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Thow 8 Maintaining Physical Activity in Cardiac Rehabilitation 195 Adrienne Hughes and Nanette Mutrie Appendix A – Glossary 220 Index 224 Contributors Gillian Armstrong BSc MCSP Senior Physiotherapist generic ventolin 100 mcg visa asthma treatment assessment questionnaire, Cardiac Rehabilitation ventolin 100 mcg visa asthma treatment with herbs, Glasgow Royal Infirmary, University NHS Glasgow, 16 Alexandra Parade, Glasgow, G31 2ER. John Buckley BPE MSc PhD Lecturer in Exercise Science, School of Health and Rehabilitation, Keele University, Staffordshire, ST5 5BG. Mhairi Campbell, BSc MCSP Cardiac Rehabilitation Co-ordinator, Health at Heart Centre, Royal Alexandra Hospital, NHS Paisley, Corsebar Road, Paisley, PA2 9PN. Hilary Dingwall BSc MCSP Superintendent Physiotherapist, Cardiac Rehabilitation, Victoria Infirmary University NHS Glasgow, Langside, Glasgow, G42 9TY. Kim Ferrier BSc MCSP Senior Physiotherapist, Cardiac Rehabilitation, Glasgow Royal Infirmary, University NHS Glasgow, 16 Alexandra Parade, Glasgow, G31 2ER. Linda Harley RGN Cardiac Specialist Nurse, Vale of Leven District Hospital NHS, Main Street, Alexandria, G83 OUA. Adrienne Hughes PhD Research Fellow, University Department, Human Nutrition, Yorkhill Hospi- tal NHS Glasgow, G3 8SJ. Fiona Lough MPhil MCSP Superintendent Physiotherapist, Cardiac Rehabilitation, University College London NHS, London, WC1E 6AU. Christine Proudfoot MSc MCSP Senior Physiotherapist, Cardiac Rehabilitation, Hairmyres Hospital NHS, East Kilbride, G4 8RG. Ann Ross MPhil MCSP Superintendent Physiotherapist, Western Infirmary University NHS, Glasgow, Dumbarton Road, Glasgow, G11 6NT. Joanne Semple BSc MCSP Senior Physiotherapist, Cardiac Rehabilitation, Southern General NHS Glasgow. Thow PhD MCSP Lecturer in Physiotherapy, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 OBA. Foreword EXERCISE LEADERSHIP IN CARDIAC REHABILITATION The benefits of cardiac rehabilitation are now well established in a wide range of patients with cardiac disease. A cardiac rehabilitation programme is a vehicle for the delivery of holistic secondary prevention and could be consid- ered as one method of chronic disease management. This includes risk factor modification, prescription of appropriate medication and health behaviour change. It therefore consists of a series of evidenced based interventions designed to optimise these outcome for patients. Although several meta analy- sis have shown mortality benefits from exercise based cardiac rehabilitation programmes, the evaluation of modern programmes should focus on the outcomes described above and hospital re-admission. Cardiac rehabilitation programmes should be tailored to the individual needs of the patient and extended to the broader group of cardiac patients a step change in their condition. Programmes must deliver evidence based practise and adhere to national guidelines. Audit of cardiac rehabilitation programmes, using nation- ally agreed datasets is essential to measure outcomes, inform programme development and secure resources. This book entitled Exercise Leadership in Cardiac Rehabilitation is a com- prehensive account of the exercise component of health behaviour change within cardiac rehabilitation. It is written by clinicians for clinicians and con- tains a practical guide to exercise prescription. The book will be invaluable to clinicians involved in cardiac rehabilitation and will facilitate programme development. MacIntyre Consultant Cardiologist RAH Preface Cardiac rehabilitation (CR) is now established as part of cardiac care in the UK, and is embedded in many government policies and national guidelines, with structured exercise as a key element. Over the last ten years there has been a radical shift in the provision of exercise-based CR in the UK. Govern- ment recommendations and national guidelines encompass the traditional post myocardial infarction (MI) and revascularisation groups, but also the older patient and the more complex cardiac groups, including those with heart failure and angina. The diversity of CR patients puts new and demanding chal- lenges on the exercise leader of CR. In 20 years of research and development of CR programmes in the UK I have become aware that there is no definitive book that provides physio- therapists and exercise professionals with a comprehensive resource on the exercise components and skills of constructing and teaching CR exercise. The objective of this text is to address the scope of knowledge and skills required of exercise specialists developing, delivering and teaching exercise-based CR programmes. The book is structured on an evidence-based theoretical frame- work, but also provides practical advice and suggestions based on the clinical experience of the contributing authors, thus providing physiotherapists and exercise professionals with a comprehensive practical text that can be used to plan, develop and deliver exercise-based CR in all phase of CR. The book starts with a chapter which overviews the historical and contem- porary context of CR, including a brief overview of the potential benefits of exercise in the CR patients.

