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Seattle which showed that in women in whom the (Accepted 2 September 1998) 792 BMJ VOLUME 318 20 MARCH 1999 www cheap atorlip-5 5 mg on line cholesterol levels risk ratio. Thow Dip PE generic atorlip-5 5mg free shipping cholesterol levels while pregnant, BSc, PhD, MCSP Lecturer in Physiotherapy, Glasgow Caledonian University Glasgow, UK Exercise Leadership in Cardiac Rehabilitation An evidence-based approach Exercise Leadership in Cardiac Rehabilitation An evidence-based approach Edited by Morag K. Thow Dip PE, BSc, PhD, MCSP Lecturer in Physiotherapy, Glasgow Caledonian University Glasgow, UK Copyright © 2006 Whurr Publishers Limited (a subsidiary of John Wiley & Sons Ltd) The Atrium, Southern Gate, Chichester, West Sussex PO19 8SQ, England Telephone (+44) 1243 779777 Email (for orders and customer service enquiries): cs-books@wiley. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means,electronic,mechanical,photocopying,recording,scan- ning or otherwise,except under the terms of the Copyright,Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency Ltd, 90 Tottenham Court Road, London W1T 4LP, UK, without the permission in writing of the Publisher. Requests to the Pub- lisher should be addressed to the Permissions Department, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester,West Sussex PO19 8SQ, England, or emailed to permreq@wiley. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The Publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the Publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data Exercise leadership in Cardiac Rehabilitation: An evidence based approach / [edited by] Morag K Thow. I would like to dedicate this book to Alex and Sylvia Johnston who were our first cardiac rehabilitation participants at Gartnavel General Hospital, Glasgow. Also to all the other cardiac rehabilitation participants and partners at Jordanhill Heartbeats who have given me as much as I hope I have given them. Contents Contributors ix Foreword xi Preface xiii Acknowledgements xv 1 Cardiac Rehabilitation Overview 1 Christine Proudfoot 2 Risk Stratification and Health Screening for Exercise in Cardiac Rehabilitation 19 Ann Ross and Mhairi Campbell 3 Exercise Physiology and Monitoring of Exercise in Cardiac Rehabilitation 47 John Buckley 4 Exercise Prescription in Cardiac Rehabilitation 97 Hilary Dingwall, Kim Ferrier and Joanne Semple 5 Class Design and Use of Music in Cardiac Rehabilitation 133 Linda Harley and Gillian Armstrong 6 Leadership, Exercise Class Management and Safety in Cardiac Rehabilitation 161 Fiona Lough 7 Teaching Skills for Cardiac Rehabilitation Exercise Classes 183 Morag K. 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, Cardiac Rehabilitation, 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.

ROSSION order atorlip-5 5 mg with mastercard cholesterol test monitor, Pierre cheap atorlip-5 5 mg fast delivery reverse cholesterol transport definition, "Homéopathie, la mystification recommence", Science et vie, no 955, April 1997, p. ROSSION, Pierre, "La vérité sur la mémoire de l’eau", Science et vie, no 850, August 1988, p. Pathogenesis: the start of a somatic process that is masked as a disease, with or without any real basis of pathology existing. A dilution procedure, dreamed up by one Korsakov, simpler than the Hahne- mann process because successive dilutions are made in one