HSES 480 EXAM 3 slides and quiz questions

Treatment for COPD

Four areas to be considered: 1. Smoking cessation; improve patient survival. 2. Oxygen therapy; significant reduction in mortality. Goal: Maintain partial pressure of oxygen in arterial blood above 60 mmHg or percent saturation >903. 3. Pharmacological therapy; aimed at inducing bronchodilation, decreasing the inflammatory reaction, and managing and preventing respiratory infections(see Table 17.3) 4. Pulmonary rehabilitation; multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities (continued)

Scope of osteoporosis

Fracture risk at the hip is 2.5 times higher for each standard deviation decrease in hip BMD.• Osteoporosis now affects almost one out of every two women at some point in her life.• Prevalence rates in men can be as high as 15%.• Medical costs for osteoporosis are estimated at$19 billion per year.• Estimate a fivefold increase in all-cause mortality in the 3 mo following a hip fracture in older adults.

exercise testing for asthma (asthma 2)

Generally reserved for those with an unusual decline in exercise tolerance not related to the degree of airflow limitations• Symptom-limited incremental test• Measurements helpful for assessing asthma include:- Oxyhemoglobin saturation- Heart rhythm (ECG)- Metabolic cart (VO2, VCO2, anaerobic threshold) Contraindications- Acute bronchospasm- Chest pain- Increased level of shortness of breath above normal- Severe exercise deconditioning- Other comorbid conditions such as unstable angina; orthopedic limitations Exercise-induced bronchospasm (EIB)- EIB occurs in 50% to 100% of patients with asthma- Typical response: initial bronchodilation during first 10min followed by a progressive bronchospasm, peaking10 min following completion of exercise, and resolutionof EIB over the next 60 min.- Protocol: 2 min stages, 1 MET increments, maximum effort 8 to 12 min. Spirometry testing immediately following exercise and repeated at 15 and 30 min to assess airflow limitation.

Prevention of EIB

Appropriate warm-up (15 min at 60% ofVO2max)• 15 min of moderate-intensity exercise should precede significant exercise for active persons with asthma A mask or scarf over the mouth and nose may be helpful to reduce cold-induced EIB.• People who don't respond to the non pharmacologic approach can use pharmacologic intervention prior to exercise.

Candidates for Pulmonary Rehabilitation

Based on recommendations by the American Thoracic Society: 1. Severe symptoms 2. Several emergency room or hospital admissions within the previous year 3. Diminished functional status that limits activities of daily living 4. Impairments in quality of life

SCI (SCI 1)

Spinal cord injury (SCI) affects conduction of neural signals across the site of the injury or lesion• Classified by the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body• May be defined as:- Complete—without sensory function in the lowest sacral segment- Incomplete—partial preservation of sensory or motor function below the neurological level• Tetraplegia involves dysfunction of the arms• Both tetraplegia and paraplegia involve impairment of function of the trunk, legs, and pelvic organs The degree of paralysis, sensory loss, and autonomic nervous system impairment varies greatly in individuals with SCI.• Comorbidities- neurogenic hypotension- circulatory hypokinesis- myocardial atrophy• ↓ cardiac output• ↓ cardiac reserve- pulmonary dysfunction- osteoporosis- sarcopenia- obesity- metabolic syndrome- TBI, cognitive dysfunction; often mi

Signs and symptoms of asthma

Symptoms: episodic wheezing, breathlessness, cough, and chest tightness• Can be intermittent, making it difficult to diagnose• Can be related to exposure to allergens, seasonal rhinitis, dust mites, smoke, strong fumes, cold air, and exercise (exercise-induced bronchospasm, EIB)• Death can be associated with mild asthma

Patho 2 for SCI

Systemic adaptation- Cardiovascular: orthostatic hypotension- Autonomic dysreflexia- Pulmonary- Bowel and bladder function- Hyperreflexia• Spasticity- Thermoregulation- Endocrine- Osteopenia

How asthma happens.

TH2 cell --> IL5 --> eosinophil --> smooth muscle, mucus cells, epithelial tissue Eosinophil carries basic proteins, cytokines, cysteinyl leukotrienes

more pathophysiology of stroke

TIA: transient ischemic attack- Ministroke- Strong predictor of subsequent stroke• 10% have a stroke within 90 days of TIA• 5% have a stroke within 2 days• "All older people should be screened for possible prior TIA because about 50% of patients who experience a TIA do not report it to a clinician. Hemorrhagic—hypertension is the major risk factor for hemorrhagic stroke, which makes up approximately 10% of strokes.35 Hemorrhagic strokes can also be caused by aneurysm, drug use, brain tumor, congenital arteriovenous malformations, and anticoagulant medication. Hemorrhagic strokes can be further broken down to intracerebral and subarachnoid.• Intracerebral: bleeding inside the brain• Subarachnoid: bleeding in and around the spaces that surround the brain

Exercise testing responses

Table 17.2 Exercise Test Responses in Patients With COPD Compared With Normal Healthy Subjects 1 Parameter 2 Finding Peak work rate Decreased Peak oxygen consumption Decreased Peak heart rate DecreasedPeak ventilation Decreased Heart rate reserve IncreasedVentilatory reserve Decreased Arterial partial pressure of oxygen Decreased Arterial oxygen saturation Decreased Lactate threshold Occurs at a lower work rate Ventilatory threshold Absent

Treatment for nslbp

There is a wide range of medical management strategies, depending on the severity of NSLBP.1. Medications2. Exercise3. Passive modalities (heat, massage, spinal traction)4. Facet joint injections5. Surgeries: spinal discectomy, spinal decompression, and spinal fusion• Surgical intervention is questionable except for unequivocal disc herniation.

Signs of COPD

COPD: increased cough, purulent sputum production, wheezing, dyspnea, and occasional fever• A smoking history of 70 or more packs/years has been reported to be suggestive of COPD• Common measurements to help assess the presence and severity of COPD: lung volume measurements (FEV1, FVC, FEV1/FVC, TLC, FRC, RV), arterial blood gases, chest X-ray, computed tomography• Note: Chest X-ray can be normal in chronic bronchitis but reveal large lungs in advanced emphysema patients.

Common reasons for pediatric stress testing

To evaluate specific signs that are induced or aggravated by exercise• To assess or identify abnormal responses to exercise in children with cardiac, pulmonary, or other organ disorders, including the presence of myocardial ischemia and arrhythmias• To assess the efficacy of specific medical or surgical treatments To assess functional capacity for recreational, athletic, and vocational activities• To evaluate prognosis, including both baseline and serial testing measurements• To establish baseline data for institution of cardiac, pulmonary, or musculoskeletal rehabilitation

diagnostic testing for stroke

Ultrasound, magnetic resonance imaging (MRI), and angiography are the main diagnostic tests for assessing occlusions that lead to an ischemic stroke.- Noncontrast computerized tomography (CT) for hemorrhagic stroke has been the primary test. Can also be used to diagnose ischemic stroke.- Most recently, diffusion-weighted MRI for impending occlusions (ischemic stroke) is a promising diagnostic tool.

Clinical implications

dynamometer, hydraulic dynamometer (Jamar), 8RM upper extremity, and Berg scale decrease up to 50% in arthritis patients. 90% decrease for goniometer and electronic dynamometer

Pathologic Changes with Osteoarthritis

watch video

Conclusion

Cost and problems associated with osteoporosis will continue to increase.• Osteoporosis or osteopenia can be diagnosed with the use of DXA technology.• Bone density measurements should be seriously considered in anyone with existing risk factors for osteoporosis.

Exercise testing for nslbp

Graded exercise testing (GXT) is not needed for patients with NSLBP but may be requested to assess other comorbidities (heart and pulmonary disease).• Considerations when performing GXT on patients with a history of NSLBP:1. Select a mode of activity that does not exacerbateNSLBP (e.g., weight-bearing, forward lean).2. Avoid testing during an acute flare-up period.3. Consider submaximal testing to avoid the risk of re-aggravating NSLBP.

Exercise prescription of COPD

HR is not a reliable indicator of exercise intensity in COPD patients; therefore, intensity is monitored by dyspnea or ratings of perceived exertion. 2. Unsupported arm exercise results in greater levels of dyspnea compared with lower extremity exercise in patients with COPD. 3. Due to muscle dysfunction in COPD patients, resistance training may also prove beneficial for rehabilitation. 4. Four areas to focus on lower extremity aerobic exercise, ventilatory muscle training, upper extremity resistance training, and whole-body resistance training.

Specific Exercise Prescription Considerations

Important considerations:- Disease stage - important to know prior to developing exercise prescription- Preventing musculoskeletal injury - use interval and/or cross-training to minimize overuse injuries (e.g., weight training, pool exercise, cycle ergometry, walking)- Fatigue - beginning in the afternoon and lasting until evening- Previous joint replacement - These individuals should avoid high-impact activity. Those who have had hip replacements should not flex their hip past 90° or adduct or internally rotate the hip past neutral in the initial postoperative months- Time of day - Morning stiffness is a common problem for those with arthritis, so exercise should be performed in the late morning or early afternoon Important considerations:- Water therapy - RA is associated with Raynaud's phenomenon and Sjogren's syndrome- Raynaud's phenomenon is a vasospastic problem presenting as blanching of the hands and feet when exposed to cold or emotional stress

Medications for asthma

Long-term control (used daily to achieve and maintain control of persistent asthma)- Corticosteroids- Cromolyn and nedocromil immunomodulators- Leukotriene modifiers- Long-lasting beta-agonists- Methylxanthines Quick-relief medications- Anticholinergics- Short-acting beta-agonists- Systemic corticosteroids

Pathophysiology of multiple sclerosis

Loss of myelin interferes with conduction of impulses in affected fibers- May affect motor, sensory, and autonomic fibers- Occurs in diffuse patches in the nervous system Process likely initiated by autoreactive Tcells- Cross blood-brain barrier, proliferate, and beginmyelin damage- Cytokines "recruit microglia, macrophages, andother immune cells to participate in oligodendrocytedeath and myelin destruction."• Four major courses of clinical progression

Conclusion

MS is a chronic autoimmune disease that causes nerve demyelination and leads to plaques in the CNS.• There are 4 (or 5) major courses of MS.• The symptoms of MS are unpredictable but likely include vision, motor, fatigue, and spasticity.• Treatment for MS is also individualized.