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In Linear Kinematics we show how the position of external markers attached to the skin may be used to predict the position of internal landmarks such as the joint centres buy discount ventolin 100 mcg asthmatic bronchitis coughing up blood. In Centres of Gravity generic 100 mcg ventolin amex asthmatic bronchitis reasons, the joint centres are used to predict the positions of the segment centres of gravity; then, using numerical differentiation, the veloci- ties and accelerations of these positions are obtained. In Angular Kinematics, the anatomical joint angles are calculated, as are the angular velocities and accelerations of the segments. Finally, in Dynamics of Joints, the body seg- ment parameters, linear kinematics, centres of gravity, angular kinematics, and ground reaction forces are all integrated in the equations of motion (see Figures 1. Be aware that because we are dealing with gait analysis as a three-dimen- sional phenomenon, some of the concepts and mathematics are quite com- plex. However, our intent is that the material in this chapter be accessible to all persons who have passed a basic undergraduate course in mathematics. If you need a bigger challenge, a detailed and rigorous coverage of the material is presented in Appendix B. Body Segment Parameters A major concern for the gait analyst is personalising the body segment param- eters of the individual subject. By body segment parameters we mean • mass in kilograms of the individual segments (e. Moment of inertia is a measure of the way in which the mass is distributed about the axis of interest and has the units of kilogram•metre•metre (kg•m ). As you will see a little later in the chapter, we have chosen six segments: thigh, calf, and foot on both the left and right sides. We are making the assumption that these are rigid segments whose dimensions (and thus their segment parameters) do not change during the motion of interest. We all know, however, that the foot is not a single rigid segment and so you should be aware that any model has some limitations. We chose a 6-segment model for simplicity (and because virtually all gait laboratories do the same), but it is possible that in the future, biomechanical models will need to be more detailed. Problems in Estimation In attempting to estimate the body segment parameters for an individual sub- ject, there are various approaches that can be followed. These include • cadaver averages (Braune & Fischer, 1889; Dempster, 1955); • reaction board (Bernstein, 1967); • mathematical modelling (Hanavan, 1964; Hatze, 1980); • scans using gamma rays, axial tomography, or magnetic resonance imag- ing (Brooks & Jacobs, 1975; Erdmann, 1989; Zatsiorsky & Seluyanov, 1985); and • kinematic measurements (Ackland, Blanksby, & Bloomfield, 1988; Dainis, 1980; Vaughan, Andrews, & Hay, 1982). The cadaver averages are not suffi- ciently specific for individual subjects and very often only total body mass is used as a predictive variable. The reaction board technique is a long and tedious procedure which cannot estimate segment masses and centres of gravity independently. Mathematical modelling suffers from the disadvantage that too many variables (242 in the case of Hatze’s model) need to be measured, thus requiring an inordinate amount of time and patience. Scanning techniques, though potentially very accurate and detailed, must be seriously questioned as a routine method because of the radiation exposure and high costs. Although they have some appeal, kinematic measurements either have not yielded re- ANTHROPOMETRY, DISPLACEMENTS, & GROUND REACTION FORCES 17 sults to a satisfactory degree of accuracy or require too much time (Jensen, 1986). Anthropometry What is needed for estimating body segment parameters is a technique with the following features: • Personalised for individuals • Short time required to take measurements • Inexpensive and safe • Reasonably accurate We can describe a technique that we believe meets these criteria. Calf circumference Malleolus width Malleolus height Foot breadth Foot length There are 20 measurements that need to be taken — 9 for each side of the body, plus the subject’s total body mass, and the distance between the anterior superior iliac spines (ASIS). With experience, these measurements can be made in less than 10 minutes using standard tape measures and beam calipers, which are readily available. They describe, in some detail, the characteristics of the subject’s lower extremities. The question to be answered in this: Can they be used to predict body segment parameters that are specific to the indi- vidual subject and reasonably accurate? As mentioned earlier, most of the regression equations based on cadaver data use only total body mass to predict individual segment masses. Although this will obviously provide a reasonable estimate as a first approximation, it does not take into account the variation in the shape of the individual seg- ments. Prediction of Segment Mass We believe that individual segment masses are related not only to the subject’s total body mass, but also to the dimensions of the segment of interest. Spe- cifically, because mass is equal to density times volume, the segment mass should be related to a composite parameter which has the dimensions of length cubed and depends on the volume of the segment.