single flask. Korsakov’s principle of dilution was banned in France until, in order to satisfy the require- ments for standardization throughout Europe, it was reintroduced under a directive from the European Community on September 22, 1992. Despite repeated opposition from the Commission on Transparency, 1163 ho- meopathic medications are 65% reimbursable, a rate that is supposed, in prin- ciple, to be reserved for products that have been proven effective against prob- lems of a certain degree of severity. It is hard to assess how much harm has been done by the national medical authorities that decide on these products, given that an adequate coding system is lacking. The great heat source, or triple heater, has to do with the respiratory, digestive and genital organs in a vision of energy relations. Bader, Jean-Michel, "Des acupuncteurs piqués au vif", Science et vie, n° 823, April 1986. PIGANIOL Guy, "Pratique des manipulations vertébrales; risques et accidents; aspects médico-légaux", Revue française du dommage corporel, tome XVI, no 2, 1990. The bulk of the experimental works that have tried to lend credit to the idea that the left brain governs reason and the right brain governs desire, the pas- sions and emotions, relate to the study on neuropsychological behavior of pa- tients with brain lesions — whether due to accidents or to major surgery. When the corpus callosum (which links the two hemispheres) is severed, it creates two individual and independent halves. Besides the fact that these tests studied a small number of subjects, with pathological problems, we can- not extrapolate the results to subjects with intact brains. Excerpt from the Petit Précis d’humanisme biologique, Cited in PLUCHET, Régis, "La naturopathie c’est quoi au juste", L’Impatient, n° 26, 1976. In 1848, Arnold Rickli founded the first sanatorium where sun and air baths were practiced. MONNIER, Georges, "Pour se désintoxiquer, l’hydrothérapie du côlon" (from a photocopy distributed at a conference, undated). DADOUN, Roger, Cent Fleurs pour Wilhelm Reich, Payot, "Petite Bibliothèque", 1975. This and the following citations in the subchapter are excerpted from a tract published by a geobiologist. LARGER, Jean, "À propos d’un cas de cancer du sinus piriforme traité par les péroxydases oléiques", Annales d’oto-rhino-laryngologie, 1956, p. See ROSSION, Pierre, "Beljanski: génie ou charlatan", Science et vie, no 914, Novem- ber 1993. ROUZÉ, Michel, "La mystique biologico-marine", Science et vie, no 875, August 1990. MARTINEZ GARCIA, Francisco et CAMOV, Isabel, "Les traumatismes de la nais- sance", Incroyable et scientifique, no 4, 2nd trimester 1995. KLEIN, Bernard, "L’approche spirituelle de la dépression", Vie naturelle, no 124, February 1997. Tantric Yoga: yoga founded upon the awakening of sexual energy and kun- dalini, with a progressive increase in the energy from the sacro-coccygian 230 Notes chakra up to the occipital chakra; this awakening of energy is construed as being synonymous with progressive enlightenment. CCMM (Comité de documentation, d’éducation et d’action contre les manipu- lations mentales), Les Sectes. See BAUDET, Cécile, "Enquête sur l’Énergo-chromo-kinèse", L’Impatient, n° 171, February 1992. Jean Brudon, President of the National Order of Pharmacists, Panorama du médecin, no 3591, April 29, 1992. HAMER, Rike Geed, Fondement d’une médecine nouvelle, Éditions ASAC, Chambéry, 1988.

