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PubMed2005

Medical management of peripheral arterial disease.

Whether symptomatic or not, peripheral arterial disease (PAD), atherosclerosis in the arteries of the lower extremities, is a common disorder in the general population. The prevalence increases with age and under the influence of vascular risk factors. The most classic symptomatic expression of PAD is intermittent claudication. However, the majority of patients with PAD is asymptomatic or has leg symptoms other than classic intermittent claudication. Both symptomatic and asymptomatic subjects with PAD have increased mortality rates, mainly due to cardiovascular and cerebrovascular expressions of atherosclerotic disease. This review focuses on the current available medical therapies for PAD, including risk-factor modification and antiplatelet therapies, as well as strategies for symptomatic relief in both patients with intermittent claudication and patients with critical limb ischemia. In general, risk factor modification and antiplatelet therapy is essential in all patients with PAD to prevent systemic atherosclerotic complications. Furthermore, for symptomatic relief exercise therapy is the main intervention while pharmacological treatment should be only complementary. In patients with critical limb ischemia, when revascularization therapy is not possible, an attempt should be made to avoid amputation with conservative treatment using analgesics, vasodilators and/or anticoagulants. In case of an acute onset of critical limb ischemia, thrombolysis is indicated.

Anticoagulants↗
PubMedDate not supplied

Pharmacotherapy for peripheral arterial disease: emerging therapeutic options.

Although endovascular therapy has revolutionized the management of patients with peripheral arterial disease (PAD), noninterventional regimens, such as structured exercise therapy, atherosclerotic risk factor modification, and pharmacotherapy, are effective in patients suffering from mild-to-moderate PAD and intermittent claudication (IC). For more than a decade, the only pharmacologic therapy for IC available in the United States was pentoxifylline, which had demonstrated superiority in improving walking distances but offered minimal clinical benefit. Recently, basic research into the pathophysiology of IC has led to the development of cilostazol, a new pharmacologic agent approved for treatment of this condition in 1999. Ongoing research in the use of angiogenic growth factors has further broadened the range of potential alternatives to treatment in patients with PAD. Revascularization procedures, including nonsurgical and surgical techniques, can thus be reserved to improve patency and reduce the risk of limb loss in patients with PAD and IC with more severe impairment.

Anticholesteremic Agents↗
PubMed1992

A community of caring. Patients in a rehabilitation unit experience holistic healing through a spiritual support group.

Empowered by empathic knowledge of the pain and suffering endured by patients, a pastoral care giver can foster holistic healing, integrating a spiritual dimension into the lives of responsive individuals by helping them form a circle of love, a Community of Caring. A Community of Caring can be effective in many specialized hospital units or long-term care centers. In a hospital physical rehabilitation unit, for example, a chaplain successfully provided a time, place, and ambience where patients could share their deepest feelings, thoughts, and concerns and learn together techniques of coping. This Community of Caring helped patients overcome feelings of inadequacy and low self-esteem, encouraged self-acceptance despite physical losses, and stimulated new concepts of spirituality, notably the importance and the sacredness of the present time spent in recuperation. Participants in the Community of Caring discussed ideas such as the concept that all activity, even mundane rejuvenative therapy exercises, can be--at least potentially--sacramental activity; the importance of fully using all facets of physical therapy; and the idea that days spent in recuperation can be a time for deepened relationship with self, others, and a compassionate God. The sessions helped many patients mobilize their inner resources and assume greater personal responsibility for their healing and recovery.

Catholicism↗
PubMed1999

Understanding new pharmacologic therapy for type 2 diabetes.

As the understanding of diabetes continues to improve and treatment methods expand, the clinician can now offer patients with diabetes a greater chance of improved health with fewer complications from diabetes. Aggressive, early treatment of type 2 diabetes, with the goal of achieving a maximum HbA1c of 8% and an ideal of less than 7%, is both health-enhancing and cost-effective. Nonpharmacologic treatments, such as nutrition therapy, exercise, weight loss, and self-management education programs are the most important aspects of care. Pharmacologic therapy should be based on a number of factors and should be individualized for each patient. Treatment options in diabetes will continue to expand as new medications become available and further refinements in treatment decisions occur.

