THE 12 MOST IMPORTANT HEALTH INNOVATIONS OF THE YEAR

Source: http://www.popsci.com/

Alyssa Favreau and Claire Maldarelli

Sanofi Pasteur's Dengvaxia: Finally, A Vaccine For Dengue

Dengue—a virus most commonly transmitted by the Aedes aegypti mosquito—infects some 400 million people yearly. It causes high fever, severe headaches, vomiting, and sometimes death. About 40 percent of the world’s population is at risk, and as the climate warms and travel increases, that risk will only climb. This year, the World Health Organization ­started recommending the first vaccine to prevent dengue, and inoculations have begun in hot zones like Brazil and the Philippines. Four viruses cause dengue, so developing a vaccine that protects against all four took researchers 20 years to do. If 20 percent of the population gets vaccinated, dengue cases could drop 50 percent within five years. Controlling dengue could also reduce the $9 billion the disease costs global economies each year.

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Courtesy Braeburn Pharmaceuticals

Braeburn Pharmaceuticals' Probuphine Implant: Easy Opioid Maintenance

During treatment for opioid addiction, missing one or two doses of withdrawal meds can trigger a relapse. Once under the skin, where they stay for up to six months at a time, four matchstick-size Probuphine implants deliver a constant dose of buprenorphine, an opioid derivative that in small, steady doses combats withdrawal symptoms. The device is currently FDA-approved for patients in active recovery from opioid addiction.

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Amgen

Amgen's IMLYGIC: A Virus That Fights Cancer

Scientists have long known that viruses could trigger the immune system to attack cancer, but modifying the viruses without affecting our resistance to them has taken time. In late 2015, IMLYGIC became the first FDA-approved viral cancer drug. Green-lit to treat melanoma, the modified herpes virus is injected into a tumor, where it may ignite an immune response to the cancer.

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Abbott

Abbott's Absorb: A Disappearing Cardiac Stent

Metal stents—small tubes that unclog and heal blocked arteries—are a mainstay in cardiac surgery. But because that metal stays around indefinitely, plaque can rebuild around it. Absorb is a fully bioabsorbable stent that does the same healing work, but it dissolves when it’s finished. Made of polylactide—a biodegradable polymer also used in dissolving sutures—the device proved to be on par with its metal counterpart in clinical trials.

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Sam Kaplan

Withings' Thermo: A Friendlier Thermometer

Home oral thermometers take up to three minutes to get readings. Thermo takes only two seconds. Sixteen infrared sensors take more than 4,000 readings from the temporal artery—all without touching the skin. $100

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Children's National Medical Center

Children’s National Medical Center's STAR: Most Dexterous Robot Surgeon

The Smart Tissue Autonomous Robot (STAR) can suture one of the trickiest areas of the human body: the intestines. A sensing system in STAR’s surgical tools feels and reacts to tiny pulls and pressure changes, upping the robot’s precision. When sewing a pig’s intestine, which is as flexible as a human’s, STAR spaced its sutures more evenly than both human and human-assisted robotic surgeons—a sign of a procedure well-done.

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Melanie Gonick/MIT

Olivo Lab's Second Skin: Stick-On Skincare

Sun damage, wrinkles, discoloration: These inevitable markers of age could soon be hidden—or even prevented—with an invisible elastic polymer. Second Skin, or XPL, can be placed directly on the skin as a coating, where it mimics the properties seen in younger skin, such as elasticity. It could also be used as a vehicle for delivering drugs (like eczema meds) or cosmetics (like sunscreen) so that they wouldn’t rub off during the day.

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Nima

Nima: A Pocket Gluten Detector

People with celiac disease normally have to take a cook’s word on whether their meal is truly gluten-free. Nima lets them test the food for themselves. Antibodies on the card-deck-size device’s test strips react to gluten levels as low as 20 parts per million, the gluten-free limit set by the FDA. In the future, the company plans to expand its ingredient detection to include other common food allergens, such as peanuts. $199

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Abbott

Abbott's FreeStyle Libre: A Prickless Glucose Test

People with insulin-dependent diabetes stick their fingers up to 10 times a day to check their blood sugar. The FreeStyle Libre system eliminates the painful finger pricking. A small, round sensor on the upper arm contains a tiny filament that, when inserted just under the skin, continually monitors glucose. Patients use a smartphone-size scanner to check their levels. Those who used the system were in a state of low blood sugar 38 percent less often.

There are two versions of the FreeStyle Libre. A professional one, the FreeStyle Libre Pro, meant for use under a doctor’s supervision, was FDA-approved in September. A consumer version, the FreeStyle Libre, is currently being reviewed by the FDA.

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Courtesy of MIT

MIT's Rapid Zika Test: A Low-Cost Zika Test

Zika’s biggest threat is its potential to cause birth defects, yet expectant mothers might not know they’re infected. Conventional lab tests take days and require facilities unavailable in rural areas. Researchers at MIT created a paper-based test that gets results within three hours. When exposed to a Zika-containing blood sample, yellow dots on the paper turn purple. Researchers think the same approach can rapidly diagnose other diseases, like malaria.

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Courtesy St. Renatus

St. Renatus' Kovanaze Nasal Spray: Needle-Free Dentistry

The anesthetic shot is often the worst part of a tooth filling. Kovanaze does the same work in the form of a nasal spray. Two squirts in the nostril on the side of the offending tooth make the filling pain-free.