Multiple sclerosis (27-1)

MS is an inflammatory autoimmune disease of the CNS.- Characterized by nerve demyelination- Plaques (sclerosis) in the brain and spinal cord• Develop into permanent scars• Impaired nerve transmission- Symptoms of weakness, fatigue, and impaired motor function

Physical Examination

Medical history should address:- Presence of symptoms- Pattern of symptoms- Physical examination of the chest• Diagnostic testing (spirometry):- FEV1 (<80% of predicted)- FEV1/FVC (<65% of predicted)- Flow-volume loop Asthma will show improvements in spirometry following bronchodilator administration.• See figure 19.2 for flow-volume tracings of a patient with asthma and a patient with emphysema. (pg 13, asthma 1) Bronchial provocation testing- Methacholine or histamine- >20% decline in FEV1 following administration of the irritant suggestive of asthma- Exercise challenge may be useful to uncover airflow limitations Other studies- Chest roentgenogram (X-Ray)- Sputum production (eosinophilic or neutrophilicinflammation)- Consider other causes for patient's symptoms(pneumonia, pneumothorax, congestive heartfailure)

Autonomic Dysreflexia

Potential medical emergency in spinal cord injury- Acute increase in blood pressure- 50-70% of individuals with SCI lesions at or above T6 experience autonomic dysreflexia symptoms• SCI above T6 usually associated hypotension due to loss of sympathetic outflow, but...• Intact spinal reflexes below lesion• AD: irritant → (+) sympathetic spinal circuits, no modulation from higher brain centers• Above lesion → mainly parasympathetic response• Below lesion → mainly sympathetic response

Scope of Arthritis

Leading cause of disability in United States• 50 million affected (22% of adult population)• ~$128 billion in health care spending eachyear• Prevalence higher in women• Common types- Osteoarthritis (OA)—most common- Rheumatoid (RA)- Gout- Spondylarthropathies

Exercise prescription for asthma

1. Assess patient's underlying respiratory status and goals for exercise. 2. Assess maximum level of exercise. 3. If maximum level of exercise has been determined by measurement of oxygen consumption and carbon dioxide production (cardiopulmonary exercise testing), begin exercise prescription at an initial intensity level just below the anaerobic threshold. 4. If such measurements are unavailable, begin exercise at a level of exercise at which the patient is comfortable performing for 5 min. 5. Instruct the patient to continue exercise for20 to 60 min per session. 6. Have the patient perform sessions 3 to 5 times per week. 7. Increase exercise intensity by 5% with each session. 8. When maximal level of intensity is attained, increase exercise duration by 5%. SpecialConsiderations • Exposure to cold air, low humidity, or air pollutants should be minimized.• Intermittent exercise or lower-intensity sports performed in the presence of warm, humid air are generally better tolerated. If maximal oxygen consumption is obtained using a metabolic cart, training can be initiated at an intensity level of 50% to 85%of the heart rate reserve.• For patients with more limiting asthma, a target intensity based on perceived dyspnea(such as a Borg scale) may be more appropriate.

Benefits of pulmonary rehabilitation

1. Improvements in quality of life 2. Increased sense of well-being 3. Increased self-efficacy 4. Increased functional capacity **Functional status has been shown to be a strong predictor of survival in patients with advanced lung disease following pulmonary rehabilitation.

Pathophysiology of NSLBP

85% of low back pain has no identifiable cause.• The most common presenting diagnosis of "low back pain" is not really a diagnosis but a symptom.• NSLBP may be caused by multiple anatomic structures that may all respond similarly to the appropriate regimen.

Scope of SCI

237,000 to 301,000 U.S. citizens have a SCI.• Incidence approaches 40 new injuries per million U.S. persons per year.- ~40% die before reaching a hospital.- ~7,400 Americans will survive a new SCI each year.• Rate of SCI in men is four times that in women.• Most SCIs occur in 16 to 30 yr olds.- motor vehicle collisions- violence- falls (esp in the elderly)- sports injuries Economic Costs- if injured at age 25:• lifetime medical costs ~ $1.7 million• Lost earnings and fringe benefits ~ $2.1 million• Improved outcomes - especially acute phase care- If age 20 at time of C5-C8 tetraplegia injury: 40 year life expectancy- If age 20 at time of paraplegia injury: 45+ year life expectancy

Exercise prescription for stroke

A major goal is to improve functional capacity(FC) since the average FC of a stroke patient 14.4 ml · kg −1 · min −1 whereas 20 ml · kg −1 ·min −1 is the minimum for independent living.• Typically, standard therapy does not provide sufficient aerobic stimulus; therefore the CEP should strongly promote aerobic exercise in the rehabilitation process. Significant reductions in muscular strength and endurance are commonly observed in stroke patients and should also be addressed.• Loss of flexibility is also common with stroke patients.• Exercise training programs should focus on aerobic exercise, strength training, and flexibility. Rimmer et al study- 3 x week: 60 min session, 30 min cardio, 20 min strength training, 10 min flexibility Cardiovascular exercise- Following ACSM's guidelines for frequency, intensity, and duration in apparently healthy adults has produced favorable results.- Suggested modes of activity:• Walking on the ground or on a treadmill (balance, coordination, gait abnormalities)- Weight-bearing activities for bone density• Cycle ergometry• Water-based exercise Special considerations• If there is concern about stumbling during walking on treadmill, supported treadmill exercise can be suggested, allowing the patient to exercise at higher velocities without the risk of falling.

Scope of asthma

A worldwide problem with an estimated 300million affected• 22 million Americans affected• 5% increase per year in the world• Most childhood asthma begins in infancy (<3yr of age)• Higher in some populations (23% of inner-city African Americans vs. 5% of Caucasians)

Specific training recommendations for aging

ACSM/AHA- Aerobic• 5x/week , 30 min per session @ moderate intensity (< 70% HRR, or 5-6 on 10 point RPE scale), OR• 3x/week, 20 min per session @ vigorous intensity (>70% HRR, or 7-8on 10 point RPE scale)- Strength• 2x/week- Flexibility• 2x/week Cardiovascular recommendations- Large muscle group emphasis- Low- to moderate-intensity exercise can be done daily, but high intensity only three to five times per week- High-intensity interval training may be beneficial but has not been completely assessed by researchers for effectiveness and safety- "Older individuals with low exercise capacity often best tolerate(and enjoy) multiple daily sessions of short duration."

Clinical considerations for SCI

Acute hospitalization management issues- Spine management: imaging of cervical, thoracic, lumbar, sacral spine- Surgical or orthotic stabilization of unstable spinal column injuries and spinal cord decompression- Range of motion limitations to allow complete bony and soft tissue healing of spinal elements. Respiratory management issues- Assisted ventilation is often required for high injuries Tetraplegia below C5 typically spares voluntary control of the diaphragm, although expiration remains impaired.• Ventilation worsens as the level of disability increases.• Aggressive spirometry and exercise training may improve it.- Secretion management essential because of impaired cough and increased parasympathetic nervous system influence on pulmonary secretions- Assisted cough required for SCI above T6attributable to intercostal and abdominal muscle paralysis

Treatment for stroke

Advanced carotid atherosclerosis (70-99%narrowing)- Carotid endarterectomy is a common surgical procedure• Plaque is physically removed from the artery wall- Stenting with an embolic protection device is also useful• Carotid artery balloon angioplasty and stenting• Pharmacologic treatment• Clot-busting agents (beneficial within 3 hours of ischemic stroke onset);- Tissue Plasminogen Activator (tPA); streptokinase- See table 28.3, next slide, for summary of common meds. Warfarin (anticoagulant), ticlopidine, clopidogrel, aspirin (antiplatelet), rampril, enalapril (angiogensin) nimodipine (Ca++ blocker, may increase exercise capacity), diuretics Standard rehabilitation for stroke patients usually includes physical therapy, occupational therapy, and speech therapy; depending on the patient's condition may also include registered dietitians and psychological counseling.- PT: restore balance, movement, and coordination; strengthening exercises, ROM exercises, assisted and unassisted walking, functional activities (eg chair stands, transfers)

Special considerations of osteoporosis

Aerobic: no jogging, avoid risk of falling. Severe kyphosis may need to only perform stationary bike. Strength: Target legs and back muscles, most common Cardiorespiratory endurance: weight bearing is the most beneficial for retaining bone density.