Blood Glucose↗
PubMed1985

Use and misuse of behavioral homework exercises in sex therapy.

This paper examines uses of sexual exercises and their role in effecting changes in attitudes, behaviors, and feelings. In reaction to the charge that exercises are overly mechanistic, clinicians now underutilize exercises and/or give only general suggestions. The common errors of nonspecificity, use as a cookbook, quick abandonment, and setting performance criterion are discussed. The use of semistructured, written exercises which function as in vivo desensitization, facilitate development of verbal and stimulation skills, and provide a positive model of sexuality are most efficacious. A case example illustrating the multiple therapeutic benefits of exercises is presented.

Attitude↗
PubMed2000

Osteoarthritis: manageable scourge of aging.

Osteoarthritis is one of the most prevalent diseases of aging. An overview of osteoarthritis including definition, joints affected, clinical course, and classification is provided. Contributing factors, such as age, sex, ethnicity, obesity, diet, estrogen, and activity are discussed. Nursing interventions encompass weight control, adequate nutrition, evaluation of hormone replacement therapy, exercise and muscle strengthening, the use of assistive devices, medication assessment, pain control, psychosocial support, and the use of alternative therapies. Osteoarthritis can be successfully managed with the use of multifocal modalities.

Aging↗
PubMed1996

Effects of aquatic therapy on joint flexibility and functional ability in subjects with rheumatic disease.

Currently, there is a deficit of objective data showing the efficacy of aquatic exercise therapy in improving function in individuals with rheumatic disease. The purpose of this study was to quantify the effectiveness of aquatic therapy in changing joint motion, functional status, assistance, pain, and difficulty in 13 subjects with rheumatic disease. Active joint motion and Functional Status Index scores of assistance, pain, and difficulty were taken prior to and following 8 weeks of aquatic therapy. Multivariate analysis of variance, analysis of covariance procedure controlling for pain, and a Pearson correlation between active joint motion and Functional Status Index changes and between assistance, pain, and difficulty scores of the Functional Status Index were conducted. Results showed a significant difference between the pre and post means of active joint motion, Functional Status Index, pain, and difficulty (p < .05); a significant, negative relationship between pain and active joint motion of select joints; and positive correlations between assistance and pain, assistance and difficulty, and pain and difficulty. The decreased pain and difficulty experienced in performing daily tasks contributed significantly (94%) to the overall increased functional status and active joint motion for select joints. These findings support aquatic therapy as an effective means of increasing joint flexibility and functional ability while reducing pain and difficulty with daily tasks.

Activities of Daily Living↗
PubMed1981

Long-term antianginal action of verapamil assessed with quantitated serial treadmill stress testing.

The long-term efficacy of verapamil in a dose of 360 mg daily in patients with chronic stable angina pectoris was assessed by quantitated serial treadmill exercise tests. Twenty-eight patients were investigated with a placebo-controlled, double-blind, crossover protocol of 2 weeks each and afterward all patients were put on long-term therapy. Exercise tests were performed at the end of the placebo period and after 2, 4, 8, 16, 24 and 52 weeks of verapamil therapy. All 28 experienced angina during treadmill tests on placebo and the mean (+/- standard error of the mean) exercise time was 6.6 +/- 0.5 minutes. This increased to 9.2 +/- 0.8 minutes at 2 weeks and 50 11.2 +/- 0.8 minutes at 4 weeks. Fifteen and 20 of the 28 patients became angina-free during treadmill exercise at 2 and 4 weeks, respectively. The consumption of nitroglycerin showed a similar improvement. The improvement was maintained at 1 year of follow-up. The on-line computer-analyzed S-T segment changes showed a statistically significant improvement at all follow-up periods. Withdrawal of verapamil produced a return to pretreatment levels. The adverse effects noted were constipation in seven patients and reversible P-R interval prolongation in two. No heart failure occurred in any patient. These findings suggest that verapamil possesses a powerful and sustained antianginal action and, in a dose of 360 mg daily, merits a place as a primary therapeutic agent in the management of chronic stable angina.