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Sam Kaplan

Shift Labs' DripAssist: Simpler IV Control

In developing countries or military outposts, nurses often count IV fluids drop by drop to ensure medicine flows into a vein at the proper rate. Infusion pumps common in hospitals are expensive, large, and require electricity. The DripAssist is a stripped-down, compact infusion monitor that runs on a single AA battery. Attached near the bag end of an IV tube, the 5-inch device monitors flow for a fraction of the cost of hospital pumps. $395

THE ROLE OF PHYSIOTHERAPY IN BREAST CANCER REHABILITATION

Source: http://www.unitehealth.com.au/the-role-of-physiotherapy-in-breast-cancer-rehabilitation/

Susan Czyzo (Bachelor of Physical Education and Health, Master of Science in Physical Therapy)

The Australian Institute of Health and Welfare estimates 16,084 new cases of breast cancer in Australia in 2016, amounting to 12.3% of all new cancer diagnoses (27% of all new cancers in females) and 6.5% of all deaths from cancer. Although the incidence of breast cancer has tripled in thirty years (1982 to 2012), the likelihood of surviving at least 5 years after diagnosis is currently at 90%. Being labelled a survivor of breast cancer, however, does not automatically translate to a clean bill of health. There are a number of additional health obstacles that many women experience following breast cancer treatment. Fortunately, physiotherapists possess the skills necessary to lessen or even eliminate these obstacles.

LYMPHOEDEMA

All women who undergo breast cancer surgery are at risk of developing lymphoedema, which may not appear until months or even years post surgery. Risk is higher for women who have undergone a full axillary lymph node dissection.  Radiation treatment may also cause, or if already present, exacerbate lymphoedema. Pain, loss of range of motion and strength in the upper extremity, as well as impaired function are common effects of lymphoedema.

As exercise has shown to be a safe and essential part of lymphoedema management, physiotherapy can play a meaningful role in prevention and treatment. It’s important to be aware that different types of exercise can be beneficial. For example, sustained periods of deep inspiration such as with aerobic exercise help by enhancing venous and lymphatic return. Flexibility training, alternatively, minimizes tightness associated with scarring, a contributor to the blocking of lymphatic flow. Hydrotherapy, with the movement of water exerting a healthy level of compression on the body, is also believed to aid in improving lymphoedema.

In addition to prescribing and supervising a specialized exercise program, kinesiotaping and education on activities or movements that trigger lymphoedema are other ways that physiotherapists can assist with lymphoedema management.

BONE LOSS

The rate and magnitude of bone loss caused by cancer treatment is significantly higher than age-related bone loss in the non-cancer population. Chemotherapy-induced premature menopause and anti-estrogen therapies, for example, are believed to contribute to the increased rate and magnitude in this population.

As within the general population, initial management for decreased bone density includes education on the benefits of a lifestyle that includes, among other interventions, regular weight-bearing exercise. Physiotherapists are able to confidently advise these individuals on safe exercise options to maximize bone integrity.

 UPPER EXTREMITY DYSFUNCTION

Decreased range of motion, rotator cuff strain, adhesive capsulitis, paraesthesia and weakness are all common developments in the upper extremity post breast cancer surgery and/or radiation therapy. Whether appearing independently or in combination, these impairments can severely impact activities of daily living and employment, resulting in functional disability and a decreased quality of life.

Physiotherapy has been shown to be effective in managing post-surgical musculoskeletal symptoms. For example, exercise rehabilitation has shown to result in clinically meaningful improvements in shoulder range of motion.

FATIGUE

Fatigue is a frequently reported yet poorly managed symptom reported by cancer patients. It is a complex symptom with various overlapping causes, some of which include anaemia, pain, sleep disturbance, thyroid dysfunction, and mood disorders. Physiotherapists can help their cancer patients manage fatigue through a focused history screening to determine the main contributors; by teaching the importance of planning and pacing their day; by designing a graduated exercise program to increase strength and energy levels; and through GP referral if the cause of their fatigue requires further investigation.

PAIN

Another complex symptom with multiple causes reported by cancer patients is pain, often requiring a multi-disciplinary approach to management. A physiotherapist’s role in pain management comes in the form of exercise prescription and acupuncture, both of which have been shown to be effective treatments for pain in this population.

THE IMPORTANCE OF PROMOTING AND PRESCRIBING PHYSICAL ACTIVITY

Engagement in regular physical activity is routinely stressed as a key preventive measure for many chronic health problems and breast cancer is no exception. However, it appears that historically healthcare professionals have been overly conservative with exercise prescription in cancer rehabilitation. The literature reports that many cancer survivors are not meeting standard exercise guidelines. Within breast cancer survivors, strength guidelines in particular are not being met. Today’s guidelines within cancer rehabilitation recommend the following:

Return to normal daily activities as soon as possible after diagnosis as early exercise interventions are showing to be more effective that delayed interventions. Exercise is safe during chemotherapy and radiation treatment and therefore patients should be encouraged to maintain their activity level during treatment as much as possible.

For substantial health benefits, patients should aim for at least 150 minutes of moderate aerobic exercise or 75 minutes of vigorous aerobic exercise per week. Strength training should be completed at least 2x/week. Gradual intensity weight-training is a safe way to improve upper limb strength without increasing the risk of lymphoedema.

PILATES AND BREAST CANCER

Clinical Pilates exercises taught by a physiotherapist are an excellent starting point for addressing any of the above listed health concerns post breast cancer treatment. With its focus on core engagement, precision and flow of movement, Pilates is an ideal exercise form for developing efficient movement; is safe for painful joints and muscles; and is easily adaptable to fit within pain, fatigue, and energy levels, as well as with upper extremity dysfunction. The focus on posture that Pilates involves also makes it a great option for addressing the postural changes that present post breast-cancer surgery. In addition, the diversity of Pilates allows it to be a challenging exercise option as strength and function improves post treatment.