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Also the relationship between the electroencephalogram (EEG) and speci®c cognitive activities in VE can be investigated in a therapeutic session buy 100mcg ventolin overnight delivery asthma treatment cycle. Traditionally generic ventolin 100mcg overnight delivery asthma question, the radiologist interprets 2-D x-ray images of the patient to support medical decision making. Since the introduction of CT to the ®eld of diagnostic imaging, radiologists have gained experience in interpreting 3-D x-ray, nuclear, and MR images. These 3-D im- ages, however, are often visualized on a slice-by-slice basis rather than in 3-D, although fully 3-D applications have already been introduced. VE technology may provide a whole new repertoire of applications to diag- nostic radiology. All applications should depart from scanned patient data from which computer models are extracted and represented in VE. The main advantage of moderating patient data to the physician through graphic models may be that this type of representation is closer to looking at real body organs than are gray-level images. Physicians have become familiar with screening gray-tone images for faint ¯aws in structures, symmetry, brightness, etc. These tools allow them to interactively put markers at locations of interest without wasting the original patient data. Obviously, where telecommunication is ap- plied, some kind of human±system interface is needed, of which VE should be considered. Telemedicine can be applied for remote consultation (physician± physician and patient±physician). Remote diagnosis and surgery can be carried out by a specialist giving assistance to a nonspecialist in, e. Teletriage is de®ned as a special type of teleconsulta- tion, aiming at supporting the military physician in a war or crisis situation 2. Although the military physician is examining a casualty, he or she can report the ®ndings to a remote medical expert by voice. The medical expert, or a team of experts, can respond by pro- jecting instructions through VE technology onto the eye of the military physi- cian, freeing his or her hands. The physician is able to receive being instruction from specialists without having to be a specialist himself or herself. Linking the VE triage support system to electronic triage systems (ETS) based on picture archiving and communication systems (PACS) is yet another possibility (72). The need of advanced imaging tools in combat situations has already been reported (73). Eventually, remote surgery in a combat situation will be controlled by a surgeon in one of the higher echelons through teletriage support systems. Instructions from the specialist can be sent to the consulting physician through VE. The local and remote physicians can share the same virtual space in which the patient is present. In this way, the normal and pathologic anatomy can be projected onto the eye of the consulting physician while examining the patient. Hazardous environments can be found in war situations, and submarines and other navy vessels in full operation are considered to be inaccessible environments. Telemedicine can be particularly interesting helpful in peace-keeping missions of the United Nations in politically unstable areas with a poor medical infrastructures. Relatively simple sensor systems can be applied for human posture recognition, which, in turn, can be applied to interactive posture correction. A help-yourself posture correction session can help the disabled, althletes, and physically active in- dividuals, and can be integrated in the process of designing optimal equipment. From a pragmatic point of view, the great promise of VE lies in the fact that a long, complicated, and expensive trainingÐinvolving textbook studies, laboratory practice on animals, and eventually supervized practice on human subjectsÐmight be shortened, be carried out at a lower risk, and require far less involvement of scarce expert supervisors. Of particular concern in medical applications are issues related to verity, ®delity, and validity.

