This document outlines a study that will investigate the effects of a physical fitness program called "Younger Longer" on patients with resistant hypertension. A meeting is held where concepts for post-graduate research presentations are discussed. One concept presented is a randomized controlled trial that will examine the cardiovascular effects of the Younger Longer fitness program in managing resistant hypertension. The presenter receives feedback on refining their study design and methodology. Supervisors are then assigned to provide guidance on the proposed research.
This document discusses various health screening tests that can be performed to monitor health status. It describes primary health screening tests that can be done without a physician's prescription to check factors like blood glucose, cholesterol, and blood pressure. Secondary tests are done after a diagnosis to monitor disease. Common tests discussed include lung function tests using spirometry to evaluate lung capacity and diffusion, as well as cholesterol tests using calorimetry to determine cardiovascular disease risk. Health screening services are important for early detection of disease and monitoring health accurately and cost-effectively.
This study compared cardiovascular responses to exercise between normotensive offspring of normotensive parents and normotensive offspring of hypertensive parents. It found that resting diastolic blood pressure was significantly higher in offspring of hypertensive parents. During a 6-minute walk test, there was a decreased diastolic blood pressure response to exercise in offspring of hypertensive parents. However, the distance covered during the test did not differ between groups. The study concludes there is an early trend toward higher blood pressure in offspring of hypertensive parents and an abnormal pattern of heart rate and blood pressure recovery from exercise.
Mrs. Archana Morey is an assistant professor of nursing who authored a document about cardiac rehabilitation. The document defines cardiac rehabilitation as measures used to help people with heart disease return to an active life and prevent future cardiac events. It describes the benefits of cardiac rehab such as reducing the risk of death from heart problems and improving quality of life through lifestyle changes like exercise and diet. The document outlines the cardiac rehab process and team as well as expectations, risks, and outlook.
The Historical And Clinical Significance Of The 6 Minute Walk Testdgrinnell
The 6-minute walk test (6MWT) is a simple, objective test used to assess functional capacity. It measures how far a patient can walk in 6 minutes. The test has been used widely since the 1980s to evaluate patients with cardiovascular and respiratory diseases. While the test is easy to administer, variations in protocols have led to inconsistencies. However, standardized guidelines from the American Thoracic Society in 2002 helped reduce variations. The 6MWT provides clinically useful information about a patient's functional status and can predict morbidity and mortality, with shorter distances correlated with worse health outcomes.
Impact of a designed nursing intervention protocol on myocardial infarction p...Alexander Decker
This study examined the impact of a designed nursing intervention protocol on myocardial infarction patients' outcomes at a university hospital in Egypt. Forty adult myocardial infarction patients were included. The study found that after exposure to the nursing intervention protocol, patients had significantly higher total mean knowledge scores and total mean practice scores. It also found that patients had medium to high levels of compliance to lifelong instructions. The results support the hypotheses that the nursing intervention protocol improved patients' knowledge, practices, and compliance. The study concluded that a nursing intervention protocol can have a positive impact on myocardial infarction patient outcomes.
Cardiac rehabilitation aims to reverse the adverse physical and psychological effects of cardiac events through exercise training, education, counseling, and risk factor management. The goals are to reduce the risk of further heart issues, relieve symptoms, potentially reverse atherosclerosis, and help patients resume normal activities. Rehabilitation occurs in three phases - inpatient monitoring during recovery, outpatient sessions two to three times per week for up to 36 sessions, and optional long-term maintenance under supervision. Each phase includes monitored exercise, education, and lifestyle counseling.
This document discusses various health screening tests that can be performed to monitor health status. It describes primary health screening tests that can be done without a physician's prescription to check factors like blood glucose, cholesterol, and blood pressure. Secondary tests are done after a diagnosis to monitor disease. Common tests discussed include lung function tests using spirometry to evaluate lung capacity and diffusion, as well as cholesterol tests using calorimetry to determine cardiovascular disease risk. Health screening services are important for early detection of disease and monitoring health accurately and cost-effectively.
This study compared cardiovascular responses to exercise between normotensive offspring of normotensive parents and normotensive offspring of hypertensive parents. It found that resting diastolic blood pressure was significantly higher in offspring of hypertensive parents. During a 6-minute walk test, there was a decreased diastolic blood pressure response to exercise in offspring of hypertensive parents. However, the distance covered during the test did not differ between groups. The study concludes there is an early trend toward higher blood pressure in offspring of hypertensive parents and an abnormal pattern of heart rate and blood pressure recovery from exercise.
Mrs. Archana Morey is an assistant professor of nursing who authored a document about cardiac rehabilitation. The document defines cardiac rehabilitation as measures used to help people with heart disease return to an active life and prevent future cardiac events. It describes the benefits of cardiac rehab such as reducing the risk of death from heart problems and improving quality of life through lifestyle changes like exercise and diet. The document outlines the cardiac rehab process and team as well as expectations, risks, and outlook.
The Historical And Clinical Significance Of The 6 Minute Walk Testdgrinnell
The 6-minute walk test (6MWT) is a simple, objective test used to assess functional capacity. It measures how far a patient can walk in 6 minutes. The test has been used widely since the 1980s to evaluate patients with cardiovascular and respiratory diseases. While the test is easy to administer, variations in protocols have led to inconsistencies. However, standardized guidelines from the American Thoracic Society in 2002 helped reduce variations. The 6MWT provides clinically useful information about a patient's functional status and can predict morbidity and mortality, with shorter distances correlated with worse health outcomes.
Impact of a designed nursing intervention protocol on myocardial infarction p...Alexander Decker
This study examined the impact of a designed nursing intervention protocol on myocardial infarction patients' outcomes at a university hospital in Egypt. Forty adult myocardial infarction patients were included. The study found that after exposure to the nursing intervention protocol, patients had significantly higher total mean knowledge scores and total mean practice scores. It also found that patients had medium to high levels of compliance to lifelong instructions. The results support the hypotheses that the nursing intervention protocol improved patients' knowledge, practices, and compliance. The study concluded that a nursing intervention protocol can have a positive impact on myocardial infarction patient outcomes.
Cardiac rehabilitation aims to reverse the adverse physical and psychological effects of cardiac events through exercise training, education, counseling, and risk factor management. The goals are to reduce the risk of further heart issues, relieve symptoms, potentially reverse atherosclerosis, and help patients resume normal activities. Rehabilitation occurs in three phases - inpatient monitoring during recovery, outpatient sessions two to three times per week for up to 36 sessions, and optional long-term maintenance under supervision. Each phase includes monitored exercise, education, and lifestyle counseling.
This document provides information about cardiac rehabilitation. It defines cardiac rehabilitation as restoring patients with cardiovascular disease to their optimal physiological and psychosocial status. The goals of cardiac rehab are to return patients to work or an active lifestyle and reduce coronary risk factors. Cardiac rehab occurs in phases, starting with inpatient assessment and education, then progressing to outpatient exercise and risk factor reduction programs, and finally long-term maintenance. The document discusses exercise prescription and contraindications for cardiac patients. It also covers special populations like heart transplant recipients.
The document summarizes cardiac rehabilitation, including its definition, goals, phases, guidelines, benefits and outcomes. It discusses:
- Cardiac rehab aims to help patients resume normal life after a cardiac event through physical, psychological and social support.
- It has 4 phases from inpatient to long-term maintenance, focusing on exercise training, education and lifestyle management.
- Benefits include reduced mortality, improved functional capacity and symptom control through risk factor modification like smoking cessation.
- Exercise is individually prescribed based on clinical assessment and progresses from early mobilization to independent activities.
Cardiac rehabilitation programs involve exercise training, education, and counseling in three stages: inpatient rehabilitation (Phase 1), outpatient rehabilitation (Phase 2), and long-term maintenance (Phase 3). Exercise training improves exercise tolerance, decreases symptoms, and is recommended as part of cardiac rehabilitation. Strength training can also be included safely for stable patients. While exercise alone does not significantly impact lipids, weight, or blood pressure, multifactorial programs including lifestyle changes can positively influence these risk factors. Exercise training enhances psychological well-being but other interventions may also be needed. Cardiac rehabilitation exercise is very safe with low complication rates and may reduce mortality when combined with other lifestyle modifications.
Acupuncture and/or moxibustion for the treatment of lumbar disc herniation: q...LucyPi1
This document summarizes a systematic review that assesses the quality of 18 systematic reviews on the use of acupuncture and/or moxibustion for treating lumbar disc herniation. It finds that acupuncture and moxibustion show some advantages in efficacy and safety for lumbar disc herniation treatment. However, the quality of evidence is generally low according to GRADE assessments. While the methodological quality of the reviews was moderate and report quality was good, the original research had poor quality, which was reflected in the low quality of evidence ratings. More high-quality studies are still needed to determine if acupuncture is more effective than other treatments.
This case study involves a 53-year-old African American man who presents with elevated blood pressure. Key findings include a loud S2, sustained PMI at the 5th intercostal space, and an S4 gallop. Additional tests show LVH by voltage on EKG and prediabetes based on fasting blood glucose and A1C. The summaries address the patient's diagnoses of hypertension and prediabetes, pharmacologic treatment plan starting ACE inhibitors/ARBs and metformin, and lifestyle modifications recommended.
Cardiac Rehabilitation has been defined as:
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning so that they may, by their own efforts, resume and maintain as normal a place as possible in the community
This study examined the effects of higher-intensity and lower-intensity robot-assisted therapy (RT) compared to control treatment (CT) for stroke rehabilitation. Fifty-four patients with chronic stroke were randomly assigned to one of the three 4-week interventions. The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment, a primary outcome measure of motor impairment, compared to the lower-intensity RT and CT groups. Within each group, secondary outcome measures also improved but differences between groups were not significant. Patients with moderate initial motor deficits benefited more from higher-intensity RT than those with severe or mild deficits.
Discriminative validity of metabolicand workload measurementAMMY30
This study examined the ability of cardiopulmonary exercise testing (CPET) to distinguish between women with chronic fatigue syndrome (CFS) and sedentary control women. 51 women with CFS and 10 sedentary control women underwent two maximal exercise tests on a stationary bike 24 hours apart. No significant differences were found between the groups for the first test, but the second test found significantly lower oxygen consumption and workload values at peak exercise and ventilatory threshold for the CFS group, accurately differentiating the groups 95.1% of the time. This suggests a single exercise test is insufficient and that post-exertion fatigue unique to CFS is better demonstrated on a second test.
This document provides a summary of the 2017 Clinical Practice Guidelines on Management of Dyslipidaemia published by the Ministry of Health Malaysia. It outlines the rationale and process for developing the guidelines, which was to review the evidence linking dyslipidemia and cardiovascular disease and develop strategies for assessing and managing dyslipidemia using local healthcare resources. An expert panel developed clinical questions and recommendations based on reviews of clinical trials and guidelines from other organizations. The guidelines are intended to guide healthcare providers in Malaysia on best practices for diagnosing and treating dyslipidemia to reduce cardiovascular risk.
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention...Yogacharya AB Bhavanani
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention in patients of essential hypertension and cardiac autonomic function tests
Cat using gxt to screen for cad moore 10 30-13 (final)Mike Moore
A 63-year-old man presented with severe back pain and atypical chest pain. His medical history included hypertension, hyperlipidemia, and a previous tobacco smoking history. A stress test was performed and showed evidence of ischemia. He subsequently underwent cardiac catheterization that revealed a 70-80% blockage of the mid-left anterior descending artery, which was treated with stent placement. Determining pre-test probability of coronary artery disease is important for diagnostic efficiency. The Duke Clinical Score, which incorporates additional risk factors beyond the Diamond-Forrester Method, more accurately stratifies risk and reduces unnecessary testing compared to the Diamond-Forrester Method alone. Routinely using a combined prediction model like the Duke Clinical Score is
Dr. K.V.G.S. Murty discloses his interests in herbal research companies and formulations including Cardorium Plus. Cardorium Plus is manufactured by Alakananda Herbals and marketed by Ayurveda One to address vascular endothelial dysfunction. World health statistics show increases in conditions like hypertension, diabetes and obesity globally that are associated with endothelial dysfunction. An interim report discusses an ongoing clinical trial of Cardorium Plus that shows improvements in endothelial function markers like augmentation pressure and augmentation index in subjects taking Cardorium Plus compared to placebo after 3 months. The report concludes Cardorium Plus may benefit those with conditions like hypertension, heart disease and diabetes by improving endothelial function.