SPECIAL CONSIDERATIONS

Be familiar with the common medical treatments for cancer and recognize that they are cancer-specific and are constantly changing. Keep in mind pre-existing health issues and fitness levels.

Adverse effects of cancer treatments may appear months or years after the completion of treatment and may present in multiple body systems.

 REFERENCES

Australian Institute of Health and Wellness. (2016). Breast cancer in Australia. Retrieved from http://www.aihw.gov.au/cancer/breast/

Loh, S. Y., & Musa, A. N. (2015). Methods to improve rehabilitation of patients following breast cancer surgery: a review of systematic reviews. Breast Cancer, 7, 81-98. doi: 10.2147/BCTT.S47012

Mc Neely, M. L., Campbell, K., Ospina, M., et al. (2010). Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews. doi 10.1002/14651858.CD005211.pub2

Runowicz, C. D., Leach, C. R., Henry, N. L., et al. (2015). American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. Journal of Clinical Oncology. doi 10.1200/JCO.2015.64.3809

Schmitz, K. H., Courneya, K. S., Matthews, C., et al. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise.doi 10.1249/MSS.0b013e3181e0c112

University Health Network Princess Margaret Cancer Centre. (2015). Clinical Practice Guidelines, Breast Site. Retrieved from http://www.uhn.ca/PrincessMargaret/Health_Professionals/Programs_Departments/Documents/CPG_Breast_BreastCancer.pdf

Defending the Deadlift

  Source: http://www.healigo.com

Hollan Oliver DPT, OCS, SCS

Defending the Deadlift

By Matt Quinn

Introduction: 

Helen returns home from a routine trip to the grocery store with several bags. She decides to take the two heaviest bags into the house first. As she approaches her front door, she sets the bags down, retrieves her keys, and unlocks her front door. Helen then thinks about the safest way in which she can lift the bags off the ground. She first tightens her core and sets her back in tight extension. She then hinges at her hips, and lowers herself through slight knee flexion to bend over and grasp the bags. From here, Helen maintains the angle between her torso and hips, drives her feet into the ground and stands with fully extended knees and hips. Helen has just completed a safe, and successful deadlift.

One of the greatest risk factors for functional limitations and disabilities in middle-aged to older adults is muscular weakness (Volakis et al, 2015). Thus, a muscular strengthening component should be incorporated into fitness programs for individuals in this age range (“Why Strength Training”, 2010). Specifically, fitness instructors should aim to strengthen functional movement patterns that produce transferability into activities of daily living. Functional movements patterns are based on the way our bodies are designed to move, and they mimic the biomechanical demands life places upon us. Functional movements are multi-planar, multi joint, core to extremity movements. So, is the deadlift a functional movement? As we saw in the anecdote above, the deadlift presents itself in real life situations, but does it fit the other criteria? The answer is yes.

Multi-Planar

The deadlift requires motion or stability in all three planes. The first, and perhaps most obvious, is the sagittal plane. We move through the sagittal plane as we lift the bar up off the ground. The second plane of motion is the frontal plane, which represents side-to-side motion. As we lift the bar off the ground, we must stabilize the bar in a manner that allows both sides of the bar to be elevated off the floor simultaneously. A lack of stability in this plane would result in a lopsided bar as it is lifted. Finally, the deadlift also requires stability in the transverse plane. Stability in the transverse plane resists rotational movement of the bar (Robertson, 2012). If an individual were unstable in the transverse plan, they would twist or rotate as they lifted the bar.

http://santabarbarastrength.com/stack-the-bones/

Multi-Joint

The primary joints used for force production during the deadlift are the hips, knees and ankles. The deadlift requires activation in the ankle plantar flexors and knee extensors, but demands the most significant amount of activation from the hip extensors and knee flexors (Escamilla, 2000). To better understand movement at these joints, we will re-visit Helen’s task of lifting her grocery bags, starting from the ground and moving up.

Ankle plantar flexion is achieved primarily through activation of the gastrocnemius and soleus muscle groups. Plantar flexion is loosely defined as downward movement of the foot. A good example of plantar flexion is the “push off” motion of our foot during walking (Neptune, 2001). Although her feet would remain in contact with the ground, Helen would be using her plantar flexors to push into the ground and help initiate movement of the bar.

Knee flexion is achieved through activation of the muscles of the hamstring. Although her starting position is achieved mainly through hip flexion, slight knee flexion is required in order for Helen to position herself correctly. Ideally, the proper amount of knee flexion would place her shins perpendicular to the floor. This degree of knee flexion must be maintained as the bags are lifted until hip extension has been initiated.

The quadriceps muscles assist the gluteus maximus and hamstring in producing hip extension in addition to acting as the primary knee extensors (Frigo et al., 2010). As Helen lifts the bags off the floor, the contraction of her quadriceps would oppose the actions of the gluteus maximus and hamstring, thus stabilizing her knee position in slight flexion. With a fixed knee position, her gluteus maximus and hamstring can produce maximal hip extension once the bags have reached knee level. As she extends her hips and no longer requires knee flexion, the contraction of her quadriceps extends, or straightens, her knees from their previously flexed position.

http://imhealthtoday.com/abs-workout-legs-2.html

Core to Extremity

Lifting any object off the floor, particularly a heavy one, requires both movement and stability of our core, depending upon which plane of movement we consider. When discussing core to extremity movement, it is important to understand that our body’s core is comprised of many muscle groups that work in conjunction to move or stabilize the core. While some core muscles may be acting to move the core in the sagittal plane, others will be activated in order to stabilize our torso in the frontal and transverse planes. Multiple layers of abdominal, oblique, spinal, and hip musculature work in conjunction to move and stabilize the core (Di Jensen, 2013) (Conneely, 2006). Movement with a stable core is imperative so that we ensure structural safety through efficient production and transfer of force from the core to our extremities (Bliss, 2005).