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Chapter 1 Principles of Evidence-Based Imaging 11 Assessment of Cost: All forms of economic analysis require assessment of cost generic ventolin 100mcg mastercard baby asthma symptoms uk. However buy 100 mcg ventolin with amex asthma treatment during attack, assessment of cost in medical care can be confusing, as the term cost is used to refer to many different things. Reimbursements, derived from Medicare and other fee schedules, are useful as an estimation of the amounts society pays for particular health care interventions. For an analysis taken from the soci- etal perspective, such reimbursements may be most appropriate. For analy- ses from the institutional perspective or in situations where there are no meaningful Medicare reimbursements, assessment of actual direct and overhead costs may be appropriate (32). Direct cost assessment centers on the determination of the resources that are consumed in the process of performing a given imaging study, includ- ing fixed costs such as equipment, and variable costs such as labor and supplies. Cost analysis often utilizes activity-based costing and time motion studies to determine the resources consumed for a single inter- vention in the context of the complex health care delivery system. Over- head, or indirect cost, assessment includes the costs of buildings, overall administration, taxes, and maintenance that cannot be easily assigned to one particular imaging study. Institutional cost accounting systems may be used to determine both the direct costs of an imaging study and the amount of institutional overhead costs that should be apportioned to that particular test. For example, Medina and colleagues (33) in a vesicoureteral reflux imaging study in children with urinary tract infection found a significant difference (p <. Summarizing the Data The results of the EBI process are a summary of the literature on the topic, both quantitative and qualitative. Quantitative analysis involves at minimum, a descriptive summary of the data, and may include formal meta-analysis where there is sufficient reliably acquired data. Qualitative analysis requires an understanding of error, bias, and the subtleties of experimental design that can affect the reliability of study results. Quali- tative assessment of the literature is covered in detail in Chapter 2; this section focuses on meta-analysis and the quantitative summary of data. The goal of the EBI process is to produce a single summary of all of the data on a particular clinically relevant question. However, the underlying investigations on a particular topic may be too dissimilar in methods or study populations to allow for a simple summary. In such cases, the user of the EBI approach may have to rely on the single study that most closely resembles the clinical subjects upon whom the results are to be applied, or may be able only to reliably estimate a range of possible values for the data. Therefore, some method must be used to combine the results of these studies in a summary statement. Meta-analysis is the method of combining results of multiple studies in a statistically valid manner to determine a summary measure of accuracy or effectiveness (34,35). For diagnostic studies, the summary estimate is generally a summary sensi- tivity and specificity, or a summary ROC curve. Blackmore The process of performing meta-analysis parallels that of performing primary research. However, instead of individual subjects, the meta- analysis is based on individual studies of a particular question. The process of selecting the studies for a meta-analysis is as important as unbiased selection of subjects for a primary investigation. Identification of studies for meta-analysis employs the same type of process as that for EBI described above, employing Medline and other literature search engines. Critical information from each of the selected studies is then abstracted usually by more than one investigator. For a meta-analysis of a diagnostic accuracy study, the numbers of true positives, false positives, true nega- tives, and false negatives would be determined for each of the eligible research publications. The results of a meta-analysis are derived not just by simply pooling the results of the individual studies, but instead by con- sidering each individual study as a data point and determining a summary estimate for accuracy based on each of these individual investigations. Like all research, the value of a meta-analysis is directly dependent on the validity of each of the data points. In other words, the quality of the meta-analysis can only be as good as the quality of the research studies that the meta-analysis summarizes. In general, meta-analysis cannot com- pensate for selection and other biases in primary data. If the studies included in a meta-analysis are different in some way, or are subject to some bias, then the results may be too heterogeneous to combine in a single summary measure.