PFTs are underutilized in suspected COPD cases. For a 65-year-old man with dyspnea, obesity, and a history of COPD, PFTs including spirometry with bronchodilator should be ordered to confirm airflow obstruction. PFTs revealed moderate COPD. Treatment includes smoking cessation, long-acting bronchodilators, and pulmonary rehabilitation. Regular reassessment of inhaler adherence and ability to use devices properly is important due to costs and side effects.
Based on the history, examination findings and investigations, the provisional differential diagnoses are:
1. Tuberculosis with extra pulmonary involvement (liver, spleen)
2. Chronic liver disease with portal hypertension
3. Chronic pulmonary disease like bronchiectasis
4. Chronic infective etiology like brucellosis
5. Connective tissue disease like SLE
6. Malignancy (hepatocellular carcinoma, lymphoma)
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention...Yogacharya AB Bhavanani
Background: In the Indian subcontinent, 118 million people are with hypertension, and this figure is anticipated to double by 2025. Yoga has been widely claimed to play a role in the prevention and management of psychosomatic, stress-induced, and lifestyle disorders such as hypertension. Aims and Objective: To study the effect of 12 weeks of yoga therapy as a lifestyle intervention on cardiac autonomic functions in patients of essential hypertension. Materials and Methods: Subjects with hypertension from the Medicine Outpatient Department of the Jawaharlal Institute of Postgraduate Medical Education and Research were randomized into control and yoga groups. The control group was treated only with the allopathic medicines. The yoga group was given 12 weeks of yoga therapy module designed by JIPMER Institute Advanced Center for Yoga Therapy Education and Research along with the routine medical treatment. The participants’ blood pressure and cardiac autonomic function were recorded before and after the 12 weeks of the study period. Result: No significant change was observed in the body weight (BW), body mass index (BMI), abdominal circumference, and waist–hip ratio (WHR) in both the control and yoga groups at the end of the 12 week-study period. There was a significant decrease in the resting systolic pressure (SP), diastolic pressure (DP), rate pressure product (RPP), and mean arterial pressure (MAP) in the yoga group. In contrast, there was no significant change in the SP, DP, RPP, and MAP of the control group. High frequency (HF) power, total spectral power, and HF normalized units (nu) showed a significant increase in the yoga group. Low frequency (LF) power, HF power, and LF (nu) showed a significant (p o 0.05) decrease in the yoga group at the end of the 12-week yoga therapy. Conclusion: Twelve weeks of yoga therapy reduced both the SP and DP in the yoga group. Furthermore, yoga therapy increased the heart rate variability and vagal tone and decreased the sympathetic tone in the subjects with hypertension. At the same time, it increased both the parasympathetic and sympathetic reactivity
The cardiac rehabilitation program aims to improve heart health through risk factor modification, exercise training, and education. The major goals are to reduce future heart disease risks, improve heart strength and function, lower cholesterol and blood pressure, and enhance fitness and stress management. The program provides medical evaluations, exercise sessions monitored by ECG, diet counseling, yoga, and education to help patients better manage their condition. It is led by a team of cardiologists, surgeons, dieticians, physiotherapists, and other staff.
The document describes a study that evaluated the effects of administering a mixture of 11 amino acids to patients with chronic heart failure over 3 months. The study found that amino acid supplementation significantly improved exercise tolerance as measured by increased peak VO2 and VO2 at anaerobic threshold on cardiopulmonary stress tests, as well as increased 6-minute walk test distances. However, it did not significantly change patients' quality of life scores. The study suggests amino acid supplementation may improve some measures of functional capacity in patients with chronic heart failure.
The document summarizes the key recommendations from the Eighth Joint National Committee (JNC 8) evidence-based guidelines for managing high blood pressure in adults. The guidelines recommend:
1) Treating hypertension for those over age 60 to a goal of <150/90 mmHg and for all others to a goal of <140/90 mmHg.
2) Initial treatment should include a thiazide-type diuretic, calcium channel blocker, ACE inhibitor, or ARB. For black patients, including those with diabetes, initial treatment should be a thiazide or calcium channel blocker.
3) For patients with chronic kidney disease, treatment should include an ACE inhibitor or ARB
Este documento describe seis preguntas sobre el posicionamiento de residentes en un hogar de ancianos. Las preguntas se refieren a si el personal proporcionó apoyo físico al residente, guio físicamente al residente, observó al residente o le dijo qué hacer, y si otro miembro del personal ayudó con el posicionamiento.
This document provides information about cardiac rehabilitation. It defines cardiac rehabilitation as restoring patients with cardiovascular disease to their optimal physiological and psychosocial status. The goals of cardiac rehab are to return patients to work or an active lifestyle and reduce coronary risk factors. Cardiac rehab occurs in phases, starting with inpatient assessment and education, then progressing to outpatient exercise and risk factor reduction programs, and finally long-term maintenance. The document discusses exercise prescription and contraindications for cardiac patients. It also covers special populations like heart transplant recipients.
The document summarizes cardiac rehabilitation, including its definition, goals, phases, guidelines, benefits and outcomes. It discusses:
- Cardiac rehab aims to help patients resume normal life after a cardiac event through physical, psychological and social support.
- It has 4 phases from inpatient to long-term maintenance, focusing on exercise training, education and lifestyle management.
- Benefits include reduced mortality, improved functional capacity and symptom control through risk factor modification like smoking cessation.
- Exercise is individually prescribed based on clinical assessment and progresses from early mobilization to independent activities.
Cardiac rehabilitation programs involve exercise training, education, and counseling in three stages: inpatient rehabilitation (Phase 1), outpatient rehabilitation (Phase 2), and long-term maintenance (Phase 3). Exercise training improves exercise tolerance, decreases symptoms, and is recommended as part of cardiac rehabilitation. Strength training can also be included safely for stable patients. While exercise alone does not significantly impact lipids, weight, or blood pressure, multifactorial programs including lifestyle changes can positively influence these risk factors. Exercise training enhances psychological well-being but other interventions may also be needed. Cardiac rehabilitation exercise is very safe with low complication rates and may reduce mortality when combined with other lifestyle modifications.
Acupuncture and/or moxibustion for the treatment of lumbar disc herniation: q...LucyPi1
This document summarizes a systematic review that assesses the quality of 18 systematic reviews on the use of acupuncture and/or moxibustion for treating lumbar disc herniation. It finds that acupuncture and moxibustion show some advantages in efficacy and safety for lumbar disc herniation treatment. However, the quality of evidence is generally low according to GRADE assessments. While the methodological quality of the reviews was moderate and report quality was good, the original research had poor quality, which was reflected in the low quality of evidence ratings. More high-quality studies are still needed to determine if acupuncture is more effective than other treatments.
This case study involves a 53-year-old African American man who presents with elevated blood pressure. Key findings include a loud S2, sustained PMI at the 5th intercostal space, and an S4 gallop. Additional tests show LVH by voltage on EKG and prediabetes based on fasting blood glucose and A1C. The summaries address the patient's diagnoses of hypertension and prediabetes, pharmacologic treatment plan starting ACE inhibitors/ARBs and metformin, and lifestyle modifications recommended.
Cardiac Rehabilitation has been defined as:
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning so that they may, by their own efforts, resume and maintain as normal a place as possible in the community
This study examined the effects of higher-intensity and lower-intensity robot-assisted therapy (RT) compared to control treatment (CT) for stroke rehabilitation. Fifty-four patients with chronic stroke were randomly assigned to one of the three 4-week interventions. The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment, a primary outcome measure of motor impairment, compared to the lower-intensity RT and CT groups. Within each group, secondary outcome measures also improved but differences between groups were not significant. Patients with moderate initial motor deficits benefited more from higher-intensity RT than those with severe or mild deficits.
Discriminative validity of metabolicand workload measurementAMMY30
This study examined the ability of cardiopulmonary exercise testing (CPET) to distinguish between women with chronic fatigue syndrome (CFS) and sedentary control women. 51 women with CFS and 10 sedentary control women underwent two maximal exercise tests on a stationary bike 24 hours apart. No significant differences were found between the groups for the first test, but the second test found significantly lower oxygen consumption and workload values at peak exercise and ventilatory threshold for the CFS group, accurately differentiating the groups 95.1% of the time. This suggests a single exercise test is insufficient and that post-exertion fatigue unique to CFS is better demonstrated on a second test.
This document provides a summary of the 2017 Clinical Practice Guidelines on Management of Dyslipidaemia published by the Ministry of Health Malaysia. It outlines the rationale and process for developing the guidelines, which was to review the evidence linking dyslipidemia and cardiovascular disease and develop strategies for assessing and managing dyslipidemia using local healthcare resources. An expert panel developed clinical questions and recommendations based on reviews of clinical trials and guidelines from other organizations. The guidelines are intended to guide healthcare providers in Malaysia on best practices for diagnosing and treating dyslipidemia to reduce cardiovascular risk.
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention...Yogacharya AB Bhavanani
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention in patients of essential hypertension and cardiac autonomic function tests
Cat using gxt to screen for cad moore 10 30-13 (final)Mike Moore
A 63-year-old man presented with severe back pain and atypical chest pain. His medical history included hypertension, hyperlipidemia, and a previous tobacco smoking history. A stress test was performed and showed evidence of ischemia. He subsequently underwent cardiac catheterization that revealed a 70-80% blockage of the mid-left anterior descending artery, which was treated with stent placement. Determining pre-test probability of coronary artery disease is important for diagnostic efficiency. The Duke Clinical Score, which incorporates additional risk factors beyond the Diamond-Forrester Method, more accurately stratifies risk and reduces unnecessary testing compared to the Diamond-Forrester Method alone. Routinely using a combined prediction model like the Duke Clinical Score is
Dr. K.V.G.S. Murty discloses his interests in herbal research companies and formulations including Cardorium Plus. Cardorium Plus is manufactured by Alakananda Herbals and marketed by Ayurveda One to address vascular endothelial dysfunction. World health statistics show increases in conditions like hypertension, diabetes and obesity globally that are associated with endothelial dysfunction. An interim report discusses an ongoing clinical trial of Cardorium Plus that shows improvements in endothelial function markers like augmentation pressure and augmentation index in subjects taking Cardorium Plus compared to placebo after 3 months. The report concludes Cardorium Plus may benefit those with conditions like hypertension, heart disease and diabetes by improving endothelial function.
PFTs are underutilized in suspected COPD cases. For a 65-year-old man with dyspnea, obesity, and a history of COPD, PFTs including spirometry with bronchodilator should be ordered to confirm airflow obstruction. PFTs revealed moderate COPD. Treatment includes smoking cessation, long-acting bronchodilators, and pulmonary rehabilitation. Regular reassessment of inhaler adherence and ability to use devices properly is important due to costs and side effects.
Based on the history, examination findings and investigations, the provisional differential diagnoses are:
1. Tuberculosis with extra pulmonary involvement (liver, spleen)
2. Chronic liver disease with portal hypertension
3. Chronic pulmonary disease like bronchiectasis
4. Chronic infective etiology like brucellosis
5. Connective tissue disease like SLE
6. Malignancy (hepatocellular carcinoma, lymphoma)
Randomized controlled trial of 12-week yoga therapy as lifestyle intervention...Yogacharya AB Bhavanani
Background: In the Indian subcontinent, 118 million people are with hypertension, and this figure is anticipated to double by 2025. Yoga has been widely claimed to play a role in the prevention and management of psychosomatic, stress-induced, and lifestyle disorders such as hypertension. Aims and Objective: To study the effect of 12 weeks of yoga therapy as a lifestyle intervention on cardiac autonomic functions in patients of essential hypertension. Materials and Methods: Subjects with hypertension from the Medicine Outpatient Department of the Jawaharlal Institute of Postgraduate Medical Education and Research were randomized into control and yoga groups. The control group was treated only with the allopathic medicines. The yoga group was given 12 weeks of yoga therapy module designed by JIPMER Institute Advanced Center for Yoga Therapy Education and Research along with the routine medical treatment. The participants’ blood pressure and cardiac autonomic function were recorded before and after the 12 weeks of the study period. Result: No significant change was observed in the body weight (BW), body mass index (BMI), abdominal circumference, and waist–hip ratio (WHR) in both the control and yoga groups at the end of the 12 week-study period. There was a significant decrease in the resting systolic pressure (SP), diastolic pressure (DP), rate pressure product (RPP), and mean arterial pressure (MAP) in the yoga group. In contrast, there was no significant change in the SP, DP, RPP, and MAP of the control group. High frequency (HF) power, total spectral power, and HF normalized units (nu) showed a significant increase in the yoga group. Low frequency (LF) power, HF power, and LF (nu) showed a significant (p o 0.05) decrease in the yoga group at the end of the 12-week yoga therapy. Conclusion: Twelve weeks of yoga therapy reduced both the SP and DP in the yoga group. Furthermore, yoga therapy increased the heart rate variability and vagal tone and decreased the sympathetic tone in the subjects with hypertension. At the same time, it increased both the parasympathetic and sympathetic reactivity
The cardiac rehabilitation program aims to improve heart health through risk factor modification, exercise training, and education. The major goals are to reduce future heart disease risks, improve heart strength and function, lower cholesterol and blood pressure, and enhance fitness and stress management. The program provides medical evaluations, exercise sessions monitored by ECG, diet counseling, yoga, and education to help patients better manage their condition. It is led by a team of cardiologists, surgeons, dieticians, physiotherapists, and other staff.