The deadlift is the epitome of a core to extremity movement, requiring significant activation of primary core muscles (Hamlyn, 2007). We use the core musculature to stabilize the spine while simultaneously moving the trunk towards the ground in order to reach the object. From this position, our stable core allows for transfer and production of force through our ankles, knees, hips, back, and arms as we safely elevate the object from the floor.

https://memoirsofasecondyear.files.wordpress.com

Conclusion

The deadlift is often criticized as a dangerous exercise that simply leads to injury, when in fact it is a basic human movement. While it is possible to injure yourself without proper instruction, the deadlift is a functional movement that our anatomy is built to execute. The deadlift is one of the most effective ways to train not only the posterior chain and core, but it also aids in the development of the assisting muscle groups, like the quadriceps. These muscle groups are of critical importance to everyone, whether it is an elite athlete looking to improve performance, or a father wishing to be able to safely lift his son off the ground. For these reasons, the deadlift should be an integral part of most, if not all physical activity regimens in order to best prepare individuals for the demands placed upon them by their activities of daily living.

Healigo is a Boston-based technology company building a patient adherence platform that enhances the clinician-patient relationship. To find out how Healigo can help streamline your practice, drive referrals and improve outcomes click here. 

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About the Author: Matt Quinn is a graduate of UMass Amherst where he majored in Kinesiology and played quarterback for the Minutemen. In addition to being a medical student at Brown University, he has amassed over 1000 coaching hours as a crossfit instructor at Full Range Crossfit in Providence, RI. 

References

Bliss, L., & Teeple, P. (2005). Core stability: The centerpiece of any training program. Current Sports Medicine Reports, 4(3), 179.

Conneely, M., O'Sullivan, K., & Edmondston, S. (2007). Dissection of gluteus maximus and medius with respect to their suggested roles in pelvic and hip stability: Implications for rehabilitation?. Physical Therapy in Sport, 7(4), 176.

Di Jensen, E. (2013). What are the core muscles of the body?. Retrieved 5/10, 2015, fromhttp://www.livestrong.com/article/98988-core-muscles-body/

Escamilla, R., Fransisco, A., Fleisig, G., Barrentine, S., Welch, C., Kayes, A., et al. (2000). A three-dimensional biomechanical analysis of sumo and conventional style deadlifts. Medicine and Science in Sports and Exercise, 32(7), 1265--1275.

Frigo, C., Pavan, E., & Brunner, R. (2010). A dynamic model of quadriceps and hamstrings function.. Gait and Posture, 31(1), 100.

Hamlyn, N., Behm, D., & Young, W. (2007). Trunk muscle activation during dynamic weight-training exercises and isometric instability activities.  . Journal of Strength and Conditioning Research, 21(4), 1108.

Neptune, R., Kautz, S., & Zajac, F. (2001). Contributions of the individual ankle plantar flexors to support, forward progression and swing initiation during walking. Journal of Biomechanics,34(11), 1387.

Robertson, M. (2012). Saggital plane first. Retrieved 5/11, 2015, fromhttp://robertsontrainingsystems.com/blog/sagittal-plane-first/

Volaklis, K. A., Halle, M., & Meisinger, C. Muscular strength as a strong predictor of mortality: A narrative review. European Journal of Internal Medicine, (0)

Why strength training?. (2011). Retrieved 5/10, 2015, fromhttp://www.cdc.gov/physicalactivity/growingstronger/why/

Robo-suit and virtual reality reverse some paralysis in people with spinal cord injuries

www.ciencemag.org
By John TravisAug. 11, 2016 , 10:00 AM

Two years ago, just before leading a controversial demonstration at the World Cup in which a paralyzed man in a futuristic-looking exoskeleton controlled by his brain appeared to kick a soccer ball, neuroscientist Miguel Nicolelis hinted in an interview that his research team would aim for something equally impressive to grab the world's attention during the 2016 Summer Olympics in his native Brazil.

In a study published today, Nicolelis makes his bid. He and colleagues reveal that eight Brazilians paralyzed because of spinal cord injuries regained some small but significant sensation and muscle control in their lower limbs after many months of training with the robotic exoskeleton, and by a virtual reality avatar also controlled by brain signals. None of the study participants is close to walking again unassisted, but some can voluntarily move leg muscles and have improved bladder or bowel control, significant quality of life issues for those with severe paralysis.

Nicolelis, who is based at Duke University in Durham, North Carolina, calls the results “unprecedented” and suggests that a similar training regimen could one day help many other people with spinal cord injuries or those impaired by stroke. Other researchers cautiously agree, but stress that more meaningful recoveries may demand a combination of approaches. The new work is “an advance. I wouldn’t characterize it as a dramatic breakthrough,” says University of Toronto in Canada neurosurgeon Michael Fehlings, who specializes in spinal cord injuries.  “The improvements seen are modest. It’s more exciting from a proof of concept standpoint.”

The new work, published in Scientific Reports, comes out of the Walk Again Project, a large international research consortium funded in part by the Brazilian government and based in São Paulo. A celebrity in his home country who has clashed with some in the Brazilian science community, Nicolelis organized the project. Its original goal: developing brain-machine interfaces, which use implanted electrodes or noninvasive electroencephalogram (EEG) sensors to detect brain signals and translate them into commands for prosthesis or other devices, to the point that paralyzed people could control a motorized exoskeleton—essentially a robotic suit that keeps the body upright and allows it to move.  