Staging COPD Patients

American Thoracic Society• Stage 1: FEV1 >50% of predicted, mild disease• Stage 2: FEV1 between 35% and 49% of predicted, moderate disease• Stage 3: FEV1<35% of predicted, severe disease• Global Initiative for Chronic Obstructive Lung Disease (FEV1)• Stage 1: >80% of normal, mild COPD• Stage 2: 50% to 79% of normal, moderate COPD• Stage 3: 30% to 49% of normal, severe COPD• Stage 4: <30% of normal, very severe COPD

Pathophysiology of aging

Arterial "stiffening" common in the aging process- Degeneration of elastic fibers- Deposition of collagen and calcium• Reduced LV filling rate- Concentric wall thickening- Response to both elevated SBP and aging• Increased risk of heart failure- Left atrium dependence for LV filling- Left atrial function negatively affected by atrial fibrillation• See table 30.1 for physiologic aging effects on organ systems. Peak VO2 decline- 8% to 10% per decade- Maximal HR decline ~1 beat/min per year- Reduced arteriovenous oxygen difference- Deconditioning- Musculoskeletal disease.

Arthritis (23-1)

Arthritis is a generic term for conditions that involve inflammation of one or more joints.• There are more than 100 different forms of arthritis, each characterized by varying degrees of joint damage, restriction of movement, functional limitation, and pain.

Pharmacology of nslbp

Aspirin Acetaminophen Ibuprofen Naproxen Piroxicam Diflunisal Bufferin Empirin Tylenol, others Motrin Rufen Nuprin• Naprosyn, Anaprox Feldene Dolobid Gastrointestinal (GI) distress, GI ulcerations, allergic reactions, renal dysfunction patients with history of allergic reactions or GI distress with these medications Narcotic (opiate) analgesics Meperidine Hydromorphone MethadoneCodeineMorphineOxycodone• Demerol• Dilaudid• Dolophine• Codeine• Avinza, Roxicodone• Oxycontin, OxyIR, Tylox, Percodan, PercocetPoor tolerance, gastrointestinal disturbances, sleep disturbances, drowsiness, increased reaction time, clouded judgment, misuse or abuse and dependence issues Patients with history of poor tolerance or allergic reactions, dependent personality types Muscle relaxants Cyclobenzaprine Carisoprodol Metaxalone• Flexeril• Soma• Skelaxin Central nervous system depressant, drowsiness, tachycardia, hives, mental depression, shortness of breath, skin rash, itching allergie

Asthema (19-1)

Asthma is a chronic inflammatory disorder of the airways with airway hyper responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing occurring particularly at night or in the early morning.• These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.

Conclusion

Asthma represents airway narrowing secondary to airway inflammation and bronchoconstriction.• Environmental risk factors or other triggers(such as exercise, cold air) can initiate an allergic response, leading to airway hyper responsiveness.

Emphysema

Breakdown of alveolar wall results in:- Loss of elastic fibers• Affects lung recoil on expiration- Loss of surface area for gas exchange- Loss of pulmonary capillaries• Affects perfusion and diffusion of gases- Loss of tethering/decreased support for other structures• Small bronchi may collapse. Dark coloration for necrosis. genetics and smoking play a factor.

more Exercise prescription and training for SCI

Cardiovascular exercise benefits- SCIRE: It would appear that various exercise modalities may attenuate and/or reverse abnormalities in glucose homeostasis, lipid lipoprotein profiles, and cardiovascular fitness.-As such, exercise training appears to be an important therapeutic intervention for reducing risk for cardiovascular disease and multiple comorbidities (such as type II diabetes, hypertension, obesity) in individuals with SCI. Cardiovascular exercise- Intensity: method of intensity monitoring is controversial• HR responses are variable depending on the level of injury; in many, 30% to 80% HRR correlates to 50% to 85%peak VO2 .• RPE is often used and preferred; RPE of 11 to 14correspond to ~ 60-90% able body; not evaluated yet for SCI.• Talk test.- Duration: The goal to follow guidelines for the general population and work up to 60 min per session. Cardiovascular exercise- Frequency: 3 to 5 d/wk- Consider multiple daily bouts for those with very functional status (eg < 3 METs)- Need to consider overuse syndromes of upper body Resistance exercise-Scapular stabilization and rotator cuff exercise in all patients-Initially: two sets of 10 reps for all exercises-Isometric contractions for shoulder• Protractors• Retractors• Elevators• Depressors• Internal and external rotators-Bands are useful-Free weights only for those able to use safely-Avoid overload of wheelchairs and always set brakes Range of motion exercise-Perform daily-Focus on all major joints-Particular focus on joints with contracture or spasticity-Consider care for those with osteopenia (eg support midshaft of long bones)

More clinical considerations for SCI

Cardiovascular management issues- Relative bradycardia attributable to impaired sympathetic nervous system in SCI above T6; occasionally requires pacemaker placement- Hypotension attributable to systemic vasodilation resulting from impaired sympathetic drive- Venous stasis can result in deep venous thrombosis or pulmonary embolism- Orthostatic hypotension Functional mobility issues- Upper extremity range of motion, strengthening, and endurance within limitations of orthotics and medical management- Bed mobility (including side to side, supine to prone to supine, supine to sit)- Wheelchair mobility (including forward and backward propulsion, turning, uneven terrain, curbs, ramps, hills)- Transfers (including bed to wheelchair to bed, wheelchair to toilet to wheelchair, wheelchair to bath to wheelchair, wheelchair to floor to wheelchair, wheelchair to car to wheelchair) Activities of daily living including feeding, grooming, dressing, bathing, toileting- Bladder management training, typically with intermittent catheterization or alternative- Bowel management training, typically with suppositories and digital stimulation or alternative- Skin management training with monitoring and pressure relief techniques Equipment evaluation for personal care, mobility, and public accessibility- Home and vehicle evaluation for accessibility- Psychological and social adjustment to SCI- Introduction to vocational and recreational opportunities for persons with SCI

Conclusion

Chronic Bronchitis and emphysema affect different parts of the lung. Cigarette smoking is THE major risk factor for COPD FEV1 is a reliable and easy measure to help diagnose COPD

Pathophysiology of osteoporosis

Changes in bone result from the continual process of bone resorption and bone formation—known as bone remodeling(healthy).- Bone remodeling does the following:• Maintains the architecture and strength of the bone• Regulates calcium levels• Prevents fatigue damage Pathophysiology- Bone resorption exceeds bone formation- Affects bones with a higher proportion of cancellous bone• Vertebrae• Femoral neck- Can cause compression fractures of vertebrae, wrist, hip, pelvis- Can lead to kyphosis and scoliosis (abnormal curvature of the spine) Two most important factors in the development of osteoporosis: are- Amount of peak bone mass attained- The rate of bone loss • Peak bone density (or peak bone mass)—the highest amount of bone mass attained during life (18-20 yrs old)

Exercise testing referral

Children have many conditions that may elicit a referral for exercise testing, including but not limited to:- Asthma- Cystic fibrosis- Diabetes- Obesity- Various forms of heart disease Clinical exercise testing of children may be difficult.- Children's body size for testing equipment may be problematic (equipment designed for adults).- Their peak performance may be poor.- Their attention span tends to be short and they may have poor motivation during exercise testing, most often with longer exercise protocols. The American College of Sports Medicine offers the following guidelines concerning exercise testing for children:- Exercise testing for children is not indicated unless there is a health concern.- The testing protocol should be based on the reason the test was requested and the capabilities of the child. Children should always be familiarized with the test modality and protocol before the actual test; this will help to reduce test anxiety as well as increase the chances for success of the exercise test.• A treadmill and a cycle ergometer should each be available for exercise testing.• Children are psychologically and emotionally immature and may require more motivation and support than older people to complete the exercise testing.

Signs and Symptoms in children

Children may present with a variety of signs and symptoms that would warrant the use of exercise for evaluation, as an aid diagnosis, or as a part of a treatment plan.• The signs and symptoms may not be very different from what we see in adults:- Shortness of breath, chest pain, feeling faint, dizziness, syncope, unusual fatigue, and exercise intolerance.

More exercise testing

Children should always be familiarized with the test modality and protocol before the actual test; this will help to reduce test anxiety as well as increase the chances for success of the exercise test.• A treadmill and a cycle ergometer should each be available for exercise testing.• Children are psychologically and emotionally immature and may require more motivation and support than older people to complete the exercise test. Mode- Treadmill- Cycle ergometer- Arm ergometer- It is particularly important to have an ergometer that can be adjusted appropriately to the child's size.

COPD 1 (19-1/18)

Chronic Obstructive Pulmonary Disease(COPD)American Thoracic Society (ATS)Presence of airflow obstruction that is attributable to either chronic bronchitis or emphysema. Cystic Fibrosis is technically not a COPD but displays similar symptoms. Two types Chronic Bronchitis• Productive Cough Most Days• 3 Consecutive Months• 2 Consecutive Years• inflammation and excess mucus Emphysema• Abnormal permanent enlargement of the respiratory bronchioles and the alveoli• air spaces distal to the terminal bronchioles• Accompanied by the destruction of the lung parenchyma without obvious fibrosis. alveolar membrane breaks down.

Fibromyalgia

Chronic pain syndrome affects around 5 million adult Americans Not a form of arthritis but may easily be confused with arthritis because of its associated widespread musculoskeletal pain and so-called trigger or tender points Affects at least 2% of adult Americans, women more than men (ratio 7:1)• Diagnostic criteria include widespread pain in combination with tenderness at 11 or more of the 18 specific tender point sites. Aerobic exercise is beneficial and can improve aerobic capacity and physical function; global well-being; possibly pain and tenderness; and possibly sleep, fatigue, depression, and cognition.• Recommendations for minimizing pain with strength training include limiting eccentric exercises, performing upper and lower extremity training on alternate days, and resting between repetitions.