The document describes a study that evaluated the effects of administering a mixture of 11 amino acids to patients with chronic heart failure over 3 months. The study found that amino acid supplementation significantly improved exercise tolerance as measured by increased peak VO2 and VO2 at anaerobic threshold on cardiopulmonary stress tests, as well as increased 6-minute walk test distances. However, it did not significantly change patients' quality of life scores. The study suggests amino acid supplementation may improve some measures of functional capacity in patients with chronic heart failure.
The document summarizes the key recommendations from the Eighth Joint National Committee (JNC 8) evidence-based guidelines for managing high blood pressure in adults. The guidelines recommend:
1) Treating hypertension for those over age 60 to a goal of <150/90 mmHg and for all others to a goal of <140/90 mmHg.
2) Initial treatment should include a thiazide-type diuretic, calcium channel blocker, ACE inhibitor, or ARB. For black patients, including those with diabetes, initial treatment should be a thiazide or calcium channel blocker.
3) For patients with chronic kidney disease, treatment should include an ACE inhibitor or ARB
Este documento describe seis preguntas sobre el posicionamiento de residentes en un hogar de ancianos. Las preguntas se refieren a si el personal proporcionó apoyo físico al residente, guio físicamente al residente, observó al residente o le dijo qué hacer, y si otro miembro del personal ayudó con el posicionamiento.
O documento descreve um novo serviço de streaming e download de música chamado Escute. Ele discute os segmentos de clientes-alvo, as propostas de valor do produto e serviço, os canais de divulgação, a gestão de conteúdo e parcerias, e o modelo de receitas do serviço.
1) The study examined intersensory processing of audiovisual temporal synchrony for social and nonsocial events in young children with autism spectrum disorder (ASD), typical development (TD), and developmental delays (DD).
2) It found that children with ASD showed no evidence of detecting synchrony for social or nonsocial events, unlike TD children who detected synchrony for both event types and DD children who detected synchrony for social events.
3) Across all participants, there was greater intersensory matching for social events providing enhanced intersensory redundancy, supporting the hypothesis of a general intersensory processing disturbance in ASD underlying social orienting impairments.
Eames Consulting Group connects clients in the financial and professional services sectors with talent. Founded in 2002, they have grown to over 130 employees with offices in London, Zurich, Singapore, and Hong Kong. They specialize in retained and contingent search, contract, and interim solutions in niche skills and challenging geographies. The company prioritizes relationships and offers a consultative service supported by in-depth research. Their success is founded on developing talent and long-term client and candidate relationships.
Rohan Bhardwaj is seeking to grow his knowledge in hospitality and provide world-class solutions and service. He has studied at local colleges in Mumbai, earning 51% on his SSC exam in 2010 and 49% on his HSC exam in 2012. Currently, he is awaiting results for his BMM degree from Mumbai University and has technical skills in MS Office.
Elzaki transform homotopy perturbation method for solving gas dynamics equationeSAT Journals
Abstract E-learning is a modern way of learning now days. It includes electronic media in the field of education. E-learning makes use of (ICT) information and communication technology. Now a day, In every field like learning in medical or learning in agriculture, e-learning is going popular to use. E-learning involves various types of media that provide video, audio, images and text. E-learning uses the intranet/ extranet / internet, and widens the horizon of traditional learning. This article explores the time when the concept of e-learning was introduced, mentions its basic principles, discuss the ways in which it is superior than the traditional educational system. E-Agriculture is a rising field that specialize in the improvement of agricultural and rural development through improved and updated information and communication processes. Specifically, e-Agriculture involves the conceptualization, design, development, analysis and application of innovative ways in which to use information and communication technologies (IT) within the rural domain, with a primary specialize in agriculture. E-Agriculture may be a comparatively new term and that we totally expect its scope to alter and evolve as our understanding of the realm grows. Keywords: E-Education in agriculture, E-learning, E-Education system, Internet-Education, Impact of E-Learning in Education.
Hassan Yassine completed a course on Contracts Risk Management: Understanding Contract Terms (101) on May 30, 2016. The certificate certifies that Hassan Yassine successfully completed the course. The document provides certification of Hassan Yassine completing a contracts risk management course.
Edrington is an international premium spirits company headquartered in Scotland that produces well-known Scotch whisky brands. It was facing challenges managing digital assets across its global operations stored in multiple locations. Bynder's digital asset management solution provided Edrington with a centralized platform to store and access branded marketing assets from any location. This replaced outdated systems and saved an estimated 1,768 man-hours per year. Bynder's customizable interface was easily adopted and ensures global brand consistency and compliance.
Karla Espejel Martínez comenzó su carrera en la construcción como aprendiz de albañil. Notó diferentes formas de realizar las tareas y se interesó en estudiar los movimientos humanos para encontrar los métodos más eficientes. En 1904, se casó con Lilian Moller y juntos comenzaron a estudiar los movimientos corporales para eliminar pasos innecesarios y reducir la fatiga. Dividieron los movimientos de manos en 17 elementos básicos llamados therblings. Su trabajo ayudó a aumentar la producción y reducir la
This document provides an informed consent form for a clinical trial studying the investigational drug KW-2478 in combination with Bortezomib for the treatment of relapsed or refractory multiple myeloma. The summary includes:
1) The study involves two phases to evaluate safety and effectiveness of the drug combination over 28 months total, with screening tests performed over 3 weeks prior to enrollment.
2) Participants will undergo 8 treatment cycles for Phase I and 6 cycles for Phase II, each involving scheduled visits for drug administration and monitoring over 2 months.
3) Potential risks of the study drugs include side effects like headache, nausea, and peripheral neuropathy, with unforeseen risks also possible given the investigational
This document provides guidelines for pre-anesthesia evaluation created by Advocate Safer Surgery Council. It was last revised in March 2016 and is intended as a tool for the preoperative evaluation of surgical patients based on best evidence. The guidelines are not intended to supersede the judgment of individual physicians. It provides information on testing recommendations based on procedure risk, medical history, medications, and other factors. It also provides guidelines on preoperative fasting, smoking cessation, and cardiac evaluation.
How to recognize ADRs in patients.@ Clinical PharmacyDrpradeepthi
This document discusses methods for detecting adverse drug reactions (ADRs) and summarizes four main approaches: case-control studies, cohort studies, spontaneous case reports, and vital statistics/record linkage studies. It provides details on how each method works, its advantages and limitations. The document also outlines steps for properly assessing possible ADRs in patients and stresses the importance of reporting any suspected reactions to help improve patient safety.
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Evaluation of an Exercise-Based Phase Program
as Part of a Standard Care Model for
Cancer Survivors
Jessica Marlene Brown, Daniel Yoon Kee Shackelford, Maria Lyn Hipp, and Reid Hayward
INTRODUCTION
Advancements in cancer treatments such as chemotherapy
and radiation have increased survival rates but often result in
many deleterious side effects during and after treatments.
Cancer survivors can suffer from physio-
logical toxicities affecting the cardiovascu-
lar, pulmonary, musculoskeletal, immune,
gastrointestinal, hepatic, and neuroendocrine
systems (1). In addition, many survivors will
experience psychological decrements such as
increased fatigue, increased depression, and
decreased quality of life (QOL) (2,3), whereas
exercise directly attenuates the toxicities and
decrements of cancer and its concurrent treat-
ments (4,5). The need to establish an exercise
Standard of Care Model (SCM) has been
recognized by many organizations. The
American Cancer Society has established
physical activity guidelines for cancer sur-
vivors (6), and the American College of
Sports Medicine (ACSM) established ex-
ercise guidelines endorsed by the American
Society of Clinical Oncology (7). In addi-
tion, the National Comprehensive Cancer
Network added guidelines to their inclu-
sive treatment recommendations (8). Exer-
cise programming should be included in
the survivorship plan as early as possible
and should be considered as a foundational
component to improve lifelong QOL (9).
The addition of an SCM or, more specifically, a structured
and empirically tested exercise intervention may increase
patient benefit by reducing variations in practice and stan-
dardizing program implementation.
To derive the greatest benefit, exercise-based interventions
must be comprehensive and address the multidimensional
needs of cancer survivors during and after treatment. For this
reason, a “one size fits all” approach to exercise interventions
will not suffice (10). Survivors require prescriptive exercise
that is specialized for each individual based on treatment sta-
tus, comorbidities, and placement on the cancer continuum.
At the University of Northern Colorado Cancer Rehabilitation
Institute (UNCCRI), we have developed an SCM that includes
physician referral, medical and cancer screening, initial physi-
ological and psychological assessments, and an individualized
exercise prescription and intervention using a Phase Program
School of Sport and Exercise Science and the University of Northern Colorado
Cancer Rehabilitation Institute, Univ ...
1. The study explored exercise behavior and knowledge of physical exercise among 196 type 2 diabetes patients in Thailand.
2. Most patients (65.8%) exercised regularly at least 3 times per week, with walking being the most common activity (67%).
3. While most patients exercised regularly, some lacked full knowledge about exercise principles. For example, only 50.5% knew the proper aerobic exercise frequency.
4. The researchers will use the results to provide more targeted patient education on exercise for diabetes management going forward.
Economic And Humanistic Outcomes Of Post Acs In Cardiac Rehabilitation Progra...guestaf1e4
The study evaluated a modified cardiac rehabilitation program (MCRP) compared to a conventional program in patients after acute coronary syndrome. Quality of life was measured using SF-36 at baseline and 12 months. MCRP showed improved physical and mental health scores compared to baseline and controls. MCRP was found to be highly cost-effective with minimal incremental cost ratios compared to usual care without rehabilitation. The study demonstrated that MCRP can improve patient outcomes and is a low-cost intervention that should be implemented more widely.
This document provides details about an upcoming clinical trial course on design, analysis, interpretation and reporting of clinical trials. It includes information about the course faculties from McMaster University and Christian Medical College, Vellore. The 5-day course will cover topics like types of clinical trials, CONSORT guidelines, design considerations, systematic reviews, meta-analysis, statistical analysis methods, sample size calculation and preparing FDA submissions. One of the clinical trials described is about assessing the effect of a preoperative short-term structured exercise program on postoperative quality of recovery in patients undergoing major abdominal cancer surgeries.
The Clinical Pharmacist in Cardiac Rehabilitation Phase I at Sarawak General ...guestaf1e4
A Health Related Quality of Life Study in Patients with Acute Coronary Syndromes: The Cost-Effectiveness of Clinical Pharmacy Service in the Phase I, and Short Course Phase II Cardiac Rehabilitation Program
Authors of proposal: 1, 2 Professor Dr. Sim Kui Hian, 4 Professor Dr. Mohd. Izham Mohd Ibrahim, 1, 2 Dr. Alan Fong Yean Yip, 3 Yanti Nasyuhana Sani, 3 Tiong Lee Len, 3 Bibi Faridha Mohd Salleh, 4 Dr Mohd. Azmi Ahmad Hassali, 4 Prof. Dr Yahaya Hassan, 3 Lawrence Anchah, 5 Karen Tang Siew Lang, 1 Hii Ai Ching,1 Sii Lik Ngoh
1 Dept of Cardiology, Sarawak General Hospital.
2 Clinical Research Centre, Sarawak General Hospital.
3 Dept of Pharmacy, Sarawak General Hospital.
4 School Pharmaceutical Sciences, Universiti Sains Malaysia.
5 Dept of Physiotherapy, Sarawak General Hospital.
NIH Reference No.: (4) dlm.KKM/NIHSEC/08/0804/P07-161, dated 3rd September 2007
Completed 20th Dec 2009
Researcher: Lawrence Anak Ancah, B. Pharm, M. Clinical Pharm, Candidate for Ph.D Cinical Pharmacy in Cardiovascular & HRQoL
1) The document discusses a lecture on evidence-based medicine (EBM) and critical appraisal.