The internationally televised World Cup demo failed to impress many in the scientific community, who noted that it was hard to discern how much the man actually controlled his exoskeleton. But it was far from the end of the project. The consortium ultimately recruited eight people whose lower limbs had been paralyzed for 3 to 15 years because of spinal cord injuries and guided them through three levels of training, which involved hour-long sessions twice a week. The study participants started by donning a virtual reality headset  and trying to mentally control the walking of an avatar with their brain signals, as detected by EEG sensors in a mesh cap. Next, they graduated to a treadmill system in which their body weight was supported and their brain signals controlled a robotic walker system that moved their legs. Finally, they practiced with the custom-built robotic exoskeleton shown off at the 2014 World Cup. One apparent key to the regimen’s success, Nicolelis says, is that each level of training provided neurological feedback to the brain through a “tactile shirt” that made each participant’s arms vibrate whenever they landed a step.

The neurological improvements came gradually. Some of the trainees noticed changes after more than 6 months of training, but it wasn’t until neurological exams conducted after 1 year that the research team verified some restoration of muscle control and sensation in all eight patients. At that point, the team upgraded the status of four from complete paralysis in their lower limbs to partial. Nicolelis says that since then, three of the others have also improved enough to be upgraded similarly; the only one who didn’t had to move away and discontinue training. Nicolelis notes that his team is preparing another publication on the subsequent 18 months of training and ongoing improvements they observed. “The recovery has not ended,” he says.

Although some spinal cord injuries completely transect the nerve bundle, most involve a crushing of the cord, which may leave some viable, through nonfunctioning, nerve connections. Physicians and researchers have long sought drugs or therapies, ranging from electrical stimulation to whole body harness walkers, that could rehabilitate those connections, but they have achieved few signs of success in people. As a result, Nicolelis says, his team had not expected to see much neurological  recovery from the brain-machine interface training given how long ago the injuries took place. “Something may have survived the original trauma. We may have rekindled these remaining neurons,” he said during a call with reporters. The team also documented changes in participants' brain EEG patterns that they interpret as cortical regions reorganizing to reassume some control of lower limbs.

Earlier this year, another team reported using a brain machine interface to allow a quadriplegic to move his finger and arms, but that system directly activated arm muscles with brain signals detected by implanted electrodes, bypassing the damaged spinal cord. Nicolelis’s training strategy is less invasive but would likely be hard to fully extend to a large number of paralyzed people given the expense of the custom exoskeleton. The first two stages—the virtual reality and treadmill systems—could be more easily adopted, although it’s unclear how much recovery they promoted. Fehlings suggests that brain-machine interfaces could one day be combined with several other treatment strategies—such as stem cells and drugs—to produce much greater overall benefit for people with damaged spinal cords. No single strategy will be enough to overcome severe paralysis, he emphasizes, so “it’s appropriate to be cautious.”

How Usain Bolt came from behind again to win gold medal 100 meters

http://www.nytimes.com/interactive/2016/08/15/sports/olympics/usain-bolt-mens-100-meters-final.html?_r=0


Source: Dr. Paul Brice, consultant performance biomechanist

Centro de Reabilitação do Norte vai organizar as I Jornadas de Reabilitação Cardiorrespiratória 20-22 Outubro

http://www.justnews.pt/

Publicado em 30 de julho de 2016 - 15:11

Especialistas de várias unidades e centros hospitalares do país vão estar reunidos, nos dias 20, 21 e 22 de outubro, nas I Jornadas de Reabilitação Cardiorrespiratória do Centro de Reabilitação do Norte da Misericórdia do Porto. O evento, que "vai permitir o debate entre várias áreas da Medicina Física e de Reabilitação", conta com o apoio científico da Sociedade Portuguesa de Cardiologia, Associação Portuguesa de Fisioterapeutas e Sociedade Portuguesa de Medicina Física e de Reabilitação.

Intitulada "Reabilitação Cardiorrespiratória - Articulação com os Cuidados de Saúde Primários", a primeira mesa redonda do evento conta com a intervenção da presidente da Sociedade Portuguesa de Medicina Física e de Reabilitação, Catarina Aguiar Branco, que abordará o tema: "Quem, quando e como referenciar?". Os motivos para se proceder à reabilitação e as dificuldades sentidas na prática clínica pelo médico de família perante doentes com patologia cardíaca e respiratória são outros tópicos a desenvolver nesta sessão.Na última sessão do programa são discutidos os "novo desafios" dos programas de reabilitação cardiorrespiratória. Sob a moderação do cardiologista Preza Fernandes e do pneumologista Nuno Cortesão, serão abordados temas como "Abordagem Multidisciplinar no doente com ventilação mecânica prolongada" e "Programas de Reabilitação pré e pós-transplante".

Para mais informações: jornadascrn.org@scmp.pt 

Reabilitação Cardiovascular do Idoso

Reabilitação Cardiovascular do Idoso

Autores: Elizabete Viana de Freitas, Andréa Araujo Brandão, Maria Eliane Magalhães, Roberto Pozzan, Ayrton Pires Brandão

http://www.rbconline.org.br/

Introdução

---

Os dados epidemiológicos apontam para a alta prevalência das doenças cardiovasculares (DCV) nos indivíduos com idade igual ou superior a 60 anos^1-5, como sendo a maior causa de morbimortalidade e uma das principais de incapacidade neste grupo etário. Nos idosos a ocorrência de doença arterial coronariana (DAC) com manifestação clínica é superior a 25%, assim como 55% dos quadros de infarto agudo do miocárdio e mais de 50% das cirurgias de revascularização miocárdica⁶. De acordo com o DATASUS⁵, no Brasil, três quartos do total das mortes e mais da metade dos quadros de infarto agudo do miocárdio ocorrem em indivíduos com idade igual ou superior a 60 anos.