Pathophysiology of COPD

Cigarette smoking is the primary risk factor and affects the bronchi, bronchioles, and parenchyma (alveoli).• Spirometry (airflow) - not altered until the bronchioles and parenchyma are damaged (mucus plugging, inflammation, and increased smooth muscle) Spirometry characteristics for COPD:• Reductions in Forced expiratory volume in 1 second (FEV 1 ), strong predictor of mortality rate FEV 1 /forced vital capacity (FVC)• Mid expiratory flow rate Alveolar damage (emphysema):• Loss of the tethering or supportive effect• Diminished elastic recoil of the lungs• Leads to reduction in airflow and increases the work of the respiratory muscles and the time needed for expiration• Result: hyperinflation of the lungs and flattening of the diaphragm COPD patients have skeletal muscle dysfunction; 20% to 30% reduction in quadriceps strength• Reduction in type I fibers and increase in type II fibers• Fiber changes may be related to hypoxemia, lack of physical activity, and hypercapnia• Other areas of concern in COPD patients is malnutrition (see practical application 17.1 in the book)• FEV1 reduction of 70 versus 20 to 30 ml/yr in smokers versus healthy nonsmokers

More exercise testing for SCI

Common absolute contraindications:-Autonomic dysreflexia resulting from recent fracture• may precipitate spasms or increase the risk of fatty emboli, hypertensive crisis, or cerebrovascular events-Orthostatic hypotension, with the risk of syncope-Recent deep vein thrombosis or pulmonary embolism-Pressure ulcers, which increase the risk of autonomic dysreflexia during exercise Active tendinitis (e.g., rotator cuff, elbow flexors, wrist flexors/extensors)-Chronic heterotopic ossification-Peripheral neuropathy-Pressure ulcers of grade 2 (blistering)-Spasticity Special considerations Cardiovascular: empty bowel and bladder Strength clinical measures: manual muscle testing for weakest muscles, if expecting neurological recovery.

Treatment for SCI

Common issues requiring treatment- Blunted autonomic responses- Blunted hormonal responses- Upper extremity overuse syndrome- Bowel function- Depression- Pressure ulcers- Thromboembolism- Other

Exercise testing for stroke

Contraindications for stroke to consider- Relative: Because hemorrhagic stroke is frequently related to HTN, it is important to assess pre-exercise resting BP—systolic pressure <200 mmHg and diastolic pressure of 110 mmHg.- Absolute: Due to the high incidence of CAD with ischemic stroke, it is important to assess for unstable angina. Not all stroke patients can complete a traditional GXT to assess functional capacity- Alternatives—submaximal testing using lactate, ventilatory threshold, or oxygen pulse- Ability to achieve a walking speed >0.5 mph for 30 indicative that the individual can complete a treadmillGXT with handrail support as needed- Completing a treadmill GXT at a self-selected speed with2% grade increase every 2 min appears appropriate for a stroke patient who can walk on a treadmill Alternatives to treadmill testing- Cycle ergometry in individuals who don't have the ability to walk due to a gait abnormality- Bridging—increased rate of bridging, which involves elevating the pelvis to a point of maximal hip extension (Tsuji and colleagues); the protocol uses 4min stages and increases the rate of bridges per minute from a starting point of 3 to 6, with 6 bridge per minute increases thereafter up to 24- Six-minute walk test to assess functional outcome of one's impairments, but not to assess cardiorespiratory fitness (score is limited by motor impairments)

Diagnostic testing of SCI

Electrodiagnostic studies- Assist in the diagnosis of SCI- Somatosensory-evoked potentials• Pinprick/light-touch tests- Assess motor function sensory levels- "Motor function sensory levels (pinprick and light touch) are assessed, and the injury is listed as complete if no motor or sensory function is spared at the S4 to S5 level; any preservation of function spared at these sacral levels denotes an incomplete SCI." Body composition analysis- DXA alone is not the gold standard for SCI because it does not account for hydration status- Use four-compartment modeling• Fat, protein, water, mineral- Can use DXA to assess bone mineral density (or radiographs)• Blood tests- Lipid profiles- HbA1c and fasting glucose

COPD Summary (Emphysema vs. Chronic Bronchitis)

Emphysmea - Etiology: smoking, genetic - Location pathophysiology: alveoli, destruction of walls, loss of elasticity, impaired expiration, barrel chest, hyperinflation. - Cough/Dyspnea: some coughing, marked dyspnea. - Sputum: little - Cyanosis: no - Infections: some - Cor pulmonale: perhaps late RV dysfunction Chronic bronchitis -Etiology: smoking, air pollution - Location pathophysiology: bronchi, increased mucus, glands, and secretion, inflammation, infection, obstruction. - Cough/Dyspnea: early, constant cough, some dyspnea - Sputum: large amount, purulent -Cyanosis: yes -Infections: frequent - Cor pulmonale: common

Exercise prescription and training for SCI

Exercise prescription focuses on typical parameters: aerobic, resistance, ROM• Best if developed by a multidisciplinary team:- Clinical exercise physiologist (physiological responses)- Physical therapist (orthopedic limitations)- Physician (medical concerns and oversight)• Those with complete SCI should begin exercise training under supervision. Special considerations- exercise in temperate climate due to autonomic dysfunction effects on temperature regulation- care with seating and positioning: autonomic dysreflexia, spasticity, musculoskeletal trauma- facility accessibility- transportation-Initial stages should focus on developing the habit of exercise Adapted or adaptable equipment necessary for appropriate and safe exercise training:- Abdominal binders and leg wraps- FES-LCE systems Cardiovascular exercise- Tetraplegia: aerobic exercise may have little effect on the cardiovascular system. "Central cardiovascular adaptations, such as increased peak stroke volume, cardiac contractility, or cardiac output, have not yet been documented."- Hypokinetic Circulation:• aka "circulatory hypokinesis"• smaller increase in CO per unit increase in VO2 during exercise- High heart rate- Limited increases in cardiac contractility, stroke volume, blood pressure

Conclusion for COPD

Exercise testing and training any patient with chronic disease involves individualization of treatment based on all patient information available. It is crucial that the exercise professional be familiar with each patient's history before the development of an exercise program and that the program be individualized for each patient.

Conclusions

Exercise testing and training are important in both the prevention and treatment of patients after stroke• Physical therapy alone is not sufficient to increase aerobic capacity in stroke patients• The clinical exercise specialist/physiologist likely be in increasing demand as an allied health professional in the care of patients at risk for stroke or after stroke- This is especially true for post-stroke patients with only minimal related loss of motor function

more clinical considerations of multiple sclerosis

Exercise Tolerance- Fatigue• Spasticity meds may exacerbate fatigue and exercise tolerance• Skeletal muscle fatigue may limit exercise tolerance; limits the ability of GXT to diagnose CHD.• Autonomic dysfunction may affect HR and BP response to exercise Classify by Kurtzke Function Systems- Can assist in objectively rating an individual's ability to perform certain exercises- See table 27.3 for the Kurtzke Functional Systems.• Additional functional assessments during and after exercise "can provide useful insight as to the patient's functional level over time (table 27.4)." Diagnostic testing- The goal is to categorize into definite, possible, and not MS categories.- Typical tests• Medical history—assess past and present symptoms• Neurological exam—assess the health of nervous system• MRI—can determine spatial and temporal distribution of lesions• Evoked potential response—measure electrical response to sensory stimulation (visual, auditory, somatosensory)• Cerebrospinal fluid analysis—assess for immunoglobulin level and oligoclonal bands• Blood tests—to rule out other diseases Figure 26.1 Magnetic resonance image depicting multiple (arrows) areas of demyelination within the white matter of the brain in a person with MS.

Exercise prescription for aging

Exercise Training Caveats Specific to the Elderly- The elderly population is very heterogeneous, and thus individual exercise prescription development is necessary For the frail, emphasis might be on strength gains and balance before cardiovascular conditioning.• Appropriate exercise intensity is relative to individual capabilities- Tailor exercise program to the individual's circumstances and preferences.• "Exercise adherence often ultimately relates to an individual's affinity for the activities themselves."- Warm-up and cool-down should be highly emphasized Resistance Exercise- Focused on large muscle groups- 10 to 15 reps per set- One set is beneficial, while two or three sets may provide increased benefit (20 to 30 min total)- Separate sessions by 48 h for full recovery- Intensity• Moderate: 5 or 6 on 10 point scale• Vigorous: 7 or 8 on 10 point scale- Progress every 2 to 3 wk as indicated- Consider increased reps with less weight for muscle endurance improvement Range of motion exercise- Minimum of 2 d/wk but daily is OK- Static stretching preferred over ballistic or bouncing stretching- 10 to 30 s hold per rep; 3-4 reps per exercise- Remember to breathe- Focus on major joints- Warm up; may be desirable to perform after other exercise• Balance training- Important for independent living- three times per week, "but formal dosing recommendations remain ambiguous."- Examples: various walking activities, balance balls, Tai Chi or yoga• See table 30.4 for exercise prescription review. (Nustep Nu-step Nu step is the mode primarily used for aerobic training in elderly individuals)

Treatment and pharmacology for osteoporosis

Exercise can help increase or maintain bone mass• Several non-pharmacologic and pharmacologic agents are available to increase bone mass or slow loss:- Calcium supplementation- Vitamin D supplementation- Rx - next slide Hormone replacement, estrogen/progesterone chronic use increases the risk for cardiovascular disease CVD

Conclusion for asthma

Exercise limitations and decreased levels of fitness frequently are noted in patients with asthma.• Exercise limitations and fitness levels can be improved in those patients treated with an appropriate medication and exercise regimen.