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Herpes Amongst viruses that have prompted scientific interest in relation to MS atorlip-5 5 mg cholesterol medication on the market, the herpes virus HHV-6 is one of a number currently being researched atorlip-5 5mg with amex hoe hoog mag cholesterol ratio zijn. However, as with other viral candidates for a cause of MS, this line of enquiry is controversial and much debated. Lyme disease There is no evidence that this disease, which is spread by tics living on a range of animal species in the countryside, can cause MS, although its symptoms may mimic those of MS. Research studies have failed to demonstrate any link between injections (vaccinations or inoculations) and any subsequent worsening of the MS. There is no clear definitive link that been established between the prior effects of diseases and the onset of MS. Of course as MS progresses, it may itself give rise, in effect, to other conditions, through a weakened immune system or just by ageing, for example. There is no known link between cancer of any type and MS, but it is to be expected that some people with MS will develop cancer, but no more frequently than people who do not have MS. Autoimmune diseases There are strong similarities between some aspects of other autoimmune diseases, where the immune system is triggered into mistakenly attacking normal tissues in the body, and some aspects of MS. At present these conditions are still thought to be completely separate disease entities, although it is possible that there may be some very general biological processes underlying these conditions. Stress Fatigue, and possibly what we call ‘stress’, could have had some effect, not as a cause of MS, but perhaps as an exacerbating factor on some symptoms. However, although most people with MS probably feel that undue stress in their lives may bring on a relapse, scientifically this issue is still being argued over. Even so, many people have their own ideas about things that they feel are linked with their MS symptoms, and try to avoid them. Accidents and injuries Studies have compared accident and injury rates in people with MS who have had relapses and those who have not. Almost all have concluded that there is no significant difference in rates, or evidence to support trauma as causing or worsening MS. A more general issue is whether head injuries may have broken what is called the blood–brain barrier so that some parts of the CNS may themselves become contaminated and thus be damaged by the various blood products that are released. However, the relationship of any breach of the blood–brain barrier and the onset of MS is disputed. MULTIPLE SCLEROSIS EXPLAINED 11 Diet There has also been extensive scientific research on MS and diet which may have some bearing in the medium and longer term on health in general. There is substantial research indicating that what are called ‘unsaturated fatty acids’ – essential building blocks of the brain and nervous system – may be deficient in people with MS, which is why supplements containing these fatty acids have become popular. However, there is little evidence that taking supplements with the fatty acids has any major effect on MS. More generally, there is also little evidence that any particular diet has major effects on the course of MS, although some evidence suggests that a low-saturated fat diet may be beneficial as regards relapses. Finally, there is little or no evidence that poor diet in itself causes MS – if this were so, the geographic and social distribution of MS would be very different. Diagnosing MS The diagnosis of MS has previously been a long, slow and complicated process, since there was no definitive laboratory test for MS. The newer and sophisticated brain scanning techniques that are now used, such as magnetic resonance imaging (MRI) can locate lesions or patchy scarring (scleroses) in the nervous system, but require very careful interpretation by a skilled doctor. Although many people in the early stages of MS do not exhibit the ‘classic’ symptoms considered to be the ‘textbook’ features of the disease, MRI can be the definitive test as it shows lesions in the white matter which contains myelinated fibres. Finally, many other conditions may produce symptoms almost indistinguishable from MS symptoms. Thus the difficulty in diagnosing MS lies in establishing sufficient evidence to exclude other possibilities. There is more about diagnosing MS in Multiple Sclerosis – the ‘at your fingertips’ guide (see Appendix 2). In addition to the possibility of influencing the onset of attacks, lessening their effects and increasing the length of remissions, the possibilities of longer term disease modification are now being actively considered. This chapter discusses the issues of treatment rather than cure, what medical therapies there are at present, and rehabilitation.

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Computer reconstruction and rendering of multidimensional medical and histologic image data obviate the taxing need for mental reconstruction and provide a powerful new visualization tool for biologists and physicians discount 5mg atorlip-5 amex cholesterol levels 45 year old male. Voxel-based computer visualization has a number of important uses in basic research atorlip-5 5mg generic new cholesterol guidelines chart, clinical diagnosis, and treatment or surgery planning; but it is limited by relatively long rendering times and minimal possibilities for image object manipulation. The use of virtual reality (VR) technology opens new realms in the teaching and practice of medicine and biology by allowing the visualizations to be manipulated with intuitive immediacy similar to that of real objects; by allow- ing the viewer