Nas mulheres, o início da DAC se faz mais tardiamente em relação aos homens, com diferença de aproximadamente 10 anos. Entretanto, o curso da doença é caracterizado por maior prevalência de ICC e responde por mais de 50% de todas as causas de mortalidade no sexo feminino².

Observa-se que nos idosos a DAC determina maior taxa de limitação física e incapacidade, quando comparada aos jovens. Por outro lado, nessa faixa etária a expectativa de vida é, geralmente, subestimada e os profissionais tendem a minimizar o tratamento e menos freqüentemente incluem esses pacientes nos programas de reabilitação cardiovascular (CV)⁷.

Atualmente, inúmeros trabalhos^5,8,9, entre eles o de Fletcher et al⁶, relatam os benefícios da atividade física e da reabilitação cardiovascular no idoso. Na realidade, é necessária a implantação de programas educacionais, visando ampla divulgação da atividade e da reabilitação e seus benefícios nos idosos. O Framingham Disability Study by Age and Coronary Disease Status^10,11 mostrou significativos números relativos à incapacidade por DAC em idosos, comparando indivíduos com idade entre 55 e 69 anos e 70 e 88 anos (Tabelas 1 e 2).

Esses dados revelaram que entre indivíduos portadores de DAC, com idade entre 55 e 69 anos, 56% apresentavam incapacidade, sendo 49% dos homens e 67% das mulheres, se contrapondo à taxa de 18% entre indivíduos na mesma faixa etária e sem DAC, sendo 9% dos homens e 25% das mulheres^3,12,13.

No grupo mais idoso portador de DAC a incapacidade atinge uma taxa maior que 76%^3,10,11.

A atividade física corretamente orientada, tanto em idosos saudáveis como em cardiopatas, altera favoravelmente o metabolismo lipídico e dos carboidratos, induz o aumento dos níveis de lipoproteínas de alta densidade (HDL), tem efeito benéfico sobre a distribuição do tecido adiposo, melhora a sensibilidade insulínica, sendo importante na redução do risco cardiovascular⁶.

Apesar do ainda pequeno número de trabalhos com idosos e reabilitação, é indiscutível a melhora da capacidade funcional desse grupo, justificando maior difusão dos programas de reabilitação para essa faixa etária. Os resultados apontam para melhor desempenho das atividades de vida diária e das atividades instrumentais de vida diária^4,1418.

Elementos de relevância na prescrição e na avaliação da atividade física

Considera-se que a capacidade máxima de realizar um trabalho diminui com a idade, como resultado do menor consumo de oxigênio para a realização de um exercício dinâmico. Conceitualmente o consumo máximo de oxigênio (VO₂ max) é a maior quantidade de oxigênio (O₂) que uma pessoa consegue extrair do ar inspirado, no esforço máximo, expressando a quantidade de O₂ transportado e usado para o metabolismo celular¹⁹²¹. O VO₂ max encontra-se significativamente relacionado à idade, sendo seu valor máximo encontrado entre 15 e 30 anos, caindo, a partir de então, gradativamente. Aos 60 anos, o VO₂ max é aproximadamente um quarto daquele dos 20 anos. Por outro lado, a capacidade aeróbica é beneficamente influenciada pela atividade física. Nos indivíduos inativos ocorre redução de 9% no VO₂ max por década em relação a 5% nos indivíduos ativos²¹. Um indivíduo em repouso, sentado, consome 3,5ml/O₂/kg/min, ou 3,5kcal/kg/min, representando o equivalente metabólico denominado – MET. Esta unidade permite avaliar o gasto energético durante uma determinada atividade física em relação ao repouso. Apresenta relevante importância, servindo de base para a prescrição de atividade física^19,6,18.

O VO₂ max é limitado em presença de doenças pulmonares graves e difusas. Só é atingido por esforço com duração igual ou superior a 5 minutos. É inversamente proporcional à idade¹⁹.

A freqüência cardíaca (FC) é influenciada por inúmeros fatores, incluindo a idade ^19,21,22. Nos idosos, a FC máxima encontra-se diminuída tanto em repouso como no esforço, fenômeno que parece estar ligado a uma ineficaz modulação simpática²².

No entanto, a resposta da FC ao exercício não é atribuída aos níveis mais baixos de catecolaminas; ao contrário, os níveis de catecolaminas plasmáticas nos idosos são especialmente mais altos com o exercício²³. Já a pressão arterial nos idosos tende a ser um pouco mais alta tanto em repouso como no esforço.

Reabilitação cardiovascular no Infarto Agudo do Miocárdio

O objetivo da atividade física e da reabilitação cardiovascular no idoso é melhorar ou recuperar ao máximo a capacidade funcional^24,25, seja após um episódio clínico agudo seja pela necessidade de melhorar a capacidade de tolerância ao esforço. Esses objetivos são alcançados através de programas que visam aumentar a capacidade aeróbica, a força muscular e a flexibilidade²⁶. Esse grupo de idosos, entretanto, exige cuidadoso levantamento de comorbidades que, no mínimo, podem interferir diretamente com a modalidade e a intensidade do exercício^18,20.

A reabilitação cardíaca é um programa multidisciplinar de educação e exercício, tendo em vista o desenvolvimento e a manutenção do nível funcional físico, social e psicológico desde o início do acometimento, portanto, na fase aguda da doença⁷.