2) EBM involves integrating the best available research evidence with clinical expertise and patient values. It includes formulating clinical questions, searching for evidence, appraising research, and applying the evidence to patient care.
3) The lecture reviews the principles of EBM and critical appraisal, including how to formulate answerable clinical questions using the PICO framework, search for evidence, and appraise different types of research studies.
Journal Club - EMS - "Effect of adrenaline on survival in out-of-hospital car...Farooq Khan
Summary and Critical Appraisal of:
Jacobs et al,"Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial" Resuscitation 82 (2011) 1138– 1143
This document outlines the phases of clinical drug trials. It discusses the objectives and methods of each phase. Phase I trials test drug safety in healthy volunteers. Phase II trials test efficacy and side effects in patients to determine dosage. Phase III trials test efficacy and safety in large randomized controlled trials. Phase IV trials monitor drug use after marketing to detect rare or long-term effects. Each phase uses different doses, patients, investigators, and sample sizes to progressively evaluate a drug's safety and effectiveness in humans. The overall goal is to translate preclinical animal findings into cautious human testing.
Hunter Fant is a student at Clemson University who hopes to pursue a career in physical therapy. Physical therapists diagnose and treat patients with mobility issues to improve movement. They work in various settings like hospitals, clinics, and homes. The career offers a good work-life balance and opportunities to help others. Physical therapy is a growing field with expected 36% job growth over the next decade and median pay of $81,030. Hunter has researched physical therapy programs and plans to apply to the Medical University of South Carolina program.
The document summarizes key findings from the Systolic Blood Pressure Intervention Trial (SPRINT).
[1] SPRINT randomly assigned over 9,000 adults to an intensive treatment target of systolic blood pressure under 120 mm Hg or a standard target under 140 mm Hg. [2] Those in the intensive group achieved an average systolic pressure of 121.5 mm Hg compared to 134.6 mm Hg in the standard group. [3] The intensive group experienced a 25% reduction in the primary composite cardiovascular outcome and a 27% reduction in all-cause mortality compared to the standard group.
Correlation of The Habit Consumption of Fatty Food And Physical Activities With The Hypertension Incidents On The Elderly In Muaro Bodi Public Health Center, Sijunjung District In 2015
This study examined the short-term effects of a Tai Chi class on the subjective well-being of 13 patients referred to an exercise referral scheme. Participants completed questionnaires before and after the class measuring positive well-being, psychological distress, and fatigue. Results showed statistically significant improvements in positive well-being after the class. The mean rating of perceived exertion corresponded to moderate physical activity. The study concludes that Tai Chi had positive psychological effects and could be included as an activity in exercise referral schemes.
The document discusses occupational therapy notes for cardiac conditions that were prepared between 2001-2012 based on a university curriculum. It provides an overview of the syllabus topics related to cardiac conditions including understanding clinical presentations, interpreting signs and symptoms during exercise, administering exercise protocols using equipment like treadmills and ergometers, categorizing patients for exercise prescription, and modifying work programs based on cardiac function. It lists several references used to develop the notes and provides details on exercise stress test protocols, indications, contraindications, preparations, and criteria for stopping tests. Specific protocols for treadmill tests like Balke and Naughton are also outlined.
This document outlines a Phase III clinical trial protocol to compare the efficacy and safety of a novel calcium channel blocker drug called Cardex to the drug Nifedipine in treating patients with stage 1 hypertension. The proposed randomized controlled trial would involve 600 patients across 15 centers in India. Patients would be randomly assigned to receive either Cardex or Nifedipine and their blood pressure and platelet aggregation would be measured at regular intervals over 18 months to assess the comparative efficacy, safety and pharmacokinetics of the two drugs. The protocol provides details on the study objectives, design, procedures, statistical analysis and ethical approval process.
This study examined the effects of high-intensity interval training (HIIT) compared to moderate-intensity continuous training (MICT) on metabolic syndrome and body composition in 56 outpatients with metabolic syndrome who had a myocardial infarction and completed cardiac rehabilitation. The HIIT group showed greater reductions in metabolic syndrome risk factors including waist circumference, blood glucose, triglycerides, and blood pressure compared to the MICT group. The HIIT group also demonstrated greater decreases in body fat mass and increases in lean body mass relative to the MICT group. These benefits of HIIT over MICT persisted even after matching the groups for total exercise energy expenditure.
The document defines and describes the nursing process, which is a problem-solving approach used by nurses to address patient health needs. It has 6 main components: assessment, diagnosis, planning, implementation, evaluation, and outcome identification. Assessment involves collecting a health history and doing a physical exam. A nursing diagnosis identifies actual or potential patient problems that nurses can address through independent nursing action. The nursing diagnosis is developed based on assessment data and identifies the problem and its etiology.
MedicalResearch.com: Medical Research Exclusive Interviews December 21 2014
real correction
1. KENYATTA UNIVERSITY DEPARTMENTAL POST GRADUATE PRESENTATIONS
ON 25TH AUGUST 2016
Present:
1. Dr. Gitahi Theuri Chairing
2. Dr. Gitonga Rintaugu
3. Dr. Muthomi Nkatha
4. Dr. Bulinda Hannington
5. Mr. George Kiganjo
6. Lilian Bonaveri
7. Kevin cheruiyot
8. Bonface kimanthi
9. Penenah Muthoni
10. Abraham Mwangi
11. Rhoda Wanzetse
12. George Kimani
13. Florence Muthoni
14. Karobia Anthony
15. Luka Boro
16. Muasya Vincent Recording
CONCEPT PRESENTATIONS
CONCEPT PRESENTER: George Mwangi E67/OL/25263/14
TITLE: Randomized controlled trial of the cardiovascular effects of young longer fitness
program in cure of resistant hypertension at Mulumba hospital, Kiambu
COMMENTS:
Need to refocus title to make it precise
Is your study about cure or management?
When will the BP be measured? Is it before or after exercise?
What treatment /fitness program will you expose your subjects to? FITT principle?
Why Mulumba hospital? Are there more cases of resistant hypertension?
Consider dropping the word CURE in the title.
How will you categorize your hypertension subjects?
What is the upper limit of BP you will allow for your subjects?
How will you control
Verdict: Effect suggested changes and prepare a proposal.
ASSIGNED SUPERVISORS
Dr. Gitahi Theuri
2. Dr. Mundia Francis
REFOCUSED TITLE
INSTEAD OF: Randomized controlled trial of the cardiovascular effects of young longer
fitness program in cure of resistant hypertension at Mulumba hospital, Kiambu
CHANGED TO: RANDOMIZED CONTROLLED TRIAL OF CARDIOVASCULAR
EFFECTS OF “YOUNGER LONGER” PHYSICAL FITNESS PROGRAMME IN
MANAGEMENT OF RESISTANT HYPERTENSION
1. I have replaced “in cure of “ for “ in management of “
2. I have removed completely the venue because this type of research cannot whatsoever be
affected by the choice of a venue. Body`s physiological response will only respond to
physical, mechanical and chemical stresses only and venue is none of this . In this case I
have omitted it
3. The third question of when the participant`s blood pressure will be measure, the answer is
–before and after performance, there will be also measurement following the patient`s
completion of the session or during the exercise if the participant complain of exhaustion.
4. The fourth question is purely a technical question on the component of the sessions in an
acronym FITT (Frequency, Intensity, Time and type). In this respect I have included a
paragraph in my introduction on literature review of the structure of this pioneer fitness
programme.
5. The fifth question is concerning the choice of the venue, besides being a level four
hospital, St. Matia`s Mulumba Mission hospital location is quite accessible, located east
of Thika town three kilometers along Thika-Garisa highway. This Hospital`s
management team is a very friendly team and has offered a tent fifty by thirty five feet
for the chapter two of “younger longer” physical fitness programme.St.MMML4H also
has a vibrant MOPC where the MO i/c of the hospital confess that there are a substantial
cases of resistant hypertension but adds that he cannot disclose the data before approval
of my research from my University research committee board and that of the hospital
6. The sixth question was an advise and admonition for removal of the word “cure” as per
research credibility to set realizable objectives and in this respect I have dropped the
word “cure” for the “management of “
7. Question seven is concerned with how I will classify my hypertensive subjects. I intend
to use American Heart Association, five staging method as elaborated in my literature
review under section 2.3 headed diagnosis. This will be done by a qualified physician
when I will identify my subjects.
8. The eighth question is asking me about the high limit of the BP I will allow my subjects
to exercise in a resting BP ≥ 200/110 brachia artery leadings and during exercise testing a
BP ≥ 220/115 mmHg ( study by Stan Reent,PharmD of American Heart Association 2016
)
3. 9. The question of how I will control my experiment, the control group will be “blinded”
and they will be monitored as in the normal MOPC attendant but their attendance will be
more emphasized so that those randomized may not miss to attend and that their
parameters of heath will be monitored. These are blood pressure, heart rate, cardiac
index, Vo2 max, ECG during exercise testing. Announcement will be made for all those
who have a particular BP ≥ 140/90 mmHg and taking three or more antihypertensive of
which one is a diuretic will all benefit for a free clinical evaluation and investigation
which will apply for the two groups. Heart rate will be monitored all the time the training
group will be exercising with ambulatory heart rate monitoring machine. From this
readings VO2 max will be calculated from the equation VO2 max= 15.3
HRmax/HRrestml/min/kg
4. RANDOMIZED CONTROLLED TRIAL OF CARDIOVASCULAR EFFECTS OF
“YOUNGER LONGER” PHYSICAL FITNESS PROGRAMME IN MANAGEMENT OF
RESISTANT HYPERTENSION.