Exercise Testing for COPD (19-1, 18)

Exercise testing provides an objective evaluation of the functional capacity of the COPD patient.• Can be used to:• Detect COPD and cardiovascular disease• Follow the course of the disease• Detect exercise hypoxemia• Determine the need for supplemental oxygen during exercise training• Prescribe exercise• Evaluate the response to treatment Variables that should be assessed BP• ECG• Arterial oxygen saturation• Dyspnea (Borg scale)• If available, obtain gas exchange and ventilatory measurements. See table 18.1 on exercise testing recommendations, procedures, and guidelines for the COPD patient.• Exercise test response will vary based on the severity of the disease. NO ARM ERGOMETER TESTING for cv considerations.

Continued clinical considerations for multiple sclerosis Treatment for multiple sclerosis

Exercise testing- Musculoskeletal testing:• Standard testing typically OK• 1RM can be used, but modify if significant weakness- Flexibility:• Use goniometer• Can be quite inflexible due to disease progression and level of spasticity• Seated stretching to decrease fall risk Exercise in persons with MS improves impaired bladder and bowel function, positively affects psychological health and quality of life, improves muscle weakness, and potentially reduces symptomatic fatigue."

Exercise testing for osteoporosis (24-2)

Exercise testing- The aims are to aid in the diagnosis of coronary artery disease and to determine an appropriate exercise prescription- Must be carefully evaluated to make certain that any potential benefits outweigh the risks• Contraindications- The impact associated with exercise testing could lead to fractures, even in low-intensity protocols such as walking or cycling- Osteoporosis and osteopenia: avoid exercise testing that involves high-impact skeletal loading such as jumping and stepping- Strength testing should avoid twisting movements of the spine and neck

Aging 1

Gerontology- Study of the aging process- Typically from maturity through death- Geriatrics is medical field for patients 65 yr and older- Rate of changes of physiologic processes and organ systems varies by age, genetics, the environment, disease, and lifestyle choices

Conclusion

Goal is to provide exercise therapy to enhance or maintain daily activity levels• There are no exercise training-specific guidelines for those with MS• Must adjust exercise prescription to avoid excessive fatigue or danger from improper use due to disease progression• Apply exercise to also affect psychological health, functional capacity, mobility, and quality of life

Exercise training for SCI

Goals of exercise training—attain physicalability to perform ADLs including:• Feeding• Grooming• Hygiene• Dressing• Bathing• All transfers• Toileting• Mobility• Decrease the physical strain of ADLs withimproved fitness

Exercise prescription for multiple sclerosis

Goals- Maintain ability to perform ADLs- Provide general health benefits to reduce risk of diseases related to deconditioning- Reduce symptoms- Improve QOL• No MS exercise training guidelines currently exist- Standard guidelines, as long as exercise does not exacerbate symptoms and is safe (eg fall risk)- Avoid strenuous exercise during periods of symptom exacerbation in relapsing-remitting MS Cardiovascular- Moderate intensity- 5 d/wk- >30 min/d• May be accumulated in shorter bouts of 10 or 15 min- Stationary cycling (legs, arms, or both), walking, water activities (swimming, aerobics) most common modes- Progress based on individual heart rate response• Train between 40%-70% of VO2 reserve- Pre-cooling?. Resistance- Important for mobility and independent living- Perform >2 d/wk, never 2 consecutive days- Weightlifting, stair climbing, and elastic bands are common modes. Aquatic resistance exercise maybe useful.• Modify based on fall risk- 8 to 15 repetitions per set; should go to volitional fatigue- Range of motion and ability to perform certain exercises may be limited Balance and coordination- NIH recommends 5 exercises• Standing on one foot• Walking heel to toe• Balance walking• Leg raises to the back• Leg raises to the side• Range of motion- General flexibility improvement suggested• May reduce spasticity, improve posture and balance- Gentle, slow, and prolonged (30-60 s)- Some with severe MS may require assistance with passive stretching

Treatment of Arthritis

Goals:- Reduce disability- Restore physical activity- Improve body composition- Control symptoms and reduce pain• Treatment focus is now on movement:- 69% of those with RA are inactive.- Contrary to popular belief, exercise does not increase risk for OA, nor does it exacerbate joint damage in RA patients- Exercise is beneficial and safe (based on numerous studies)for individuals with arthritis Non-pharmacologic• Education• Physical and occupational therapy• Braces and bandages• Canes and other walking aids• Shoe modification and orthotics• Ice and heat modalities• Weight reduction• Avoidance of repetitive-motion occupations• Joint irrigation and joint surgery (in select circumstances) Pharmacologic therapies for arthritis vary according to the form of arthritis, and from individual to individual according to response• Analgesics (e.g., aspirin)• Anti-inflammatories (e.g., NSAIDs)• Intra-articular injection of corticosteroid for treating OA flar

Exercise Prescription of arthritis

Goals:• Maintain or improve physical function by maintaining or improving muscle strength, cardiovascular fitness, and ROM• Improve body composition (i.e., restore muscle mass and reduce fat mass) and, when appropriate, reduce body weight Reduce the risk of comorbidities such as CVD and osteoporosis• Reduce inflammation and pain• Prevent contractures and deformities

treatment for asthma

Goal—control the overall disease process to reduce impairment and reduce ongoing risks associated with disease• Classification of severity useful for initial treatment but not ongoing treatment• Focus on asthma control, defined as the degree to which the manifestations of the disease are minimized by therapeutic interventions and the goals of therapy are met and should be assessed and monitored to adjust therapy• See table 19.2 on components of asthma severity by clinical features before treatment.

Exercise training for multiple sclerosis

Important issues:- Thermoregulation is poor.• Good hydration and fluid replacement during and/or after exercise Controlled temperature in room• Consider electric fan for more convective cooling• Consider precooling- Fatigue may occur earlier than in healthy populations.- Watch for balance and coordination issues for safety Cardiovascular- Peak VO2 and respiratory muscle function are lower in MS• May be due to lower levels of physical activity• May increase risk of diseases associated with sedentary lifestyle- Endurance training positively improves functional capacity• ↑VO2 peak• ↓ triglycerides• ↑ fatigue tolerance• ↑ health perception and quality of life• ↑ walking speed and endurance- May minimize illness due to sedentary living Resistance- Strength and power are lower in MS• ↓ MU activation• ↓ MU firing rate• Mixed data on whether there is compromised contractile function and muscle size• Spasticity and coactivation may compromise motor performance Physical inactivity may lead to strength loss- Both isometric and dynamic strength can be improved Neural adaptations and hypertrophy- Improvements noted for isometric and dynamic strength and power, Timed Up and Go test, walking speed, gait kinematics, muscle endurance, fatigue, and balance Balance- Balance is negatively altered due to a longer double-support phase, loss of strength, and gait alteration.- Resistance training and specific balance training (Bosu ball, large balls, and so on) can improve balance.

Exercise Testing for Arthritis (23-2)

Individuals with RA have an increased risk of CVD- Heightened risk is attributed to the systemic inflammatory nature of RA- Those who are sedentary for extended periods, and have other risk factors may also be at risk• Cardiovascular testing may be needed in patients who are at risk of CVD:- A symptom-limited exercise test using cycle ergometry is preferred- Exercise testing procedures for people with arthritis are similar to protocols recommended for elderly and deconditioned people(i.e., tests should have small incremental increases in workload)• Recommendations for cardiovascular exercise testing are outlined in Table 22.3 (next slide) Use a treadmill for those with minimal to mild joint impairment Special considerations for the treadmill: with the patient using handrails for support, use equations to calculate VO2 max Use cycle ergometry for those with mild to moderate lower extremity impairment Use arm ergometry for those with severe lower extremity impairment Musculosk

Pathophysiology of asthma

Inflammation is the primary issue that leads to airflow limitations, which include bronchoconstriction, airway hyperresponsiveness, and airway edema.• Asthma involves the interplay between a number of host (innate immunity, genetics)and environmental factors (airborne allergens, viral respiratory infections). Inflammation most pronounced in the medium-sized bronchi• CD4 (T cells) lymphocyte believed to promote inflammation by the eosinophils and mast cells• Structural changes (subepithelial fibrosis via deposition of collagen fibers) Hypertrophy and hyperplasia of the airway smooth muscle• Angiogenesis (proliferation of new blood vessels)• Increased mucus hyper secretion• Airway hyper responsiveness ultimately leading to airway narrowing See figure 19.1 for illustrations of normaltissue, swelling, and remodeling. (pg 9 asthma 1)

more clinical considerations for aging

Musculoskeletal testing- Not commonly necessary for those beginning strength training- Useful to set a baseline for future evaluations and to set exact workloads for training if desired- 1RM or modified (5RM or 10RM) test suggested- Aging is associated with loss of Type II muscle fibers, so decreases in power with age are typically larger than decreases in strength.- Ideally assess strength, power, and muscular endurance. Range of motion testing- Standard assessments with goniometer, tape measure, and sit-and-reach box recommended- Assess large joints of back, hips, shoulders, elbows, and knees Treatment- Multiple chronic diseases: "Senior patients are inherently more unstable and management decisions more complex."- Elderly people are often on many medications(polypharmacy).• Many medications for cardiovascular disease, hypertension, diabetes, and arthritis, which are common"...greater likelihood of unintended iatrogenic consequences." Increasing physical activity and intentional exercise is required for almost all elderly individuals.• "...sedentary lifestyles tend to worsen medical instability and accelerate progression into frailty and associated susceptibility to weakness, falls, diminished independence, and reduced quality of life."