Adult↗
PubMed2003

Automated analysis of repetitive joint motion.

Automated measurement, analysis, and comparison of human motion during performance of workplace tasks or exercise therapy are core competencies required to realize many telemedicine applications. Ergonomic studies and telemonitoring of patients performing rehabilitation exercises are examples of applications that would benefit from a representation of complex human motion in a form amenable to comparison. We present a representation of joint motion suitable for the analysis of multidimensional angular joint motion time series data. Complex motion is reduced to a concatenation motion segments, where simple dynamic models approximate the observed motion on each segment. This compact representation still enables measurement of statistics familiar to ergonomics practitioners such as cycle length and task duration. An algorithm to obtain this representation from observed motion data (time series) is given. We introduce a metric, based on a kinetic energy-like measure, to compare motions. Experiments are presented to demonstrate the representation, its relationship to previous measures and the applicability of the kinetic energy metric for motion comparison.

Algorithms↗
PubMed2003

The challenges of treating peripheral arterial disease.

Today, peripheral arterial disease (PAD) patients need effective medical care for an extended period of their lifetime. Therefore, different treatment modalities have to be tied sequentially into an effective therapeutic chain. First, preventive measures have to be reinforced and risk factors tightly controlled. Furthermore, antiplatelet agents have to be applied in every PAD patient to reduce the risk of cardiac and cerebral ischemic events, restenosis or reocclusion after revascularization, and possibly also progression of the PAD itself. Angiotensin-converting enzyme (ACE) inhibitors should be entertained in high-risk groups such as PAD patients with diabetes. In the claudicant, exercise therapy should be strongly encouraged and vasoactive drugs considered for those who are not good candidates for either exercise training or revascularization. In patients with disabling claudication or critical limb ischemia, revascularization procedures are highly effective. Especially for high-grade stenoses or short arterial occlusions, percutaneous transluminal angioplasty (PTA) should be the method of first choice followed by the best surgical procedure later on. To achieve good long-term efficacy, a close follow-up including objective tests of both the arterial lesion and hemodynamic status, surveillance of secondary preventive measures and risk factor control is mandatory.

Cost-Benefit Analysis↗
PubMed1986

Acute and sustained effects of isosorbide 5-mononitrate in stable angina pectoris.

Isosorbide 5-mononitrate (IS 5-MN) is an active metabolite of isosorbide dinitrate and is widely used as an antianginal agent. The acute and subacute (2 weeks) effects of IS 5-MN, 40 mg twice daily, were evaluated in 18 patients with stable angina pectoris using computerized exercise testing and a placebo-controlled, double-blind, randomized trial protocol. There were 2 phases of 2 weeks each in which patients received placebo or active IS 5-MN. Acute testing (8 patients) was performed 2 hours after the first dose and subacute testing 2 hours after the morning dose on day 14. Acute testing showed an increase in exercise time from a mean (+/- standard error of mean) of 8.2 +/- 0.6 minutes to 11.1 +/- 0.5 minutes (p less than 0.001) after a single dose of IS 5-MN. Time to 1 mm of ST depression increased significantly and peak exercise ST-segment depression decreased significantly. Rest and peak exercise heart rate increased significantly during acute testing with IS 5-MN; blood pressure did not change significantly. After 2 weeks of therapy, exercise time had not changed (9.9 +/- 0.6 with placebo to 9.7 +/- 0.6 minutes). The beneficial effects on ST-segment variables were sustained at 2 weeks. The data suggest that there is an attenuation of effect with respect to exercise time and sustained beneficial effect on the ST-segment variables. This may be a result of development of partial tolerance to IS 5-MN after 2 weeks of therapy.