GEORGE KIMANI MWANGI (BSc. in Physiotherapy JKUAT)
E67/OL/25263/2014
5. i
LIST OF ABBREVIATIONS
RAAS: RENIN ANGIOTENSIN ALDOSTERONE SYSTEM
NCD: NON-COMMUNICABLE DISEASES
HTN: HYPERTENSION
BLD: BLOOD
ATP: ADENOSINE TRIPPHOSPHATE
ADP: ADENINE DI NUCLEOTIDE PHOSPHATE
NADP+: NICOTINAMIDE ADENINE DIPHOSPHATE
NADPH+: DIHYDROXY NICOTINAMIDE ADENINE DINUCLEOTIDE PHOSPHATE
6. ii
Table of Contents
CHAPTER 1.........................................................................................................................................................................................1
BACKGROUND ..................................................................................................................................................................................1
PROBLEM STATEMENT....................................................................................................................................................................2
JUSTIFICATION..................................................................................................................................................................................3
RESEARCH QUESTION......................................................................................................................................................................3
1.4 MAIN OBJECTIVE .......................................................................................................................................................................3
1.4.2 SPECIFIC OBJECTIVE...............................................................................................................................................................3
THE NULL HYPOTHESIS....................................................................................................................................................................4
1.5.2 ALTERNATIVE HYPOTHESIS...................................................................................................................................................4
1.6 CONCEMPTUAL FRAMEWORK ................................................................................................................................................4
THEORY FRAMEWORK ....................................................................................................................................................................5
CHAPTER 2.0: LITERATURE REVIEW..............................................................................................................................................6
2.1 Epidemiology..............................................................................................................................................................................6
2.1.1Etiology.....................................................................................................................................................................................7
2.1.2.1 Obstructivesleep apnea....................................................................................................................................................7
2.1.2.2 Drug induced resistant hypertension .............................................................................................................................7
2.1.2.3 Secondary aldosterone......................................................................................................................................................8
2.1.2.4 Arteriosclerosis, arteriosclerosis and atherosclerosis. ................................................................................................8
2.2 Prevalence..................................................................................................................................................................................9
2.3 Diagnosis.....................................................................................................................................................................................9
2.3.1 Pre hypertensive ( systolic of 120 to 139 mmHg ) and /or diastolic of 80 to 89 mmHg) ........................................10
2.3.2 Hypertension stage 1 ( 140 to 159 mmHg ) and /or a diastolic 90 to ........................................................................10
2.3.3 Hypertension stage 2 ..........................................................................................................................................................10
2.3.4 Hypertensive crisis BP ≥ 180/110 mm Hg........................................................................................................................11
2.4 TREATMENT..............................................................................................................................................................................11
2.5 PROGNOSIS...............................................................................................................................................................................11
2.6 EXERCISES .................................................................................................................................................................................12
2.6.1 Definition...............................................................................................................................................................................12
2.6.2 Modes of exercises..............................................................................................................................................................13
2.1.1Exercise chains are either open kinetics...........................................................................................................................13
2.6.1.2 Calisthenics or non-calisthenics.....................................................................................................................................13
2.6.1.3. Length change are either shortening...........................................................................................................................13
2.7 Energy systems are three ......................................................................................................................................................13
2.7.1 Aerobic energy system........................................................................................................................................................14
7. iii
2.8 Tempo .......................................................................................................................................................................................14
2.8.1 Component of exercises (1) warm up (2) work out (3) cooling down........................................................................14
2.9 Principles of exercises : Specificity of exercises and adaptability ..................................................................................14
2.10 Physiological benefits for exercises...................................................................................................................................15
CHAPTER 3.......................................................................................................................................................................................17
3.0 Methodology............................................................................................................................................................................17
3.1 Study design-randomized controlled trial ..........................................................................................................................17
3.2 Measurement of variables.....................................................................................................................................................17
3.3 Study area.................................................................................................................................................................................18
3.4 Target population....................................................................................................................................................................18
3.4.1 Exclusion criteria..................................................................................................................................................................18
3.4.2 Inclusion criteria...................................................................................................................................................................18
3.5 Sampling technique. ...............................................................................................................................................................19
3.6 Sample size...............................................................................................................................................................................19
3.6.1unit of analysis.......................................................................................................................................................................19
3.7 Research instruments.............................................................................................................................................................19
3.8 Pre-testing................................................................................................................................................................................19
3.9 validity and reliability. ............................................................................................................................................................19
3.10 Data collection techniques..................................................................................................................................................19
3.11 Data analysis..........................................................................................................................................................................20
3.12 Logistic and ethical considerations....................................................................................................................................20
3.13 Measurement of variables ..................................................................................................................................................20
3.13.2 Exercise intensity...............................................................................................................................................................20
Appendix 1 ......................................................................................................................................................................................22
EXERCISE PROGRAM......................................................................................................................................................................24
VENUE: ST.MMML4H TENT ..........................................................................................................................................................24
Session:............................................................................................................................................................................................24
Work out..........................................................................................................................................................................................25
Cool down .......................................................................................................................................................................................27
References.......................................................................................................................................................................................28
Appendix 2 ......................................................................................................................................................................................29
THE COSTING OF THE RESEARCH PROGRAM ............................................................................................................................29
HUMAN RESOURCE .......................................................................................................................................................................30
8. 1
CHAPTER 1
BACKGROUND
“Younger longer” is a physical fitness programme which has been in existence for many years at
Thika Level 5 Hospital practiced at lunch hour. A second chapter is now running at St. Matias
Mulumba Mission Hospital of Kiambu county The program which is composed of many
callisthenic type of exercises has been noted to reduce the weight of those who participates and
make them look radiant and “health “.This program`s effect on cardiovascular has never been
tested .More so it would be interesting to find out its effect on blood pressure of those whose
blood pressure has resisted treatment. Would those who have been inflicted by this plague of
hypertension live younger longer without their blood pressure making them progress to CCF? ,
stroke, heart attack or renal disease? The answer to such a question would require longitudinal
prospective study which would be very expensive to monitor. All that would be required is
patients who are hypertensive to embrace this program but in order for them to continue with it,
it has to be proved that it works in reducing blood pressure. This can only be achieved by putting
this programme through a scientific process to prove its worth in treatment of resistant
hypertension.
A global brief on HYPERTENSION by WHO 2013 describes hypertension as a silent
invisible killer and a public health crisis affecting more than one billion people and killing more
than 9.3 million people. 45% of these hypertensive patients have resistant hypertension which
causes 55% of the above deaths (Chen et al 2013). Resistant hypertension is defined as
hypertension that remain equal to or above 140mmHg/90mmHg despite treatment with three
antihypertensive drugs of which one of them is a diuretic ( Calhoun et al 2012).Resistant
hypertension is also defined as hypertension that is poorly responsive to treatment and requires
multiple drugs to control it to acceptable ranges (Yaxley etal,2013)This chronic disease which is
also referred to as treatment resistant hypertension is serious especially due to its association
with increased risks of stroke, ischemic heart diseases, heart attack and kidney failure (Persel and
Stephen, Hypertension 57.6 (2011)). This type of hypertension is on the rise due to the increase
in aging population and with heaviness (Calhoun et al, 2008), AHA Scientific statement)
9. 2
Unlike drugs, exercises prescription has barely been possible for lack of well-developed
exercise programs in hypertensive patients (Nolte et al, 2013).This comes out clearly right from
the definition of resistant hypertension “is blood pressure that remains above or is equal to
140mmHg/90mmHg despite treatment with three antihypertensive which includes at least one
diuretics” .This definition is silent on intervention by exercises or fitness levels of the individuals
Yet despite the plethora of antihypertensive drugs, hypertension still remains a health problem by
resisting the drugs (Papademetrious et al, 2011). In this exercise programme there are 15
exercises for warm up, 30 exercises for work outs and 10 exercises for cooling down ideal for
group exercises to accompany the drug therapy. Resistance hypertension is defined as blood
pressure equal to or greater than 140/90mmhg in spite of three or more antihypertensive,
diuretics being one of them or any blood pressure controlled by four or more drugs (Dimeo et al,
2012).what type of exercises a hypertensive patient should perform at what intensity, duration
and frequency and for how long remains an issue for many patients prescribed exercises let alone
the “which ones” to be done. The program “younger longer through programmed exercises”
essentially includes two modes of exercises, the aerobic and stretching exercises
PROBLEM STATEMENT
The side effect and the cost of antihypertensive medications have led to a consensus about a need
to have a non-pharmacological treatment alone or adjunctive to drug therapy ( Schein et al 2001)
Also aconsiderable number of people fail to reach the target blood pressure despite the appropriate
life style advice and standard medical intervention, (Yaxley et al, 2015). The percentage of such
people is said to range from 5 % to 10 % of all people who are hypertensive who are below50
years (Dimeo etal,2012 ) but going by the above definition and considering whatever cause of this
resistant hypertension is, the prevalence is considered to be higher 30% and above (V.
Papademetrious etal,2011). Resistance hypertension is the most primary factor for stroke,
myocardial infarction, end liver diseases, renal disease etc. (Faselis et al, 2011). High blood
pressure is usually difficult to control but resistant hypertension is blood pressure that is difficult
to control despite the right antihypertensive medications and adherence to the regime (Viera et al,
2009).With the awareness of the aftermaths of the persistent above goal of the resistant
hypertension despite, such patients who adhere to the medications despite the failure to achieve
optimal blood pressure would be perhaps more than willing to include exercise in their endeavors
( Dimeo et al 2012 )
10. 3
JUSTIFICATION
Physical activity is recommended by European and American guidelines for management of
hypertension however it remains elusive whether exercises /physical activity can reduce resistant
hypertension (Dimeo et al, 2011).The number of patients with resistance hypertension is growing
day by day, possibly due to the increasing number of aging people and other comorbidity
illnesses for example diabetes, obesity, renal and liver diseases (Faselis et al.2011).These
conditions make hypertension more difficult to treat. Studies on hypertension and exercises has
been few and even fewer on resistant hypertension (Ribeiro et al, 2015).To depart from or
supplement the traditional exercise of walking, jogging or running on a treadmill, this program
will provide a group dynamic opportunity where participants will learn the training best skills
from one another for in every `jig` there will be individuals who will display it better than others.
If this program proves effective as it prospects, it should be a prescription to accompany drug
management of hypertension in our hospital settings. This is because it requires only a space and
an instructor who have participated in the training for six weeks.
RESEARCH QUESTION
1. What is the effect younger longer fitness program on resistant hypertension?
2. Can twenty four session spread in six weeks at a frequency of four session per week, 55
to 60 minutes per session induce reduction of blood pressure in patients suffering from
resistant hypertension?
1.4 MAIN OBJECTIVE
To clinically include exercise in our hospitals as a distinctive prescription for management of
resistant hypertension and create a space for its demonstration.
1.4.2 SPECIFIC OBJECTIVE
1. To demonstrate that younger longer fitness program can be effective in helping to lower
systolic blood pressure in resistance hypertension.
2. To demonstrate that younger longer fitness programme can be effective in helping to
lower diastolic blood pressure in resistance hypertension.
11. 4
THE NULL HYPOTHESIS
There`s no significant difference of blood pressure between those who underwent the programme
and those who didn`t
1.5.2 ALTERNATIVE HYPOTHESIS
There`s significant lowering of blood pressure between those who underwent the programme of
younger longer than those who didn`t.
1.6 CONCEMPTUAL FRAMEWORK
CONCEPT: EXERCISE CAN DISTINCTIVELY AND ADJUCNTIVELY TREAT
HYPERTENSION IF DONE APPROPRIATELY
Independent variable
EXERCISE
Mode –aerobic
Intensity vo2max ( 50-750 )
Volume-repetition +session
time ( 55-65 minutes )
Frequency ( 4 times a week
)
Time to goal – 6 weeks )
Hypertension
Systolic ≥140 mmHg
Diastolic≥90 mmHg
Pulsepressure≥ 50
Mean pressure ≥ 106
Dependent variable
Normotensive
Systolic ≤139 mmHg
Diastolic≤89 mmHg
Pulsepressure≤ 50
Mean pressure ≤ 106
13. 6
CHAPTER 2.0: LITERATURE REVIEW
Systemic arterial hypertension (defined as blood pressure > 140mmHg/90mmHg) is the leading
risk factor for the four eventual fatal events (stroke, heart attack, end renal and liver disease)
(Hendricks et al 2012). If this arterial hypertension persists despite treatment with three
antihypertensive drugs of which one of them is a diuretic it is then referred to as resistant
hypertension. Patients whose blood pressure is controlled with four or more antihypertensive
drugs are also regarded to have resistant hypertension (CA Calhoun et al, 2011). High blood
pressure is usually difficult to control and resistant hypertension is blood pressure that is difficult
to control despite the right antihypertensive medications and adherence to the regime (Viera et
al, 2009).A diagnosis of true resistant hypertension should only be made only after a thorough
assessment to exclude apparent or pseudo-resistant hypertension(A Mya teal,2012).Resistant
hypertension should not be confused with uncontrolled hypertension which steps from non-
compliant to treatment. This resistant hypertension, has been shown to resist drugs and has yet to
be demonstrated to resist drugs with say exercises and diet interventions combined(Rebeiro
etal,2015) This implies that such patients whose physiology is not responding to correct the
anomaly needs together with antihypertensive other interventions which are non-
pharmacological (F.Dimeo et al,2012). Resistant hypertension has no known etiology but has
multifactorial secondary causes .drug –induced hypertension, obstructive sleep apnea, primary
aldosteronism .With the awareness of the aftermaths of the persistent of above goal of blood
pressure despite adherence to medications, such patients would be perhaps more than willing to
include exercise regime to their endeavors ( F. Dimeo et al 2012 ).