Conclusion

NSLBP is one of society's most common problems.• Pain, leg numbness, and leg weakness are common symptoms

Scope of NSLBP

NSLBP represents the most expensive musculoskeletal affliction and industrial injury and is the most common cause of disability for Americans under the age of 45.• Nearly 65 million Americans report a recent episode of back pain. Some 16 million adults (8 percent of all adults) experience persistent or chronic back pain.• Potential confounding variables are age, depression, and obesity.• Peak NSLBP occurs between 45 and 60 yrs of age.• Chronic back pain direct cost estimates in the United States is $100 billion each year, including lost wages and decreased productivity

Treatment for multiple sclerosis

No cure for MS• Goal is to reduce or slow effects of MS and treat symptoms• Several FDA-approved medications for "disease modification"- eg Interferon β-1a and β-1b, glatiramer acitate• See table 26.7 for some common medications used for persons with MS.- Spasticity: eg Botox, Baclofen- Tremor- Bladder dysfunction- Depression- Pain- Corticosteroids for inflammation reduction Attempt to start "immunomodulatory" therapy as soon as possible to prevent disability.• Drugs that affect MS directly- Interferon-b (INF- b)• Types: 1a and 1b• ↓ attack rate in RRMS, slows progression and severity- Mitoxantrone (chemotherapy drug)• Used to inhibit T cell, B cell, and macrophage effects on myelin• ↓ attack rate in RRMS- Glatiramer Acetate• Synthetic protein mimics myelin protein• May act as a decoy for T cells that attack myelin protein• Corticosteroids - decrease attack duration; do not affect severity, disability• Other drugs to treat secondary complications: spasticity, fatigue, depression, erectile dysfunction, bowel function, urinary tract infections, bladder spasms. Consider:- Physical therapy- Occupational therapy- Speech pathology- Cognitive specialists- Complementary treatments (e.g., Chinese medicine, relaxation, yoga), although the research on these is very limited- Assistive devices—canes, crutches, orthoses, and the like "Exercise in persons with MS improves impaired bladder and bowel function, positively affects psychological health and quality of life, improves muscle weakness, and potentially reduces symptomatic fatigue."

(NSLBP 1)

Nonspecific lower back pain (NSLBP):• Pain experienced in the lumbosacral region in the absence of major identifiable pathology.• The pain is typically diffuse and located in the areas of the back below the ribs and above the distal fold of the buttocks.

Pathophysiology of Arthritis

Osteoarthritis (OA)- Degradation of joints- Affects articular cartilage and subchondral bone- Results in a host of processes leading to joint space narrowing, loss of cartilage, bone-on-bone rubbing, ligaments train/weakening- Hands, feet, spine, hips, knees, and shoulders are most often affected• Loss of normal range-of-joint motion• Pain with weight bearing and use- Exact etiology of OA is not known;- However, there is some genetic link- Obesity and joint injury or trauma are known to predispose an individual to OAJoint space Rheumatoid arthritis (RA)- Progressive joint damage- Result of a chronic autoimmune disorder• Systemic inflammation- Typically affects synovial joints• Hands and feet most often affected- More likely in females• Familial predisposition RA occurs due to an abnormal immune response• Rheumatoid factor (RF = autoantibody against IgG); anti-citrullinated protein antibodies, and anti-nuclear antibodies(ANA) form antigen-antibody comple

Osteoporosis

Osteoporosis occurs in two forms Primary- Idiopathic- Age 50+ years- Decreased sex hormones (estrogen deficiency = rapid loss of bone mineral density)- Decreased calcium intake• Secondary- As a complication of another disorder:» Hyperparathyroidism = é PTH release = ê calcium in bone = é calcium in blood» Cushing's disease = Adrenal glands produce excess cortisol = bone loss Bone mineral density During the pre-pubertal and adolescent growth years, bone mineral density (BMD) (also known as bone mass) increases in healthy individuals Once people are >40 years of age, small amounts of bone mass are lost each year (leads to primary osteoporosis)- In women, bone loss accelerates during a 3-5 year period after menopause- Estrogen deficiency in women for any reason at any stage of life results in rapid bone loss

Children 1 Scope of children

Pediatrics is the branch of medicine concerned with children and their diseases. Children are the population between infancy and adolescence. Children do not, in and of themselves, constitute a clinical population, clinicians need to know about the exercise responses of children and how they may influence exercise testing, exercise training, and exercise prescription.• Children can present with many different clinically relevant signs and symptoms, diseases, and disorders. In recent years the number of children who are overweight or obese has increased dramatically.• Children are now being diagnosed with chronic diseases that we often see in adult clinical populations, such as type 2 diabetes, hypertension, dyslipidemia, and metabolic syndrome. Children may present with a variety of conditions (cardiovascular, pulmonary, musculoskeletal, neurological).• It is, therefore, appropriate for clinicians to use exercise with children similarly to the way they do in adult clinical populations, with an understanding of the underlying differences.

Conclusion

People with SCI tend to be sedentary and are excellent candidates for regular exercise training.• Because of the many potential medical and possible exercise-related problems, a team approach to evaluation, exercise prescription development, and exercise training guidance is recommended.

Conclusion

Prevention should be the primary focus.• Bone must be loaded to induce growth and prevent atrophy.• Balance training should be incorporated for individuals at risk of falls.

Pathophysiology for SCI

Primary injury can damage neural tracts, cell bodies, and vascular structures that supply the cord.• Secondary injury occurs because of hemorrhage and local edema within the cord.- Can compromise vascular supply, resulting in local ischemia• Infarction of the gray matter occurs within 4 to 8 hours after injury if blood flow cessation persists.• Necrosis can enlarge over one or two vertebral levels above and below the level of injury• Injury obstructs neural transmission → Loss of somatic and autonomic control at sites innervated below level of lesion Somatic nervous system disruption- Somatic: motor and sensory neural pathways• Brain to Body- Complete SCI interrupts transmission of these signals, and voluntary movement and sensory perception are absent below the lesion.• Autonomic nervous system disruption- Sympathetic and parasympathetic- Control HR, SV, BP, blood flow, ventilation, thermoregulation, and metabolism.

Conclusion

Properly performed exercise is safe and effective for individuals with OA, RA, and AS.- In the short term, exercise• increases strength,• increases aerobic capacity,• increases range of motion,• improves body composition,• enhances physical function, and• attenuates stiffness and often pain.

Exercise test protocols in children (children 2)

Protocols for adults can usually be used for children.• Occasionally adjustments will be needed to accommodate the earlier onset of fatigue in children (i.e., stage time may be shortened), or the large increases in metabolic equivalent (MET)values from stage to stage may be lessened to accommodate children in cases in which large jumps in METs could be discouraging and affect motivation to complete the test. If general health or fitness assessment is all that is needed, the use of the American Alliance for Health, Physical Education, Recreation, and Dance FITNESSGRAM is suggested.• Most of the assessments in this battery airfield-based tests but should be used from only a functional, not a diagnostic, point of view. Participation in these field-type tests should be limited to children who are free of contraindications to exercise participation or testing.

Exercise testing for SCI

Rationale:- Establish a relationship between fitness and return to work- Determine how fitness level changes overtime- Determine progress in rehabilitation- Assist exercise prescription- Diagnostic for CHD• Field testing:- Easiest and least expensive to perform- Low relationship to peak VO2, possibly due to variability in testing conditions Lab testing- Modes:• Wheelchair• Upper body ergometry• Functional electrical stimulation (FES)- Assessment:• Intermittent BP and ECG determination• Low/moderate work rate progressions each 2 to 3 min(~25 W per)• Functional (CPX or estimated work rate) versus diagnostic testing (ECG, echo, or radionuclide)- For people undergoing testing to rule out ischemic heart disease, post-exercise echocardiography or nuclear imaging studies may improve the sensitivity of the exercise stress test."- VO2peak values range from 12 ml/kg/min in tetraplegia to > 30 ml/kg/min in low level paraplegia• Peak power ranges from 30 to 100 watts Accommodations:- Devices for improved grip and reduction in risk of various injuries- Trunk stabilization- "Abdominal binders and leg wraps may improve pulmonary dynamics and venous return, which reduce the risk of hypotension."• Risks:- Hypotensive response• Be prepared to halt exercise and tilt back to elevate lower extremities above the level of the heart, aiding venous return.- If resting SBP < 100 mmHg, watch closely for hypotensive response even with binders and leg wraps

Indications of severe spinal or general pathology

Red flags: under 20 or over 55 sig med history: carcinoma, systemic steroids, HIV, high-impact trauma, thoracic pain, persistent pain systemic unwellness: unexplained weight loss, fever, nausea, vomiting, current/recent infection, etc. 24.1 table Inflammatory disorders

more exercise prescription for stroke

Resistance exercise- Resistance training is an important part of an exercise prescription due to the neuromuscular compromise following a stroke.- ACSM's recommendations for strength training could easily be followed with some modifications in the mode of training.- Depending on the degree of muscular strength and endurance deficit, consider low-resistance modalities, such as elastic bands, body weight exercises, and sandbags. For extremely weak individuals, consider exercises against gravity (e.g., shoulder and leg abduction).- It is important to focus on completing activities of daily living (e.g., stair climbing, chair stands, walking through obstacles ). Flexibility- Stroke patients can perform traditional flexibility exercises as outlined by ACSM.- Focus should be on all major joints, but special attention should be given to the paretic limbs, especially muscle groups that are experiencing a large degree of muscle spasticity.- Having a raised platform can be very useful because it assists patients' ability to lie down and return to a standing position after exercising.