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In other words order ventolin 100mcg free shipping uncontrolled asthma definition gina, they can find information that they do not initially know they need discount ventolin 100mcg with visa asthmatic bronchitis while pregnant, but which, as we have seen, is important for good clinical practice. It allows people to assess the likelihood of benefiting from a particular treatment or activity rather than just considering the underlying mechanism. In the space provided below, write down a question in relation to either yourself or one of your patients. If you are stuck, write down the last patient you saw and we will work out a question. In the next section (page 23), we will look at how to turn your questions into a form that can be used to search the medical literature in less than two minutes. Write down a clinical question here 19 Notes 20 EBM step 1: Formulate an answerable Steps in EBM: question 1. Track down the best First principle evidence of outcomes First, you must admit that you don’t know. Critically appraise the evidence (ie find out how method to find answers to questions without having any prior knowledge of good it is). Apply the evidence (integrate the results with clinical expertise and patient values). Dissecting the question into its component parts and restructuring it so that it is easy to find the answers is an essential first step in EBM. Te intervention or indicator What is the management strategy, diagnostic test or exposure that you are interested in (such as a drug, food, surgical procedure, diagnostic test or exposure to a chemical)? Te comparator or control What is the control or alternative management strategy, test or exposure that you will be comparing the one you are interested in with? Te outcome What are the patient-relevant consequences of the exposure in which we are interested? All clinical or research questions can be divided into these four components, which we call ‘P I C O’. Remember the PICO principle P Population/patientPopulation/patient II Intervention/indicatorIntervention/indicator C Comparator/control O Outcome 24 Different types of questions By far the most common type of clinical question is about how to treat a disease or condition. In EBM, treatments and therapies are called ‘interventions’ and such questions are questions of INTERVENTION. PROGNOSIS AND PREDICTION In each case the P I C O method can be used to formulate the question, as shown in the following examples. Te same approach can be used to research qualitative questions about health issues of a more general nature (PHENOMENA). Te studies that you will need to search for are different for the different types of questions and we will discuss this further in the next section (see ‘EBM step 2: Track down the best evidence’). Interventions can include individual patient care or population health activities (for example, screening for diseases such as cervical or prostate cancer). Example 1 A 28-year-old male presents with recurrent furunculosis for past 8 months; these episodes have been treated with drainage and several courses of antibiotics but keep recurring. To convert this to an answerable question, use the P I C O method as follows : P Population/patientPopulation/patient = patients with recurrent furunculosis II Intervention/indicatorIntervention/indicator = prophylactic antibiotics CC Comparator/control = no treatment O Outcome = reduction in recurrence rate of furunculosis Question: ‘In patients with recurrent furunculosis, do prophylactic antibiotics, compared to no treatment, reduce the recurrence rate? Other interventions you know about are nicotine replacement therapy and antidepressants. Develop a clinical research question using P I C O: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 27 Example 3 At a routine immunisation visit, Lisa, the mother of a -month-old, tells you that her baby suffered a nasty local reaction after her previous immunisation. Recently, a colleague told you that needle length can affect local reactions to immunisation in young children but can’t remember the precise details. Develop a clinical research question using P I C O to help you find the information you need: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 28 Example 4 In browsing one of the medical weeklies, you come across mention of imiquimod cream for treatment of basal cell carcinomas (BCC). Te idea of a cream for BCCs is surprising, so you wonder about the effectiveness and particularly the long-term cure rate of imiquimod cream. Develop a clinical research question using P I C O to help answer your query: P Population/patientPopulation/patient = II Intervention/indicatorIntervention/indicator = CC Comparator/control = O Outcome = Question: 29 Aetiology and risk factors Questions of aetiology and risk factors are about what causes a disease or health condition. Tey are the reverse of intervention questions because they deal with the harmful outcomes of an activity or exposure. Such questions commonly arise in relation to public health issues, such as whether eating certain foods increases the risk of heart disease, or being exposed to an environmental chemical increases the risk of cancer, and so on. Example 1 George has come in to your surgery to discuss the possibility of getting a vasectomy. He says he has heard something about vasectomy causing an increase in testicular cancer later in life.

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