2.1 Epidemiology
The Persons with treatment resistant hypertension are increasing in numbers due to increase in
incidence rate. Numerous cross-section prevalent studies and large numbers of longitudinal
prospective studies have reviewed increasing prevalence of resistant hypertension from 5%-10%
in 2005 to a mean point prevalence 30%-45% especially among the advancing in age with more
than one comorbidity (P.A Sarafidis etal, 2011).The socio-economic burden on these population
with continuing increasing risk of both cerebral and cardiac events is makes them poorer and
vulnerable to stress. This has leads to increased mortality and morbidity rate .More than 1 billion
14. 7
adults globally suffer from hypertension representing 25% world population. More than seven
million people die annually from events related to hypertension making it the leading cause of
death among the NCDs (D.A Calhoun et al 2008)
2.1.1Etiology
Resistant hypertension is a compensatory phenomenon caused by vasoconstriction of main,
middle size arteries and arterioles due to atheroma and arteriosclerosis respectively .It’s a
reaction to overcome hypoxia of the tissue ( Theodre A.Cochen 2011,in his brief review of
historical trends of hypertension ) . In 1912 Sir William Osler in his public address to Glasgow
Southern Medical society on association of arteriosclerosis and hypertension he stated that in this
group of cases its significant to recognize that the extra pressure is purely a mechanical affair
……………get it off your head, if possible that the primary feature is the elevated blood
pressure and particularly the feature to treat. In recent times resistant hypertension has been
associated with obstructive sleep apnea, post-secondary aldosterone and drug induced
hypertension (Dimeo et al 2012).
2.1.2.1 Obstructive sleepapnea
Obstructive sleep apnea is stopping to breathe while one is asleep measured at a scale of apnea-
hypoxia index ≥ 10 events/hour resulting from repetitive collapse of pharyngeal airway during
sleep (white et al 2012). This causes the sympathetic autonomic nervous system undue
stimulation which leads to resistant hypertension. Several processes have been blamed for this,
falling of lung volume during sleep, edema due to pooling of blood to the pharyngeal area,
physiological anomaly of respiratory drive and the negative reflex associated to control normal
breathing (White et al 2012).This sequela can positively be affected by exercises.
2.1.2.2 Drug induced resistant hypertension
Several classes of pharmacological agents can increase blood pressure and contribute to its
treatment resistant. Paradoxically, some drugs meant for lowering hypertension raises it, the
prediction for such drugs whether to raise or lower blood pressure depends on renin levels
(Alderman et al, 2010).Given their widespread use non-narcotic analgesics including NSAIDs
aspirin and acetaminophen are probably the most offending. These drugs inhabit the enzyme
15. 8
cyclooxygenase which catalyze the production of prostaglandin from arachidonic acid. This is
produced in the endothelial cells of the blood vessel which in form of prostacyclin is a local
vasodilator and thus lowers blood pressure (Calhoun et al, 2008). In the events of its inhibition
blood pressure is bound to rise. Prostaglandin made by catalyzing effect of COX 1 has protective
effect on gastro-intestinal tract which prevents its ulceration. Exercises decrease renal flow of the
blood thus decreasing to some extent the role of the kidney in regulation of blood pressure which
has been interfered with by the NSAIDs in the inhibition of the prostaglandin. In the peripheral
vascularization, exercise causes vasodilation and venodilation of blood vessels both in the skin
and the skeletal muscles thus lowering the blood pressure
2.1.2.3 Secondary aldosterone
Aldosterone is a mineralocorticoid derived from cholesterol and is almost exclusively produced
in zona glomerulosa of the adrenal gland. It controls minerals in the blood plasma by causing the
reabsorption of sodium ions in the distal convoluted tubule. Sodium is co-transported with water
and thus aldosterone controls the volume of the blood. Majorly aldosterone production is
stimulated by Renin Angiotensin Aldosterone Axis. In secondary aldosterone’s, other anomaly
other than the adrenal gland causes the high level of plasma aldosterone. This disorder is caused
RAAS axis in an ischemic kidney where by more sodium ions are reabsorbed in the distal tube
and more potassium and hydrogen are lost which may lead to hypokalemia and hyper alkalinity
(Chrosous et al, 2015). Since exercises reduce the renal blood flow, excretory role of the kidney
is supplemented and as such blood pressure is controlled with exercise training
2.1.2.4 Arteriosclerosis, arteriosclerosis and atherosclerosis.
These are terms which are usually confused which leads to faulty intervention. They all cause
hypertension and have different meaning. Arteriosclerosis a non-atheromatous loss of elasticity
or hardening of major and middle sized arteries whose total cross section is estimated at 24.5 cm2
holding10% volume of the circulating blood while arteriolosclerosis also refers to non-
atheromatous loss of elasticity or hardening of arterioles whose total cross section is estimated
400 cm2 holding 1% volume of the circulating blood (Lam et al 2012). On the other hand
atherosclerosis is narrowing, hardening or loss of elasticity arteries due to infiltration of tunica
intima lamina by white blood cells and fatty acids resulting in formation of form cells of
macrophages forming a fatty strict which grows into multiple hard lesion called plaques (Urbina
16. 9
et al,2008) . The cause is turbulent flow due to continued raised blood pressure that erodes the
endothelial cells triggering migration of leucocytes, monocytes (macrophages) neutrophils and
fatty acids, connective tissues into the base of tunica intima.
2.2 Prevalence
The reported prevalence of hypertension worldwide is varied with India recording the least
(3.4% male and 6.8% female) and Poland recording the highest (68.9 % male and 72.8 %
female) (Kearney et al, 2015.) But in an overall, approximately 20% of the worldwide adults are
hypertensive and it increase with age ( Dreisbach et al 2014, epidemiology of research).The
prevalence dramatically raises in individuals above 60 years to 50%. More than one billion
people in the world suffer from hypertension, causing an annual mortality of more than 7.1
million( Dreisbach et al,2014) In sub-Sahara Africa , hypertension in rural community River
State , Niger Delta of Nigeria , prevalence was 20.5% male and 20.1% female (CA Alikor etal,
2013) .In rural Kenya the prevalence of hypertension is estimated to be 23.7% (Hendrick et al
2012) but Health Heart Africa and Kenya Demographic Survey 2012 state that one in three
individuals within the age group ≥ 55 years are hypertensive
2.3 Diagnosis
Hypertension is diagnosed in terms of persistent sign of systemic arteries in brachial artery blood
pressure measured using a sphygmomanometer in millimeters of mercury ( Theodore A Kotchen
2012 , brief review of historical trends and milestone in hypertensive research ). The mercury
Sphygmomanometer has essentially been replaced with aneroid and electronic devices. Mercury
is still used for calibrating these devices and standardized protocols have been recommended to
assure their accuracy. Blood pressure ≥ 140/90 mmHg is regarded as hypertensive. American
Heart Association has described five categories of blood pressure by staging both the systolic
and diastolic in ranges of millimeters of mercury as follows in the below chart
17. 10
2.3.1 Pre hypertensive (systolic of 120 to 139 mmHg) and /or diastolic of 80 to 89 mmHg)
This BP range is supposed to warn this population that they stand a risk of progressing to
hypertension and Doctor`s advises them to change their life style and should not take medicine
2.3.2 Hypertension stage 1 (140 to 159 mmHg) and /or a diastolic 90 to
In this range these populations are regarded to be hypertensive and are recommended to change
their life style and advised to start with a diuretic this time distal convoluted tube thiazide. A
diuretic lowers blood pressure by helping the body to get rid of extra water and sodium.
Diuretics are usually very effective, have few side effects and are inexpensive
2.3.3 Hypertension stage 2
Systolic of 160 mmHg and over up to 179 mmHg and a diastolic of 100 mmHg to 109 mmHg
then you have stage 2 hypertension. Treatment here is lifestyle modification, take a diuretic and
another hypertensive. May be a third type if necessary. Normally more than two thirds of these
patients require more than three antihypertensive
Hypertension
categories
Systolic And Diastolic
Categories of
hypertension
Systolic (mmHg) And Diastolic ( mmHg)
Normal blood
pressure
>120 Or >80
Pre hypertension 120 to 139 Or 80 to 89
Hypertension stage 1 140 to 159 Or 90 to 99
Hypertension stage 2 160 to 179 Or 100 to 109
Hypertension crisis
(emergency care
needed )
≥ 180 Or ≥110
18. 11
2.3.4 Hypertensive crisis BP ≥ 180/110 mm Hg
Patients who attends outpatient with complains of severe headache, severe anxiety, nose bleeding
and a BP ≥ 180/110 mmHg are scared by the look of medical stuff. Emergency measures,
admission with administration of hydralazine in most cases. A planned admission and when
these patients walked themselves to the hospital occasionally but not such patients leave the
hospital paralyzed one side of the body. Hypertensive crises must include physical activity to
overcome tissue hypoxia
2.4 TREATMENT
Pathogenesis and etiology of hypertension remains unclear consequently treatment of
hypertension currently is based on using of drugs with an emphasis to reducing the elevated
blood pressure rather than treating the cause (B.C Berk et al 2004).The antihypertensive
medications are viz: Diuretics, beta blockers , nitroglycerines , alpha blockers , sympathomimetic
, calcium channel blockers , potassium channel blockers , ACE antagonist and inhibitors etc.
Treatment resistant hypertension is treated using three or more antihypertensive of which one
must be a diuretic to deal with tissue volume problem. In addition to taking more than three
antihypertensive medications patients who have drug resistant hypertension are strongly advised
to make behavioral and dietary modification such as losing weight , exercising , reducing sodium
intake an increasing potassium intake as advised by the physician (Persell et al,2011).Note that
physicians emphasizes more on antihypertensive management and there has to be advocacy for
the other behavioral factors and to come up with a novel treatment exercise package need be
meticulously developed. Post exercise hypotension has been observed in in many incidences of
raise blood pressure which proves that exercises can lower elevated blood pressure just like the
antihypertensive. Can drug resistant hypertension resist exercises just as it resist antihypertensive
medications? This is the question this experiment will answer.
2.5 PROGNOSIS
55% of cardiovascular, cerebral malady fatal events are cause by treatment resistant hypertension
(Chen et al 2013). End organ disease increase for more than 2 fold for those suffering from
apparent treatment resistant hypertension. Apparent treatment resistant hypertension has been
blamed for 50% end renal disease and its eventual mortality rate. Stroke and mortality, morbidity
and DALYs are also reported to be complications from apparent treatment resistant hypertension
19. 12
(Daugherty et al, 2012). 50% heart failure are also caused by resistant hypertension and if these
are caused by also hypertension that is also controlled by antihypertensive with 3
antihypertensive or multiple antihypertensive then it means that treatment with antihypertensive
may be a failure and not with understanding a novel treatment protocol need to be instituted.
2.6 EXERCISES
2.6.1 Definition
There so many definition of exercise but the most striking one I came across is one by Oxford
dictionary press describing an exercise as an activity requiring physical effort, carried out to
sustain or improve health or fitness. Other dictionaries e.g Cambridge English dictionary define
it as a physical activity that you do to make your body strong and healthy yet another dictionary
Macmillan dictionary defines exercise as a physical activity that you do repeatedly to make part
of your body strong or more healthy . The first definition brings out the idea of voluntary
movement “effort” and effort depicts that there is humoral-neural involvement and thus
voluntary contraction of muscles. The motor functions after receiving of commands to perform
functions depicts that there is a motor intention from thoughts. This is due to the ability of the
cortex cells to convert thoughts to an electrochemical impulse (Zscholarish et al, 2013). Through
pre-synaptic motor nerve action potential acetylcholine anchors across the synapse the
electrochemical impulse created by cortex cells from the thoughts (Castillo et al, 2015). The
neural muscular joint picks it up and through the “T” tubules of the sarcolemma exciting the
sarcoplasmic reticulum to release calcium ions and also allows more calcium into the cells whose
concentration is less twelve thousand times in the cytoplasm than in the extracellular. Calcium
ions increased levels initiate muscle contraction by troponin C which weakens the troponin-
tropomyosin relax able protein. This displaces tropomyosin which exposes the binding site on
the actin and the thick myosin with its ATP on the head seizes the opportunity splitting the ATP
thus initiating the cross-bridge which triggers the latchet mechanism causing the actin thin
filament to slide on the thick myosin. One troponin reaction exposes seven sites for the head of
myosin to attach. Note this process requires enzyme myosin ATPase. This is a demand the
presence of enzyme and oxygen which are the main factors in physical fitness and good health.
20. 13
2.6.2 Modes of exercises
Before beginning any exercise program, a clinical evaluation by a physician is recommended to
rule out potential risks. Once health and fitness level are determined and any physical restriction
identified, the individual exercise program should begin under supervision of a health care or
other trained health professional ( Mishra et al , 2011).Exercise programme normally followed by
the participants are referred to as modes .Majorly there are three modes of exercises and two
exercise chains .The exercise modes are
Aerobic
Stretching exercises
Anaerobic (Strengthening exercises and explosive movements )
2.1.1Exercise chains are either open kinetics (single or double lose packs) or closed chain
(double closed pack.