Exercise prescription of osteoporosis

Several forms of exercise training have the potential to increase BMD as well as bone strength, but RT appears most beneficial.• Current experimental knowledge indicates that an osteogenic exercise regimen should include the following:- Load-bearing activities at high magnitude with few repetitions Create variable strain distributions throughout the bone structure (load the bone in directions to which it is unaccustomed).- Bone responds to loading in a site-specific manner(load joints that are at greatest risk for fracture such as hip, wrist, and lower back).- Exercise should be long-term and progressive.- Added benefit may result from dispersing loading activities throughout the day rather than completing the exercise all at one time. Cardiovascular training:• In older individuals, prolonged endurance training can increase fitness levels by 10% to 30%.• Endurance training can decrease cardiovascular disease risk factors such as hypertension and cholesterol.• Resistanc

Clinical considerations of multiple sclerosis

Signs and Symptoms- Visual impairments• Optic neuritis• Nystagmus- Motor function difficulties• Weakness - esp in lower extremities• Paresthesia• Spasticity—can affect range of motion and movement during high-speed flexion/extension- Tiredness/Fatigue• Often rated as the worst symptom• Worsens with heat• Cooling is a concern, especially with exercise Signs and Symptoms- Difficulties with walking and balance/coordination—may lead to falls• Assistive devices• Sensory difficulties play a role, but also weakness, spasticity, low activity levels- Psychological effects• Impaired cognition• Memory loss• Depression History and physical exam—assess for indicators that will affect the exercise prescription:- Review medical history and medications- Current symptoms- Assess• Balance• Flexibility• Strength• Endurance• Gait abnormalities• Vision may affect ability to exercise

Clinical considerations for stroke

Signs and symptoms of stroke- Memory loss and paralysis are two of the more consistent symptoms of stroke.- The brain damage causes paralysis on the opposite side of the body.- Right brain damage• Vision problems; awkward or inappropriate behavior- Left brain damage• Speech and language; slow and cautious behavior A patient suffering from acute stroke can have one of the following symptoms Numbness or weakness of the face, arm, or leg• Confusion, speech problems, and cognitive defects• Impaired bilateral or unilateral vision Impaired coordination and walking• Headache History and physical exam- Assessment of hemiplegic gait of stroke patients- Risk factors for CVD such as hypertension and diabetes frequently present.- Underlying CAD is often present; therefore resting electrocardiogram (ECG) and symptoms of ischemia should be assessed.- Most stroke patients develop mental depression during the post-stroke period, so a psychological referral may be necessary.

Clinical considerations of arthritis

Signs and symptoms- Joint• Pain• Stiffness• Effusion• Synovitis• Deformity• Crepitus (continued) History and physical exam- General assessment of joint range of motion, alignment, and function- Assess symptoms and family history (genetic component) for arthritis- Assess for extra-articular features specific to types of arthritis to aid diagnosis- Cardinal signs:• Redness• Swelling• Pain• Heat Diagnostic testing- There are no definitive tests or markers for arthritis diagnosis• However, some serum and synovial fluid tests can assist in arthritis type differentiation• For the presence of rheumatoid factor (RF)• For the presence of anti-citrullinated protein antibodies• For the presence of anti-nuclear antibodies• Joint imaging (X-ray, ultrasound, MRI) is also useful for determining the correct arthritis diagnosis• Table 22.2 summarizes The American College of Rheumatology diagnostic criteria for the classification of hip, knee, and hand OA, R

Clinical considerations of aging

Signs and symptoms- Pain often from arthritis- Dyspnea from deconditioning, heart or lung disease- Fatigue also from causes of dyspnea• History and physical examination- General H&P should be performed- Careful attention to typical conditions of aging (e.g., heart disease, arthritis, lung disease)- Always assess medications for proper use- Gait disorders assessed- Cognitive deficits assessed See table 30.3 for exercise testing review.• 12-lead ECG—can be used before a stress test- Assess for arrhythmias• Assess gait, balance, and range of motion• Exercise test- Most healthy older adults (controlled BP and no CV events)can begin low- to moderate-intensity exercise without a stress test- If high risk or desiring to do high-intensity (>60% peak VO2 )exercise, then perform- Also perform if older adult desires to begin resistance training Cardiovascular exercise testing- May cycle if issues with gait or pain- Lower-level protocols with smaller workload increases (e.g., ~ 1 MET per increment) may be prudent- Normal assessment of ECG (e.g., ST segment, arrhythmias), HR, and BP should be performed- Assess for symptoms of chest pain, dyspnea, and soon• 6-min hall walk test may be useful for assessing functional capacity if full stress test is not needed.

Clinical. considerations of osteoporosis

Signs and symptoms• Osteoporosis is asymptomatic, so the disease may go undetected until a fracture occurs Low bone mass can be assumed to exist in postmenopausal Caucasian women with low body weight diagnostic testing/screening should be performed in these individuals• A risk factor assessment can be conducted to determine the likelihood of the disease. Signs and symptoms• Osteoporosis is asymptomatic• Must consider possible risk factors:

(Stroke 29-1) Stroke

Stroke is a leading cause of both death and disability, making stroke patients a key population for the clinical exercise professional.• May be defined as:- A stroke is the loss of blood flow to a region of the brain. Ischemic Stroke- Loss of blood flow can occur because of a manifestation of cardiovascular disease, characterized by the buildup of atherosclerotic plaque in cerebrovascular arteries, ultimately resulting in an ischemic stroke.- In most ischemic strokes, a blood clot ultimately seals off the narrowing artery.• Hemorrhagic Stroke- Strokes can also occur because of excessive bleeding in a cerebral artery, also known as a hemorrhagic stroke. When a stroke occurs, neurons in the brain die, and the accompanying brain damage is the main cause of subsequent disability in stroke survivors• Brain damage can impair voluntary muscle movement, speech, vision, and judgment

Scope of stroke

Stroke is the second leading cause of death among all causes of death from cardiovascular disease 43.6 deaths are due to stroke per 100,000people, making stroke the third leading cause of death in the United States, behind coronary artery disease and cancer• One stroke occurs every 40 seconds in the United States Each year, almost 800,000 Americans will experience a stroke, and the vast majority of these will be new stroke events Stroke has a large influence on quality of life Indirect and direct costs for stroke are estimated at $73.7 billion for 2010 Gender: Overall, stroke incidence in men between 55and 64 years of age is 1.25 times that for women; but these differences become smaller with increasing age, to the point where incidence is higher in women over the age of 85- Estrogen replacement therapy can increase the risk of cardiovascular disease and stroke in post-menopausal women• Ethnicity: 3.9% of adult American Indians and AlaskaNatives have had a stroke, contrasted with 4.1% of African Americans, 2.7% of Caucasians, and 1.8% of Asians (see table 28.1, next slide)• Residents of southeastern states have a higher prevalence of stroke- Likely reflects cultural differences regarding diet and physical activity

Conclusion

Stroke remains a significant cause of death and disability• The two main types of stroke are Ischemic & and Hemorrhagic• TIA is a strong predictor of a "full" stroke.

(SCI 2) History and Physical Exam for SCI

The H&P should focus on the following:- Respiratory complications- Coronary artery disease- Peripheral arterial disease- Circulatory hypokinesis leading to hypotensive responses- Obesity- Type 2 diabetes mellitus- Pressure sores- Joint contractures Osteopenia- Smoking- Pressure-related skin damage- Neuropathic pain that might inhibit exercise- Medications- Indications of an overuse injury- Spasticity affecting exercise- Ossification limiting the range of motion- Overwork of upper body musculature, eg shoulder Men 40 or more years of age and women 50 or more years of age who have SCI should be considered at moderate risk for events during exercise, independent of traditional coronary artery disease risk.- Persons with SCI should obtain medical clearance from a physician knowledgeable in SCI care before performing regular exercise."

Pathophysiology of stroke

The atherosclerotic process that causes cerebrovascular disease, and ultimately an ischemic stroke, proceeds in the same fashion as plaque progression in coronary artery disease(CAD)- Refer to chapter 13(12) if you want to review the pathophysiology of CAD• The same traditional and nontraditional risk factors that are related to the development and progression of CAD and peripheral arterial disease (PAD) is associated with the development of ischemic cerebrovascular disease;- Diabetes mellitus, hypertension, atherosclerosis, systemic lupus erythematosus, history of transient ischemic attacks (TIAs), heart disease, obstructive sleep apnea- Smoking- Sedentary lifestyle- Congenital malformation of blood vessels- Increasing age (> 65 years of age) Ischemic strokes can be further categorized as thrombotic, embolic, and hemodynamic.- Thrombotic: occlusive thrombus develops in or outside an ulcerated plaque- Embolic: embolic strokes are typically from the carotid or other arteries that travel to the brain and lodge into a smaller cerebral artery or arteriole.- Hemodynamic: due to hypoperfusion, eg due to heart failure, hypotension, or occlusion of carotid or cerebral arteries

Conclusion/summary aging

The elderly are a quickly growing segment of the population in the United States and worldwide.• Most do not meet recommended guidelines for physical activity and exercise.• Most are on multiple medications to treat multiple medical conditions. Elderly individuals can make gains in fitness through regular exercise.• MVPA must be incorporated into the exercise programs of older adults.• Strength and muscle mass can be increased by resistance training.