Diversas condições clínicas são passíveis de programas de reabilitação: infarto do miocárdio, revascularização miocárdica, angioplastia, angina estável, insuficiência cardíaca crônica, troca de válvula, hipertensão arterial, entre outras^5,9.

Algumas situações clínicas, contudo, contra-indicam o início da reabilitação cardiovascular: infecções sistêmicas, tromboembolismo, endocardite, doenças musculoesqueléticas, insuficiência cardíaca descompensada, miocardites e pericardites, hipertensão arterial não-controlada, arritmias complexas, distúrbios metabólicos descompensados e fase precoce de cirurgia cardíaca^21,27.

Todos os pacientes devem ser submetidos a teste ergométrico (TE) com o objetivo de avaliar a segurança do programa a ser instituído. Nos idosos, a estabilidade musculoesquelética deve ser analisada com cuidado, já que costumam mostrar restrições conseqüentes, principalmente, a processos osteoarticulares²⁸.

O TE analisa a capacidade aeróbica, o balanço entre a carga de trabalho e a FC, além de estratificar o risco de cada indivíduo. Por outro lado, estabelece um padrão inicial, definindo um parâmetro que servirá de base para o acompanhamento da resposta ao plano de reabilitação instituído (Quadro 1).

Nos idosos são utilizados, com freqüência, protocolos modificados para a realização de TE. São esperados, como resposta, FC mais baixas e níveis maiores de pressão arterial sistólica.

No Brasil ainda não é comum a realização de TE em indivíduos com limitação física através de ergômetros para braço.

O TE define critérios para a individualização de programas de exercício. Nos pacientes anginosos é determinada a FC e a carga de esforço que desencadeiam o sintoma, adequando-se o programa de exercício para um estágio abaixo⁹. Nos hipertensos e coronariopatas, o nível de esforço deve manter a pressão arterial sistólica abaixo de 200mmHg e a diastólica abaixo de 110mmHg. O consumo de oxigênio deve ser mantido entre 60% e 70% do VO₂ max e a FC entre 50% e 60% da FC

de reserva. O duplo produto, resultado da multiplicação da pressão arterial sistólica pela FC no pico de esforço, deve ser mantido dentro dos valores normais. A FC estabelecida, seja limitada pelo cansaço, determinada por sintoma ou por nível percentual de FC, é chamada freqüência cardíaca de treinamento (FCT)²⁷. Em geral a FCT corresponde de 50% a 75% da freqüência cardíaca de reserva determinada pela aplicação da fórmula: (FCmax-FCR) x 50% (ou75%) + FCR, em que FCmax = freqüência cardíaca máxima, FCR = freqüência cardíaca de repouso⁶. A freqüência máxima é calculada pela fórmula de Karvonen – FCmax = 220-idade.

A depressão do segmento ST induzida pelo esforço deve ser menor que 2mm nos pacientes aceitos para reabilitação, devendo ser reavaliados com utilização de nitrato sublingual para a determinação da freqüência cardíaca de treinamento, isto é, a FC máxima que manterá o segmento ST acima de 2mm de infradesnivelo²⁷. O supradesnivelo de segmento ST superior a 1mm por isquemia miocárdica primária contra-indica o início do programa de reabilitação, enquanto que decorrente de fibrose ou hipertrofia ventricular requer a adoção de criteriosos cuidados^8,27.

No IAM, objetivos específicos na reabilitação cardíaca incluem estratificação de risco, melhora de bem-estar social e psicológico, redução dos fatores de risco, alívio nos sintomas e melhora da capacidade funcional, propiciando boa qualidade de vida.

Esse programa é constituído pela fase hospitalar, fase I, envolvendo o período de internação; fase II, envolvendo o período inicial após a alta hospitalar, algumas vezes ainda requerendo telemetria; fase III realizada em grupos e ainda sob supervisão de equipe especializada e a fase IV habitualmente sob autocontrole^7,29.

A fase I pode ser subdividida em duas etapas: A fase I A é aquela que ocorre na fase aguda do infarto do miocárdio, tendo lugar na unidade coronariana e envolvendo exercícios de baixa intensidade, de até 3 METs; são especificamente exercícios de condicionamento e de treinamento para as atividades funcionais, correspondendo de 30% a 40% da FC max, incluindo movimentação passiva e exercícios respiratórios. A fase I B se refere à fase de reabilitação CV orientada por equipe hospitalar especializada; é iniciada no quarto após êxito na fase I A, implicando em exercícios ativos de braços, de pernas e deambulação, correspondendo a até 4 METs de intensidade^23,30. Todas as etapas desta fase são realizadas com monitoramento cardíaco via telemetria. Um dos objetivos da fase I B é propiciar uma transição segura do ambiente hospitalar para a reabilitação ambulatorial, portanto, do paciente já em residência^7,29. A fase I é importante para reduzir os sintomas de hipotensão ortostática, os riscos de tromboembolismo, as complicações musculoesqueléticas e a hipoventilação.

A fase II tem início 1 ou 2 semanas após a alta hospitalar, já com o paciente em casa e reúne um conjunto de medidas que envolve programa educacional com modificação de estilo de vida, além do programa de atividade física supervisionada, determinada pelo TE, atingindo de 60% a 75% da FC do TE. Nesta fase já é permitida atividade sexual. Interrupção   do   fumo,   redução   de peso, normalização dos lípides sangüíneos, controle dos níveis de estresse e modificações dietéticas, principalmente, complementam os programas de reabilitação física com o objetivo de promover prevenção secundária³¹ e melhora da qualidade de vida. É iniciada nos IAM pequenos e após os procedimentos de trombólise ou angioplastia. No pós-operatório de cirurgia de revascularização miocárdica o programa de exercícios é iniciado a partir da terceira semana ^21,27,30.