2.6.1.2 Calisthenics or non-calisthenics.
The exercise mode is the program of the exercise followed by the trainer and trainee the
exercise done are in two types calisthenics (without machines or equipment) or non-
calisthenics (with machines or equipment assisted) and the chains of exercises are open and
closed kinetic exercise
Types of muscle contraction are isotonic (with change of length) or isometric (without change in
length but change in tone)
2.6.1.3. Length change are either shortening (concentric) or lengthening (eccentric)
2.7 Energy systems are three
High energy phosphate ( ATP-CP) ,ATP stored in muscles and creatine
stored in muscles combining with ADP and inorganic Phosphate used in the first 3 second and
next 8-12 seconds of initial stages of exercises. This system is also referred to as anaerobic
alactic energy system
Glycolysis or anaerobic lactic system where by the body involves cells
active systems and enzymes in breaking glucose or glycogen in absence of oxygen which is the
next energy system and occurs in the next 30 to 90 seconds following the 10 or 15 seconds of
the first energy system making it may be a maximum of 120 second
21. 14
2.7.1 Aerobic energy system
This is as well referred to as mitochondria activity system which is slowest and
thrives in presence of oxygen .This is involvement of enzymes, coenzymes and
electron transfer system which produces water and ATP
2.8 FITT
How hard (intensity), how long (volume, duration of exercises), how often (frequency) time
taken per session or time to goal (target training weeks) (Hawley, 2002) Type (mode e.g aerobic,
anaerobic)
2.8.1 “younger longer” Component of exercises (1) warm up (2) work out (3) cooling down
Acronym FITT for younger longer fitness program
Frequency – four consecutive days in a week
Intensity – moderate for warming up, severe in working out, low intensity in cooling down
Time – 55 to 65 minutes
Type – mobilizing exercise of the trunk component in double closed chain, stretching exercises
and aerobic. Aerobic is the dominant type in case of “younger longer”
2.9 Principles of exercises: Specificity of exercises and adaptability
Exercise would only be beneficial if they are done according to the intended objective and
in principle eg cardio exercises must affect the heart rate (Burgomaster et al 2007)
Adaptability .The body is unique in that the body systems used adapt to the physical stress
they are exposed to. In low resistant exercises high intensity like sprinting the phosphagen
energy system is fanned/improved or example the biceps of a carpenter develop to be big
and body builders develop body “ cuts “
Cardiorespiratory exercises must affect the heart rate and pulse rate
Endurance exercises not the same with cardiovascular exercises brings out the essence of
time length accompanied with exercises
Resistant exercises not necessarily strengthening
22. 15
2.10 Physiological benefits for exercises
Decreases/lowers heart rate at ret and work
Increases the adaptability of left ventricle
Decreases work of heart wall/sarcomere
Allows the cardiac output increase to a higher maximal level
Decreases or reverses ST segmental depression
Increases dimension of coronary arteries collaterals formed in case of exercises as a result
of ischemic heart attacks
Increases cardiac work rate
Increase peak power output
Increases VO2max
Increases total blood volume
Increase tone of peripheral veins
Increases central blood volume
Increases resting stroke volume
Better sustained Ejection Fraction during vigorous effort
Increases A-V oxygen difference which increases ventilation
Increases ventricular fibrillation threshold
Increases respiratory of muscles
Increases vital capacity
Increases maximal voluntary ventilation
Decrease fat mass increase lean mass
LOWERS BLOOD PRESSURE
IMPROVES LIPID PROFILE
Increases flexibility
Strengthens tendons and articular cartilages
Decreases catecholamine
Decrease creatine kinase during exercises
Increase oxidative enzymes during exercises
Decreases serum lactate dehydrogenase during exercises
23. 16
Increase growth like insulin factor
Increase bone density
Increase muscle development
Increase maximal muscle force
Increase neuronal firing
Increase fraction of total pool of motor neurons
Increases relaxation of antagonists
Lengthens diastolic phase and decreases heart rate which improves myocardial perfusion
Altered balance between sympathetic and parasympathetic drives to cardiac pacemaker
SA node ( adapted from Hes 800 exercises in chronic diseases )
24. 17
CHAPTER 3
3.0 Methodology
Pseudo resistance, including lack of blood pressure control secondary to poor medication
adherence or white coat hypertension must be excluded. Exercise tress test must be done,
electrocardiogram tests for the patients must also be done. All base line investigation to rule out
exercise contraindication like fasting blood sugars, random blood sugars, full hemogramme and
taking of blood pressure before and after exercises .Resting heart rate and that of during
exercises will be monitored using pulse rate monitors. Maximum age predicted heartrate will be
calculated.
3.1 Study design-randomized controlled trial
Patients with hypertension will be recruited from list of patients screened at Kaindutu Slum in
Thika Town by Health Heart Africa, Hunduma Centre of Kiambu County, Medical Outpatient of
TL5H, Medical Outpatient of St.M.M.ML4H, Records from CIPLA free camp at
ST.M.M.ML4H, Records from HHA by the staff of ST.M.M.ML4H, Records from Various
clinics of physicians at Thika Town. One big record will be made which will serve as the
sampling frame .Those who have Resistant hypertension will be identified by two medical
doctors. Simple randomized sampling (Rotary) will be used and still by simple randomization
process two groups will be chosen one which will undergo the younger longer fitness program
for 6 weeks which will be compared with the control group
3.2 Measurement of variables
BP (dependent), Blood pressure during recruitment will be measured by six nurses to verify what
will be on record using an Omron digital machines and patients will be taught how to measure
blood pressure at home. At least we will identify 12 patients who will be provided with Omron
digital machine who will be requested to use the machine strictly alone and not share with
anybody else for record purposes. Exercise intensity and duration (Independent factor) will be
taken by Master s of exercise science and sport of Kenyatta University. AN exercise pulse rate
monitor will be used and intensity will be calculated by % Maximal age predicted heart rate
25. 18
=0.6463× VO2 max + 37.182 (Swain et al, 1994) which is only applied for a heart rate rage of 63
% to 92 %. From this equation the independent variable will be calculated. SPSS and student T
test will be used for analysis which will also be applied to the controlled group and compared.
Another estimate of VO2max equation is by Uth-Sorenen-OvergaardPedersen estimate VO2max
=15.3×HRMAX/HRREST ml/min/kg
3.3 Study area
Kiandutu (a slum at Thika) location of study, cords from MOPC records of TL5H,
ST.MMML4H, HHA, CIPLA, CHURCH ADVERTISEMENTS –St. Matias Mulumba Hospital
HHA staff.
3.4 Target population.
Patients with resistant hypertension as screened by HHA at Kiandutu Slam in Thika, record from
MOPCs of TL5H and ST.MMML4H,Huduma centre record, Record from Various physician in
Thika Town, CIPLA records at ST.MMML4H, Records from HHA of ST.MMML5H.
3.4.1 Exclusion criteria.
By aid of consent form which will rule out other types of hypertension eg white coat blood
pressure, uncompliant to drugs, risks which can be exacerbated by exercises
eg.CCF,Symptomatic peripheral arterial occlusive disease,Aortic insufficiency or stenosis more
than stage 1, Hypertrophic obstructive cardiomyopathy , uncontrolled atrial/ventricular flutter or
fibrillation,Systolic BP ≥ 180 mmHg , signs of acute ischemia in exercise ECG,And a change of
antihypertensive medicine I the last 4 weeks before the inclusion of the study or the follow up
period.
3.4.2 Inclusion criteria. Those patients who have a BP ≥ 140/90 mmHg and on more than 3
antihypertensive of which one of them is a diuretic ( eg loop diuretics frusemide, bumetanide,
torsemide, Thiazide diuretics – hydrochlorothiazide, hydroflumethiazide, chlorthalidone, esidrix
, zaroxolyn, Potassium –sparing diuretics ( aldactone,dyrenuim ), CCB,beta blockers , ARBs (
angiotensin receptor blockers ) , ACE inhibitors ,nitroglycerines , angiotensin II type 1 blockers ,
aliskren , α-blockers – moxonide, clonide and minoxidil . the preexisting antihypertensive
26. 19
medicine will remain unchanged throughout the study . To minimize the bias of compliance of
antihypertensive drug intake during the study all the patient will be insistently and repeatedly be
requested to take care of an accurate drug intake. Written informed consent will be obtained from
all participants before the study.
3.5 Sampling technique.
From the above enlisted records of antihypertensive patients a list will be made which will serve
as a sample frame from which a sample size will be drawn from
3.6 Sample size.
Will be drawn from the above explained sample frame.
3.6.1unit of analysis
Test statistic (student t test, SPSS)
3.7 Researchinstruments.
Omron brachial digital blood pressure machine , ambulatory pulse rate monitor, glucometer
,ECG monitor, lipid profile , chest x-ray film for heart size assessment, treadmill ,
antihypertensive medicines , Human resource ,medical officers (3), physician consultants ,
Nurses (6) , record health information officer, phlebotomist (2) , physiotherapist (2), exercise
scientist (3 ) , exercise trainer (3) , transport and a supervisor to coordinate all the activities.
3.8 Pre-testing.
Will be done at Kenyatta University exercise science lab with permission from the chair
3.9 validity and reliability.
The training programme has taken care of these two research characteristics because the trainer
will be required to follow it religiously
3.10 Data collection techniques.
BP recording will be done prior to exercises and after the exercises and in each session, intensity
and duration of exercise will be emphasized
27. 20
3.11 Data analysis.
SPSS and student T test will be used
3.12 Logistic and ethical considerations.
Consent for the Research will be obtained from Kenyatta University School of applied Human
sciences research committee, Kiambu county ministry of health research committee and from
TL5H and ST. MMML4H respective research committees.
3.13 Measurement of variables
At the commencement of the exercises training blood pressure will be taken by six nurses , two
will be per patient .The patient will be sited with knees apart and at 90o and will be given 5
minutes to rest , two sets of machine will be made available ,2 sphygmomanometer BP machine
and 2 Omron digital machine . After 5 minutes rest patient will be taken blood pressure on the
left and right brachial arteries simultaneously using sphygmomanometer and then Omron digital
machine will follow. These initial readings will be recorded on a form which will be provided
and will be done for both control and the study group. Resting heart rate will also be recorded
from the Omron digital machine. Consecutive blood pressures for patients will always be taken
before and after exercises. Random blood sugars will be taken for all patient before starting the
study to avoid undiagnosed diabetes mellitus .ECG will be mandatory before the study
commences. Chest x-ray will be one of the investigation to be instituted for the size of the heart
dimension which will be reported by a qualified radiologist
3.13.2 Exercise intensity .Ambulatory pulse rate monitors will be used for this purpose. All the
patients participating in the study will be fitted with a heart rate monitor which will monitor
exercising heart rate which will be recorded immediately after exercises. The maximum heart
rate will be recorded and the mode heart rate. A provisional converting table for VO2max will be
provided for all participants. The two equations provided at section 3.2 (measurement of
variables) will be used for the calculations. Borgs rating for perceived exertion scale (RPE)
28. 21
APPENDIX 1
The scale is as follows
TO GAUGE THE INTENSITY OF PHYSICAL EXERCISES
Borgs Rating of Perceived Exertion (RPE) Scale
While doing physical activity, we want you to rate your perception of exertion. This feeling
should reflect how heavy and strenuous the exercise feels to you, combining all sensations and
feelings of physical stress, effort, and fatigue. Do not concern yourself with any one factor such
as leg pain or shortness of breath, but try to focus on your total feeling of exertion.
Look at the rating scale below while you are engaging in an activity; it ranges from 6 to 20,
where 6 means "no exertion at all" and 20 means "maximal exertion." Choose the number from
below that best describes your level of exertion. This will give you a good idea of the intensity
level of your activity, and you can use this information to speed up or slow down your
movements to reach your desired range.
Try to appraise your feeling of exertion as honestly as possible, without thinking about what the
actual physical load is. Your own feeling of effort and exertion is important, not how it compares
to other people. Look at the scales and the expressions and then give a number.