Adult↗
PubMed1994

Lymphedema reduction by noninvasive complex lymphedema therapy.

Noninvasive complex lymphedema therapy (CLT), a technique of manual lymph drainage, compressive bandaging, and specific physical therapy exercises, has been utilized successfully to treat lymphedema in Europe and Australia. This paper reports the results of such therapy in 38 patients (16 females with arm lymphedema secondary to breast surgery, 18 patients with unilateral lower extremity lymphedema, and 4 individuals with bilateral leg disease) for 1 month. Reduction of edema averaged 73% among the patients with arm disease, and 88% among those with leg lymphedema; both reductions are statistically significant. Thirty patients have been followed for up to 1 year. During this period, their average reduction in lymphedema of 80% improved to 86%. We conclude that CLT significantly and safely reduces lymphedema. Reductions not only are maintained after the initial therapy but may increase in magnitude.

Adolescent↗
PubMed1984

Long-term efficacy of diltiazem assessed with multistage graded exercise tests in patients with chronic stable angina pectoris.

The long-term efficacy of diltiazem, 360 mg/day, in patients with grade II or III stable exertional angina pectoris (Canadian Cardiovascular Society criteria) was assessed by multistage graded exercise tests. Seventeen patients undertook a placebo-controlled, double-blind, dose-titration protocol and all received long-term therapy. Exercise tests were performed at the end of 2 weeks of placebo treatment and after 6, 18, 26, 40 and 52 weeks of diltiazem, 360 mg/day. All patients had angina during treadmill testing with placebo and the mean (+/- standard error of the mean) exercise time was 5.8 +/- 0.7 minutes. This increased to 10.8 +/- 1.0 minutes after 6 weeks, 11.3 +/- 1.1 minutes after 18 weeks, 11.4 +/- 1.1 minutes after 26 weeks, 12.9 +/- 1.2 minutes after 40 weeks and 11.6 +/- 1.3 minutes after 52 weeks of continuous diltiazem therapy (p less than 0.001 vs placebo at all stages). Four patients were withdrawn after 26 weeks of treatment; one patient underwent coronary artery bypass surgery and 3 patients required the addition of beta-adrenoreceptor blocking agents. In 1 patient an irritant rash developed on the torso, legs and arms after 39 weeks of diltiazem and disappeared after discontinuing the drug. One patient complained of swelling and stiffness of the fingers and 3 patients complained of shoulder and elbow pain. Another patient had a myocardial infarction after 8 weeks of diltiazem treatment and died. No other adverse effects were observed during this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1999

Keeping children with exercise-induced asthma active.