Historical and physical examinations

The first step, as with adults, is to obtain a complete medical history and physical exam, along with any pertinent laboratory findings.• The information gleaned from this will help the clinician evaluate the child for risk of exercise, through stratification for level of risk, and to determine contraindications to exercise testing and exercise participation. The goal is to make sure that, in the case of exercise testing, the benefit of the testing outweighs the information to be gained by having the child attempt to complete the exercise test.

exercise prescription of nslbp

The focus of exercise in patients with NSLBP should be to reduce risk factors and minimize recurrences.• It is important to start at low levels of intensity, perform frequently, and progress as suggested by the ACSM guidelines.• Adherence to exercise could potentially be a problem with recurrent or chronic NSLBP.• Focus should be on promoting function improvements rather than reducing pain. General guidelines for exercise in people with NSLBP: Watch for the following complaints, which may suggest that the individual's condition is being exacerbated and that the exercise regimen should be reevaluated.1. Pain that is severe enough to halt exercise. Pain that persists for more than 3 h after cessation of exercise3. Pain that results in several days of disability or sleep disturbances

Physical exam of nslbp (nslbp 2) CEP role in nslbp

The initial focus should be on ruling out any serious neurological problem (sensation, motor function, and reflexes).• Assuming there are no serious neurological problems, further screening can include range of motion and flexibility testing (hamstring and hip flexor tightness, spinal flexion).• Ideally the examination should include aerobic testing and spinal and abdominal muscle strength testing, assuming the patient is not having a flare-up of pain. The CEP can perform palpation on common superficial anatomical landmarks to determine soft tissue irritability and help locate the source of pathology• A more thorough neuromusculoskeletal examination by a physician or physical therapist may be the appropriate referral.

Cerebral angiography

The middle cerebral artery(MCA) is a major artery that supplies blood to a large area of the cerebral cortex Left frontal lobe damage is anterior to the Sylvian fissure.The area of involvement corresponds to the left MCA superior division territory. The superior division of the MCA is one of the most common locations for embolic stroke.

special considerations for nslbp

The patient should obtain medical clearance for exercise. 2. Patients experience a fear-avoidance behavior when they believe that movement and activity will further damage or injure the spine.3. The exercise specialist should monitor for red flag findings. Deconditioning may be greater in these patients than in sedentary healthy individuals. This deconditioning may be more severe in smaller phasic muscle groups than in larger tonic musclegroups.5. The exercise specialist should use caution if loading through the spine and should consider unloading in some cases for pain management.6. Progression should be slow and initial exercise levels low.7. Smokers may need a slower progression.

Conclusion

The patient with SCI presents with unique obstacles and considerations to consider, in in order to provide safe and optimal exercise testing and training oversight.• C8/T1 and T5/T6 are critical lesion sites that will significantly alter function and physiological outcomes.• Cardiopulmonary, endocrine and thermoregulation are among the many systems (in addition to function) that may be affected by SCI

Signs and symptoms of NSLBP

The person presenting with NSLBP may complain of localized or generalized lumbosacral region pain of variable intensity, duration, and frequency. Radiating pain with a specific distribution of sensory changes, numbness, or lower extremity weakness can be associated with more serious pathology and can indicate specific tissue involvement.• It is important to rule out any more serious areas of concern ("red flags"); see table 24.1. Factors associated with NSLBP:1. Age, increasing into midlife2. Decreased hamstring and back extensor muscle flexibility and lower trunk muscle strength3. Obesity4. Smoking5. Whole-body vibration (prolonged driving)6. Heavy lifting or lifting with twisting7. Psychosocial and work environments Though recovery from NSLBP isrelatively high (75% to 90%) within a fewweeks, risk of additional episodes withina year is 60% to 75%. yellow flags pg 9 nslbp 1

Osteoporotic Vertebral Body (Right) Shortened by Compression Fractures, Compared to Normal Vertebral Body (Left)

The picture shows a compressed vertebral body on the right way smaller than the normal vertebral body.

diagnostic testing on osteoporosis

The primary means of assessing bone health is to measure BMD- Dual-energy X-ray absorptiometry (DXA) is the most commonly used technology for measuring BMD(DXA = low dose X-ray)- DXA measures the amount of bone mineral content per unit area (bone density measured by DXA is reported in g*cm 2-Bone density mineral density is often measured in the spine, hip, and wrist because these are the most common sites for fracture in osteoporosis

Contraindications to exercise testing in children

The safety of the child is always the first priority. As with adults, strict compliance with the contraindications to exercise testing ACSM's Guidelines for Exercise Testing and Prescription is warranted.• The criteria for test termination specified in the ACSM guidelines should be strictly adhered to. Paridon and colleagues for the American HeartAssociation 21 list three general reasons for terminating a clinical exercise test in children:- In cases in which diagnostic findings have been established; continuing the test would not produce any further information- Failure of monitoring equipment- Appearance of signs or symptoms indicating that continuation of the test would put the patient at potential risk for an adverse event

Scope of COPD

The third leading cause of death in the UnitedStates• estimated that 16 million people in the United States may be currently diagnosed with COPD• A major cause of morbidity and disability and a major health care cost, estimated at $50 billion in 2019• In 2017, the average length of stay for COPD was 4 days

conclusion

The three main forms of Arthritis are OA,RA, and AS.• All 3 have causes related to genetics.• OA is related to joint damage and obesity.• RA is a autoimmune disease.• AS cause not known, but appears to be autoimmune as well.

Conclusion

There are many considerations that clinicians need to take into account when working with children: Exercise testing protocols, testing modalities, and the Exercise responses of children, all of which may affect the exercise prescription for children with various clinical conditions. It is imperative for clinicians to keep in mind that children are not small adults and to treat children appropriately in order to maximize results from exercise testing and exercise programming.

Scope of aging

United States- Currently ~55 million ≥65 yr (58.5% female)• People ≥85 yr are the fastest-growing group of those over the age of 65 yr- By 2030, ~ 70 million >65 yr; ~ 20% of the US population- Currently ~9.5 million >80 yr (66% female)- Increased longevity (plus baby boom bulge)• Worldwide- Also experiencing aging population• An aging population applies pressure to the healthcare system- Expenditure up to four to five times that for younger• Physical activity levels are greatly reduced- Only 20% to 25% of those >65 yr exercise at least 30 min five times per week Aging increases risk of comorbid diseases- Hypertension- Cardiovascular disease- Heart failure- Atrial fibrillation- Stroke- Obesity- Diabetes- Dyslipidemia- Peripheral artery disease- COPD- Anemia- Arthritis- Sarcopenia

Scope of multiple sclerosis

Up to 400,000 diagnosed in the United States• Initial diagnosis typically between ages 20 and 50 yr- Women affected about two times the rate for men• Complex susceptibility- Related to genetic, infectious, and environmental factors• >50% unemployed within 10 yr of diagnosis- Lower functional capacity• Lifetime medical costs can top $1 million Factors that may contribute to the development of MS:1. Genetic factorsGenes of the Major Histocompatibility Complex (MHC)Interleukin 7 receptor gene (IL7R gene)2. Infectious FactorsHerpes simplex virusEpstein-Barr virus3. Environmental factorsSmokingGeographic location, sunlight/UVR exposure and possibly low Vitamin D (1,25(OH)2D3)

Exercise testing for multiple sclerosis (27-2)

Useful for baseline measures for future comparison effectiveness of exercise training- Provides information on individual responses and exercise tolerance- Cardiovascular testing:• Consider cycle ergometer if ambulatory impairment exists- Ergometer with arm poles - Airdyne, Nu-Step• Treadmill if safe walking is not an issue Watch for indications of overheating and fatigue; electric fans, fluid replacement, and cooler room temperatures help• Low-level protocols for most due to deconditioning Exercise Testing Cardiovascular testing (continued):• There are no specific contraindications to exercise testing that are unique to MS- Use chapter 5 guidelines Watch for attenuated BP response, especially if autonomic dysfunction has been diagnosed Note potential issues with temperature regulation and sweating; increased risk for hyperthermia- Use fans for cooling- Cooling packs- Fluid replacement• Pay attention to RPE• Skeletal muscle fatigue may limit exercise performance before cardiovascular limits A low-level protocol beginning with a 1 to 2 min warm-up period is recommended. Workload increases should occur at 10 to 25 W for leg ergometry and 8 to 12 W for arm ergometry and should be no more than 2 metabolic equivalents (METs) on the treadmill. Each stage should last approximately 2 to 3 min or until a steady state is achieved."

Conclusion

most people with nonspecific back pain can use exercise to restore function and decrease disability.• Programs should be initiated with modifications to accommodate individual impairments and should progress to maintenance programs that are as close as possible to those suggested for general fitness with healthy populations. Although people with back pain may need extra encouragement• Those who are able to do so can hope for considerable improvement in function and quality of life. Reassurance, education, and encouragement with self-management are important components of care• For most people, back pain is nonspecific and can be best managed with conservative yet active treatment strategies.

Signs and symptoms of multiple sclerosis

muscle weakness, fatigue, numbness, visual disturbances, walking problems, poor coordination, dizziness, depression, bladder/bowel dysfunction, etc. (pg. 12) SIGNS spasticity, optic neuritis, paresthesia, nystagmus,

What happens to residual volume in the lungs during an asthma attack?

swelling, mucus, alveoli filled with trapped air. tightening of smooth muscles.