6 – No exertion at all
7 – Extremely light
8
9 – Very light
10
11 – Light
12
13 – Somewhat hard
14
15 – Hard
16
17 – Very hard
18
19 – Extremely hard
20 – Maximal exertion
# Level of Exertion
6 No exertion at all
7
7.5 Extremely light (7.5)
8
9 Very light
10
11 Light
12
13 Somewhat hard
14
15 Hard (heavy)
16
30. 23
The Bruce Treadmill Test is an indirect test that estimates VO2 max using a formula rather than
using direct measurements that require the collection and measurement of the volume and
oxygen concentration of inhaled and exhaled air. This determines how much oxygen the athlete
is using.
The Bruce Protocol The Bruce Protocol is a maximal exercise test where the athlete works to
complete exhaustion as the treadmill speed and incline is increased every three minutes (See
chart). The length of time on the treadmill is the test score and can be used to estimate the VO2
max value. During the test, heart rate, blood pressure and ratings of perceived exertion are often
also collected.
Bruce Treadmill Test Stages
Stage 1 = 1.7 mph at 10% Grade Stage 2 = 2.5 mph at 12% Grade Stage 3 = 3.4 mph at 14%
Grade Stage 4 = 4.2 mph at 16% Grade Stage 5 = 5.0 mph at 18% Grade Stage 6 = 5.5 mph at
20% Grade Stage 7 = 6.0 mph at 22% Grade Stage 8 = 6.5 mph at 24% Grade Stage 9 = 7.0 mph
at 26% Grade
The Bruce Protocol Formula for Estimating VO2 Max
For Men VO2 max = 14.8 - (1.379 x T) + (0.451 x T²) - (0.012 x T³)
For Women VO2 max = 4.38 x T - 3.9
T = Total time on the treadmill measured as a fraction of a minute (ie: A test time of 9 minutes
30 seconds would be written as T=9.5).
Because this is a maximal exercise test, it should not be performed without a physician's
approval and without reasonable safety accommodations and supervision.
Bruce Protocol Norms for MenVO2 Max Norms for Men - Measuredin ml/kg/min
Age Very Poor Poor Fair Good Excellent Superior
13-19 <35.0 35.0-38.3 38.4-45.1 45.2-50.9 51.0-55.9 >55.9
20-29 <33.0 33.0-36.4 36.5-42.4 42.5-46.4 46.5-52.4 >52.4
30-39 <31.5 31.5-35.4 35.5-40.9 41.0-44.9 45.0-49.4 >49.4
40-49 <30.2 30.2-33.5 33.6-38.9 39.0-43.7 43.8-48.0 >48.0
50-59 <26.1 26.1-30.9 31.0-35.7 35.8-40.9 41.0-45.3 >45.3
60+ <20.5 20.5-26.0 26.1-32.2 32.3-36.4 36.5-44.2 >44.2
A
VO2 Max Norms for Women VO2 Max values for Women as measured in ml/kg/min
Age Very Poor Poor Fair Good Excellent Superior
13-19 <25.0 25.0-30.9 31.0-34.9 35.0-38.9 39.0-41.9 >41.9
20-29 <23.6 23.6-28.9 29.0-32.9 33.0-36.9 37.0-41.0 >41.0
30-39 <22.8 22.8-26.9 27.0-31.4 31.5-35.6 35.7-40.0 >40.0
40-49 <21.0 21.0-24.4 24.5-28.9 29.0-32.8 32.9-36.9 >36.9
50-59 <20.2 20.2-22.7 22.8-26.9 27.0-31.4 31.5-35.7 >35.7
60+ <17.5 17.5-20.1 20.2-24.4 24.5-30.2 30.3-31.4 >31.4
lso See: VO2 Max Norms for Women
31. 24
Appendix 3
EXERCISE PROGRAM
VENUE: ST.MMML4H TENT
INSTRUCTOR: YOUNGER LONGER TRAINER
TRAINEE: Patients with resistant hypertensive, normotensive, controlled tensives
Mode: aerobic, stretching
Type of exercises:Calisthenics
Exercise chains: open and closed chain kinetics
Muscle contractions: both isometrics and isotonic
Contraction mode: Both concentric and eccentrics
Energy systememployed: Phosphagen, Glycolysis and Aerobic
Duration of session: 55- 65 minutes
Frequency: 4 times in a week
Tempo: high (maximal) intensity
Time to goal: 6 weeks
Time of exercise: 4.55 pm – 6pm
Session:
Calling class to order: warm up (284 activities in 15 minutes)
“finding energy line” instruction “ imagine its early in the morning and you`ve just have risen
from bed ,lifting your right hand bending it backward with your left hip ,trunk in back extension,
make a fist ,bend your elbows, retract your shoulders tighten your fist, your arms, your back,
your gluteal , your thighs , your legs , your feet, your toes, common tighten, tighter and tighter
and tighter
32. 25
1. Breathing exercises in all coronal , sagittal and horizontal plane × 4
2. “ let’s go igo-meaning facing up and biting 40 times
3. “ Masaai” imitating a Masaai dance – repeated 40 times
4. Neck movements : flexion , extension , rotation , circumduction in all plains × 10 times
each
5. Shoulder movements , flection , abduction , elevation , circumduction , horizontal
flection and extension in all plains × 10
6. “ Aeroplane “ shoulders abducted in coronal plain, fist formation , elbow flexion each ×
10
7. Trunk ( divided into four quadrant in sanding in an anatomical position ) flection ,
extension in all plains × 10
8. Lower trunk rotation to the right and left × 10 in horizontal plain
9. “ hips flexed and opposite extended –rocking forward and backed –repeat each side × 10
10. Squatting × 2
Work out (640 activities)- 30 minutes
1. “ Single Alice “ posture – anatomical standing position right shoulder flexed arm
elevated in back extension , left leg in hyper extension open chain kinetic of lt.leg
crisscrossing with hand with the arm in alternate shoulder flexion × 10 , repeat with
alternative limbs × 10
2. “Double Alice “. Shoulders in flexion arms elevated with rt leg drawn in hyper extension.
Action :front swing in extension of both upper limbs with open kinetic rt. lower limb
flexion to crisscross the leg with the hands × 10 .Repeat with the lt.leg × 10
3. Extended rt. foot forward step with a draw back in hip extension × 10 .Repeat with the lt
foot × 10
4. “Ngucu” (a kikuyu dance step). Action : stepping from a central point towards the right
then lt. and stepping back to the same point with the rt. then lt × 20
5. Forward and back step with the rt. foot and kicking from behind of the same rt. foot and
kicking with same from behind and alternating from rt to lt × 20
6. Marching on the spot “ narrow “ × 20 “ March wide “ × 20
7. “ march wide ,march narrow” × 20
33. 26
8. “A march and a tap with hill front “× 20. Repeat with the sides ,rt alt.lt × 20 and behind
step after a march × 20
9. A spot march and front step , then a march and step on the side and behind once in the
three directions × 20
10. Skip and skip × 20
11. A skip and clap under the knee × 20
12. Hip curls in coronal plane hips immoderately abducted side swing to the rt. alternating to
the lt. × 20
13. Running on the sport run × 40 counts
14. Low jump “ jump on the spot jump” jump one two three jump – “ Miriam” jump × 3 each
× 10
15. “Susan`s jump” command: apart together across apart together is a combination of double
open chain in hip abduction followed by midline hip adduction of alternate foot × 20
16. “Mitugo`s jump “command: from behind .forward, from behind forward. whose Mitugo`s
eee… Mitugo,…aaa….× 20 Repeat- the hip is drawn far in extension then with a swing
flung in a pendular manner an open kinetic chain of one leg is alternated rt and lt
17. Number 16 exercise is repeated but this time the hips are hyperextended far behind and
front × 20
18. “Njogu`s jump” Command: feet apart far apart right left they go, right left they go whose
Njogu`s oh..ooh Njogu`s × 20 Repeatedtwice- alternate side open chain
19. “Munyambo`s jump “Command: sea shore Munyambo`s eee , Munyambo`s
aaa….Munyambo`s eee..Munyambo`s aaa…× 20 A repeat this exercise one central point
open chain kinetic swing to the left and alternatively to the right with at no any time
when both feet are together on the surface at the same time
20. “Wambugu`s jump” Command: astride and close, a stride and close, a stride and close, a
stride and close, whose Wambugu`s..eee.. Wambugu`s..aaaa, .. Wambugu`s eee,
Wambugu`s aaa × 20 A repeat . This exercise is double open chain kinetics in hip
abduction followed by double close chain kinetics in adduction
21. “Helen`s jump “command: feet inclined forward, head drawn backward, eyes fixed up
backward on the ceilings …. Who’s …. Helen`s ooooh …Helen`s..eeee, Helen`s ooooh,
34. 27
Helen`s eee, × 20 Repeat. This exercise is an alternate single open chain kinetic which is
a rhythmical forward slide away from the backward inclined trunk
22. Negating Helen`s jump
23. ‘Miriam’s jump” Command : jump on the spot jump, jump , one , two , three , jump high
, × 20 Repeat This exercise is a double kinetic chain with knees alternating from flexion
to extension
24. Star jump × 40
Cool down (364 activities) – 15 minutes
1. 16 times forced coughing
2. Scissor stand trunk stretching lt × 10 , rt , × 10
3. Imitating forward stroke in swimming × 10
4. Imitating back stroke in swimming × 10
5. Breathing exercises in all coronal , sagittal and horizontal plane × 4
6. “ let’s go igo-meaning facing up and biting 40 times
7. “ Masaai” imitating a Masaai dance – repeated 40 times
8. Neck movements : flexion , extension , rotation , circumduction in all plains × 10 times
each
9. Shoulder movements , flection , abduction , elevation , circumduction , horizontal
flection and extension in all plains × 10
10. “ Aeroplane “ shoulders abducted in coronal plain, fist formation , elbow flexion each ×
10
11. Trunk ( divided into four quadrant in sanding in an anatomical position ) flection ,
extension in all plains × 10
12. Lower trunk rotation to the right and left × 10 in horizontal plain
13. “ hips flexed and opposite extended –rocking forward and backed –repeat each side × 10
14. Squatting × 3
35. 28
References
1. Williams Ganong review of medical physiology 2008
2, Calhoun et al 2012
3. Yaxley et al 2013
4. Persel and Stephen hypertension
5. Nolte et al 2013
6. Papademeterius et al 2009
7. Dimeo et al 2012
8. Viera et al 2009
9. Rubetro et al 2015
10. Lam et al 2012
11.Urbin et al 2008
36. 29
Appendix 4
THE COSTING OF THE RESEARCH PROGRAM
Number of
item
Item description Number
required
Cost per item Total cost
1 Omron BP machine 12 8,000.00 96,000.00
2 Sphygmomanometer 2 2,500.00 5,000.00
3 Ambulatory heart
rate monitor
12 6,300.00 75,600.00
4 Glucometer 1 5,000.00 5,000.00
5 Glucostick 1packet 5,000.00 5,000.00
6 ECG investigations 12 patients 1,000.00 12,000.00
7 Chest x-ray 12 patients 500.00 6,000.00
Total 204,600
37. 30
HUMAN RESOURCE PERSONS
Number Profession Number
required
Service Service
charge per
item
Total
1 Community
owned
resource
person (corp)
2 Mediation in the
Kiandutu slams
for 4 days in 4
weeks
1,000.00 8,000.00
2 Extension
health worker
1 Coordination of
the activities in
the slam for 4
days in 4 weeks
1.500.00 6,000.00
3 Information
health record
officer
Recording and
analysis of data
50,000.00 50,000.00
4 Nurse 6 Monitoring of
BP 4 days in 4
weeks
2,000.00 48,000.00
5 Phlebotomist 1 Monitoring of
blood sugars for
4 days in 4
weeks
100.00 9,600
6 Trainer 2 Conducting the
exercise
program 4days a
2,000.00 96,000.00
38. 31
week for 6
weeks
7 Exercise
stress test
administrator
2 Asses exercise
stress test for 12
patients twice
3,000.00 72,000.00
8 Medical
officer of
health
2 Follow up of 24
patients for 4
appointments
1,000.00 96,000.00
9 Consultant 1 Assessment and
definition of
patients with
resistant
hypertension
2,000.00 48,000.00
10 Research
director
24 days for
the 24
sessions
Antihypertensive
drugs
administration
3,000.00 72,000.00
11 Transport of
the patient
Control 4
days ,study
group 24
days
Transport of
patients
300.00 87,600
Total 593,200
Total cost 204,600 + 372,400 = 797,800. 00