to enter the visualizations, taking any viewpoint; by allowing the objects to be dynamic, either in response to viewer actions or to illustrate nor- mal or abnormal motion; and by engaging other senses, such as touch and hearing (or even smell) to enrich the visualization. Biologic applications extend across a range of scale from investigating the structure of individual cells through the organization of cells in a tissue to the representation of organs and organ systems, including functional attributes such as electrophysiologic signal distribution on the surface of an organ. Medical applications include basic anatomy instruction, surgical simulation for instruction, visualization for diagnosis, and surgical simulation for treatment planning and rehearsal. Although the greatest potential for revolutionary innovation in the teaching and practice of medicine and biology lies in dynamic, fully immersive, multi- sensory fusion of real and virtual information data streams, this technology is still under development and not yet generally available to the medical re- searcher. There are, however, a great many practical applications that require di¨erent levels of interactivity and immersion, that can be delivered now, and that will have an immediate e¨ect on medicine and biology. In developing these applications, both hardware and software infrastructure must be adaptable to many di¨erent applications operating at di¨erent levels of complexity. Inter- faces to shared resources must be designed ¯exibly from the outset and crea- tively reused to extend the life of each technology and to realize satisfactory return on the investment. Crucial to all these applications is the facile transformation between an im- age space organized as a rectilinear N-dimensional grid of multivalued voxels and a model space organized as surfaces approximated by multiple planar tiles. The most complex and challenging applications, those that show the greatest promise of signi®cantly changing the practice of medical research or treatment, require an intimate and immediate union of image and model with real-world, real-time data. It may well be that the ulti- mate value of VR in medicine will derive more from the sensory enhancement of real experience than from the simulation of normally sensed reality. A successful virtual envi- ronment is one that engages the user, encouraging a willing suspension of dis- belief and evoking a feeling of presence and the illusion of reality. Although arcade graphics and helmeted, gloved, and cable-laden users form the popular view of VR, it should not be de®ned by the tools it uses but rather by the functionality it provides. VR provides the opportunity to create synthetic real- ities for which there are no real antecedents and brings an intimacy to the data by separating the user from traditional computer interfaces and real-world constraints, allowing the user to interact with the data in a natural fashion. To produce a feeling of immersion or presence (a feeling of being physically present within the synthetic environment) the simulation must be capable of real-time interactivity; technically, a minimum visual update rate of 30 frames per second and a maximum total computational lag time of 100 ms are required (1, 2). Together with Performer (3), these systems allow us to design visualization software that uses coarse-grained multiprocessing, reduces computational lag time, and improves the visual update rate. These systems were chosen primarily for their graphics performance and our familiarity with other Silicon Graphics hardware. We support ``®sh-tank' immersion through the use of Crystal Eyes stereo glasses and fully immersive displays via Cybereye head-mounted displays (HMDs). By displaying interlaced stereo pairs directly on the computer moni- tor, the stereo glasses provide an inexpensive high-resolution stereo display that can be easily shared by multiple users. Unfortunately, there is a noticeable lack of presence and little separation from the traditional computer interface with this type of display. The HMD provides more intimacy with the data and im- proves the sense of presence. We chose the Cybereye HMD for our initial work 6 VIRTUAL REALITY IN MEDICINE AND BIOLOGY with fully immersive environments on a cost/performance basis. Although it has served adequately for the initial explorations, its lack of resolution and re- stricted ®eld of view limit its usefulness in serious applications. We are currently evaluating other HMDs and display systems to improve display quality, in- cluding the Immersive Workbench (FakeSpace) and the Proview HMD (Kaiser Electro-Optics). Our primary three space tracking systems are electromagnetic 6 degree of freedom (DOF) systems. Initially, three space tracking was done using Polhe- mus systems, but we are now using an Ascension MotionStar system to reduce the noise generated by computer monitors and ®xed concentrations of ferrous material. In addition to electomagnetic tracking, we support ultrasonic and mechanical tracking systems. This allows for 3 degrees of force feedback, which we ®nd adequate for simulating most puncture, cut- ting, and pulling operations. To accommodate the various levels of com- plexity while maintaining a suitable degree of interactivity, our simulation in- frastructure is based on a series of independent agents spread over a local area network (LAN). Presently, the infrastructure consists of an avatar agent run- ning on one of the primary VR workstations and a series of device daemons running on other workstations on the network. The avatar manages the display tasks for a single user, and the daemon processes manage the various VR input/ output (I/O) devices.

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