A fase III, em geral sem telemetria, é baseada em programas determinados por novo teste ergométrico. É iniciada pelo menos após o terceiro mês do evento, atingindo o décimo segundo. São indicados exercícios isotônicos, aeróbicos, evitando-se os isométricos puros. É permitido o uso de pequenos pesos. Os exercícios podem atingir entre 60% e 70% da capacidade aeróbica máxima^21,27,30.

A fase IV já não requer supervisão^21,27, tendo início, habitualmente, a partir do primeiro ano do evento agudo, devendo o paciente manter os critérios adotados de mudança de estilo de vida e programa de exercícios de forma permanente. Também introduzida após a reavaliação por TE.

Os exercícios devem ser constituídos, após criteriosa avaliação, por um estágio de alongamento, com duração de 5 a 10 minutos, seguido por 30 a 40 minutos de exercícios aeróbicos dinâmicos contínuos como andar, pedalar, ciclismo eventualmente, de acordo com a avaliação, corridinha e leve atividade isométrica, com halteres de baixo peso para as mãos. E, por fim, uma fase final de resfriamento também constituída por exercícios de alongamento⁷.

Aspectos práticos na prescrição de exercícios

A estratégia de implantação e manutenção do programa de reabilitação cardiovascular deve seguir normas bem estabelecidas, sendo consideradas: freqüência, duração, intensidade e supervisão. Entretanto, é necessário estabelecer, como primeira medida, um elo de confiança com uma franca troca de informações, esclarecendo todo o procedimento com ênfase nos benefícios conquistados ao longo do tempo, visando despertar maior interesse pelo programa^6,21. Tal conduta é fundamental na persuasão dos pacientes idosos, em geral, mais cautelosos na adoção de novos procedimentos¹⁸.

Os exercícios devem ter uma freqüência de 3 a 5 vezes por semana, com duração de 30 minutos, obedecendo à intensidade estabelecida previamente pelo TE⁶. Os pacientes com história clínica de DCV devem iniciar o programa de reabilitação sob supervisão médica, mantida até que o paciente aprenda a conhecer os seus limites^3,4,21. Quando houver dificuldade de acesso ou financeira, o programa pode ser supervisionado por professor de educação física, porém em pacientes rigorosamente selecionados, clinicamente estáveis e capazes de assimilar os critérios de controle e interrupção da atividade. Nessa circunstância, o acesso a um eventual atendimento de emergência é mais difícil, sendo liberados para exercícios não supervisionados apenas pacientes que não apresentem quadros cardiológicos agudos, déficit inotrópico ao TE, HA refratária, baixa fração de ejeção, doenças metabólicas descompensadas, angina instável, arritmias ventriculares complexas (Lown III e IV), obesidade e capacidade aeróbica baixa²⁷.

A atividade física deve ser precedida por uma fase de aquecimento, incluindo alongamento, mobilidade articular e caminhada, indispensáveis principalmente para os idosos, mais susceptíveis às lesões articulares e musculares. O término da sessão deve ser precedido por exercícios de alongamento e por gradativa volta à calma. Algumas recomendações devem ser observadas para uma segura e adequada realização de exercícios²⁶ Quadro 2)²⁷.

A atividade física pode levar a injúrias osteoarticulares mais freqüentemente nos pacientes idosos, em especial nas mulheres, devendo ser evitados os exercícios de alto impacto. Nesses indivíduos, a atividade física deve ser iniciada progressivamente, permitindo gradual adaptação ao esforço muscular e ao impacto articular.

Mesmo após a fase supervisionada, a prescrição do programa de recuperação impõe obediência a critérios que visam dar segurança ao paciente. Os dados obtidos pelo TE orientam a prescrição através do VO₂ max e do número de METs alcançados, determinando a FC de equilíbrio.

De uma forma prática, o Quadro 3 correlaciona o nível de intensidade de algumas atividades físicas, mais utilizadas, em METs³².

A equivalência da intensidade do exercício com a queima calórica obtida é fácil de ser compreendida, considerando-se as equivalências abaixo³²:

• Caloria – é a quantidade de calor necessária para elevar a temperatura de 1g de água em 1^oC, na vizinhança de 15^oC, e à pressão constante.

• 1000 calorias = 1 kilocaloria

•5 kilocalorias = 1 litro de oxigênio consumido

• 7000 kilocalorias = 1 kg de gordura

Uma atividade diária de intensidade moderada, durante 30 minutos, consome cerca de 1400 calorias semanais^1,33.

A indicação de caminhada representa uma solução prática para idosos e sedentários, mantendo-se o critério do controle da FC antes e imediatamente após³³. É aconselhável, entretanto, a associação de exercícios de resistência e de flexibilidade com duração de 15 minutos, gerando melhor condicionamento físico. Nos idosos os exercícios com pequenos pesos colaboram para melhorar o tônus muscular e para preservar a massa óssea, enquanto que os exercícios de alongamento são importantes para melhorar a flexibilidade.

Até a década de 90, no século passado, os exercícios de resistência não eram incluídos nos manuais de reabilitação, embora há muito tenham sido reconhecidos como meio de manutenção de força muscular, desenvolvimento de elasticidade e resistência, com ganho de massa muscular. Os benefícios dos exercícios de resistência são diferentes daqueles obtidos com os aeróbicos, entretanto, hoje indicados em todas as idades¹⁸.

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