Exercise-induced bronchospasm, exercise-induced bronchoconstriction, and exercise-induced asthma (EIA) are all terms used to describe the phenomenon of transient airflow obstruction associated with physical exertion. It is a prominent finding in children and young adults because of their greater participation in vigorous activities. The symptoms shortness of breath, cough, chest tightness, and wheezing normally follow the brief period of bronchodilation present early in the course of exercise. Bronchospasm typically arises within 10 to 15 minutes of beginning exercise, peaks 8 to 15 minutes after the exertion is concluded, and resolves about 60 minutes later, but it also may appear during sustained exertion. EIA occurs in up to 90% of asthmatics and 40% of patients with allergic rhinitis; among athletes and in the general population its prevalence is between 6% and 13%. EIA frequently goes undiagnosed. Approximately 9% of individuals with EIA have no history of asthma or allergy. Fifty percent of children with asthma who gave a negative history for EIA had a positive response to exercise challenge.6 Among high school athletes, 12% of subjects not considered to be at risk by history or baseline spirometry tested positive. Before the 1984 Olympic games, of 597 members of the US team, 67 (11%) were found to have EIA. Remarkably, only 26 had been previously identified, emphasizing the importance of screening for EIA even in well-conditioned individuals who appear to be in excellent health. The severity of bronchospasm in EIA is related to the level of ventilation, to heat and water loss from the respiratory tree, and also to the rate of airway rewarming and rehydration after the challenge. Postexercise decrease in the peak expiratory flow rate of normal children may be as much as 15%; therefore, only a decrease in excess of 15% should be viewed as diagnostic. EIA is usually provoked by a workload sufficient to produce 80% of maximum oxygen consumption; however, in severe asthmatics even minimal exertion may be enough to produce symptoms. Patients with normal lung function at rest may have severe air flow limitation induced by exercise,10 and as many as 50% of patients who are well-controlled with inhaled corticosteroids still exhibit EIA. A challenge of sufficient magnitude will provoke EIA in all patients with asthma. PHARMACOLOGIC THERAPY: Exercise, unlike exposure to allergens, does not produce a long-term increase in airway reactivity. Accordingly, patients whose symptoms manifest only after strenuous activity may be treated prophylactically and do not require continuous therapy. Most asthma medications, even some unconventional ones such as heparin, furosemide, calcium channel blockers, and terfenadine, given before exercise, suppress EIA. McFadden accounts for the efficacy of these disparate classes of drugs by their potential effect on the bronchial vasculature that modulates the cooling and/or rewarming phases of the reaction. Short-acting -agonists provide protection in 80% to 95% of affected individuals with insignificant side effects and have been regarded for many years as first-line therapy. Two long-acting bronchodilators, salmeterol and formoterol, have been found effective in the prevention of EIA.18-21 A single 50-microg dose of salmeterol protects against EIA for 9 hours; its duration appears to wane in the course of daily therapy. Cromolyn sodium is highly effective in 70% to 87% of those diagnosed with EIA and has minimal side effects. Nedocromil sodium provides protection equal to that of cromolyn in children. Children commonly engage in unplanned physical activity and sometimes are not allowed to carry their own medication. Thus, a simple long-acting regimen given at home is likely to be more effective than short-acting drugs that must be administered in a timely manner. Although the 12-hour protection by salmeterol reported by Bronsky et al may not persist with continued use, the 9-hour duration of action is

Anti-Asthmatic Agents↗
PubMed1989

Focus on diastolic dysfunction: a new approach to heart failure therapy.

1. Although heart failure is commonly associated with depressed systolic function, there is increasing evidence that impaired diastolic performance is also universally present and might be a key determinant of symptoms, physical capacity and even survival in some subsets of patients. 2. Reduced diastolic distensibility increases cardiac filling pressure not only at rest, but even more during exercise when diastolic filling time is reduced. The increases in filling pressure and diastolic wall stress lead to pulmonary congestion and subendocardial ischaemia, it also triggers myocardial hypertrophy and a detrimental remodelling of the ventricular cavity. Perhaps even more importantly, impaired ventricular distensibility limits the use of the Frank-Starling mechanism, impairing systolic pump function and cardiac output adaptation during exercise. Therapies able to improve the distensibility of the ventricle are, therefore, desirable in heart failure. 3. Nitrates, angiotensin converting enzyme (ACE) inhibitors and diuretics may indirectly increase left ventricular chamber compliance by their effects on the right side of the heart. Cardiac glycosides do not improve myocardial relaxation and may even cause diastolic contracture at toxic doses. The new beta 1-adrenoceptor partial agonist, xamoterol, on the other hand, consistently lowers left ventricular filling pressure at rest and during exercise, and produces an increase in left ventricular dynamic compliance through the direct lusitropic effect of beta 1-adrenoceptor stimulation. These beneficial effects are maintained during prolonged therapy and also appear sufficient to slow the remodelling of the ventricular cavity. The improvement in symptoms and in exercise tolerance observed during xamoterol (Corwin, Carwin, Corwil, Xamtol, ICI 118,587) therapy might, therefore, be related to the improvement in left ventricular diastolic distensibility induced by this drug.

Adrenergic beta-Agonists↗
PubMed2003

Cognitive behavioral therapy and aerobic exercise for Gulf War veterans' illnesses: a randomized controlled trial.

CONTEXT: Gulf War veterans' illnesses (GWVI), multisymptom illnesses characterized by persistent pain, fatigue, and cognitive symptoms, have been reported by many Gulf War veterans. There are currently no effective therapies available to treat GWVI. OBJECTIVE: To compare the effectiveness of cognitive behavioral therapy (CBT), exercise, and the combination of both for improving physical functioning and reducing the symptoms of GWVI. DESIGN, SETTING, AND PATIENTS: Randomized controlled 2 x 2 factorial trial conducted from April 1999 to September 2001 among 1092 Gulf War veterans who reported at least 2 of 3 symptom types (fatigue, pain, and cognitive) for more than 6 months and at the time of screening. Treatment assignment was unmasked except for a masked assessor of study outcomes at each clinical site (18 Department of Veterans Affairs [VA] and 2 Department of Defense [DOD] medical centers). INTERVENTIONS: Veterans were randomly assigned to receive usual care (n = 271), consisting of any and all care received from inside or outside the VA or DOD health care systems; CBT plus usual care (n = 286); exercise plus usual care (n = 269); or CBT plus exercise plus usual care (n = 266). Exercise sessions were 60 minutes and CBT sessions were 60 to 90 minutes; both met weekly for 12 weeks. MAIN OUTCOME MEASURES: The primary end point was a 7-point or greater increase (improvement) on the Physical Component Summary scale of the Veterans Short Form 36-Item Health Survey at 12 months. Secondary outcomes were standardized measures of pain, fatigue, cognitive symptoms, distress, and mental health functioning. Participants were evaluated at baseline and at 3, 6, and 12 months. RESULTS: The percentage of veterans with improvement in physical function at 1 year was 11.5% for usual care, 11.7% for exercise alone, 18.4% for CBT plus exercise, and 18.5% for CBT alone. The adjusted odds ratios (OR) for improvement in exercise, CBT, and exercise plus CBT vs usual care were 1.07 (95% confidence interval [CI], 0.63-1.82), 1.72 (95% CI, 0.91-3.23), and 1.84 (95% CI, 0.95-3.55), respectively. The OR for the overall (marginal) effect of receiving CBT (n = 552) vs no CBT (n = 535) was 1.71 (95% CI, 1.15-2.53) and for exercise (n = 531) vs no exercise (n = 556) was 1.07 (95% CI, 0.76-1.50). For secondary outcomes, exercise alone or in combination with CBT significantly improved fatigue, distress, cognitive symptoms, and mental health functioning, while CBT alone significantly improved cognitive symptoms and mental health functioning. Neither treatment had a significant impact on pain. CONCLUSION: Our results suggest that CBT and/or exercise can provide modest relief for some of the symptoms of chronic multisymptom illnesses such as GWVI.

Adult↗
PubMed1994

[The history and clinical importance of cardiopulmonary assessment of working fitness with special reference to spiroergometry].

Spiroergometry-a synonym for ergospirometry or ergospirography - is a diagnostic procedure to continuously registrate respiration and gas metabolism during ergometer exercise. It enables to judge function and performance capacity of the cardiopulmonary system and metabolism. Spiroergometry is made up of the two components spirometry and ergometry. The first attempts to measure human gas metabolism while performing a quantified physical work can be traced back to the year 1789. The development of procedures to measure gas metabolism and respiration as well as the construction of ergometers in the 19th and 20th century are described. 1929 saw the introduction of spiroergometry and routinely performed clinical performance diagnosis. But not until the 1950s was the first spiroergometric apparatus which met all scientific requirements developed. In a historical frame, the used parameters and the physiological and pathophysiological findings by spiroergometry are given. Numerous medical fields have profited from the technique of spiroergometry: cardiology, pulmonology, sports medicine, performance physiology, biochemistry, clinical pharmacology, surgery, orthopedics, pediatrics, gerontology, etc. besides such global disciplines as preventive medicine, exercise therapy, and rehabilitative medicine.

Cardiovascular Diseases↗