By B. Sinikar. City University of Los Angeles.

In addition generic methotrexate 2.5mg online, the activ- ity goals should be tailored to the individuals’ needs and lifestyle cheap methotrexate 2.5 mg line. Good inter- personal skills are essential discount 2.5mg methotrexate amex, which consist of communication (verbal and non-verbal) methotrexate 2.5 mg with visa, active listening and expressing empathy buy methotrexate 2.5mg low price. Active listening shows the individual that the consultant has listened care- fully and understands what he or she has said. Empathy involves showing individuals that you understand what it is like to be in their world. Empathy can be expressed using examples of other patients who have been in a similar situation to the individual. As the exercise consultation is a client-centred approach, the consultant should try to avoid preaching, lecturing or providing solutions for the client. The consultant can offer suggestions, such as how to overcome a certain barrier to activity, but this is best achieved by using examples of how other individuals overcame this barrier. Further information on the client-centred approach and the interpersonal skills involved in behaviour change coun- selling is provided in guidelines on exercise consultation (Loughlan and Mutrie, 1995), and there is also a variety of books on this topic (Rollnick, et al. COMPONENTS OF AN EXERCISE CONSULTATION Assessing stage of exercise behaviour change The consultation should begin by assessing the individual’s stage of exercise behaviour change in order to select the most appropriate strategies to use in the consultation. Those who have recently completed a phase III exercise programme are likely to be either regularly physically active (i. Contemplation I am not regularly active but am thinking about starting in the next 6 months. Preparation I do some physical activity but not enough to meet the description of regular physical activity given above. Maintenance I am regularly active and have been doing so for longer than 6 months. Maintaining Physical Activity 207 ∑ Assess stage of change ∑ Assess current physical activity status (e. Increased confidence Barriers to activity Barriers to remaining active Strategies to overcome barriers 1. Do an indoor activity instead ∑ Review physical activity recommendations ∑ Explore activity options ∑ Seek support for activity plan Goal Setting 1 month 3 month 6 month 1. Swimming once per week for 15 mins week for 25 mins Preventing relapse High-risk situations Coping strategies 1. Reschedule the swim session or go attend class or go swimming out walking instead 2. Example of an exercise consultation delivered to patients at the end of phase III. Definition of regular physical activity: •A minimum of 20 minutes of moderate intensity exercise on three days per week. The aims of the consultation for individuals in action and maintenance are ensuring that they remain regularly physically active in phase IV and prevent relapse. Physical activity recommendations for phase IV participants are similar to the physical activity guidelines for healthy adults: individuals should be encouraged to accumulate at least 30 minutes of moderate intensity activ- ity on most days of the week (Pate, et al. Assessing current activity levels Assessing the individual’s current physical activity levels can be carried out using a questionnaire, such as the Stanford Seven-Day Physical Activity Recall (Blair, et al. This assessment provides the exercise consultant with information on the individuals’ actual activities and can be used to identify possible opportunities for physical activity in their daily routine (e. In addition, daily recording of activities in a diary can help individuals monitor their progress as they make changes to their exercise behaviour, and it can provide them with feedback on whether they have achieved their set goals. This assessment should be followed by a discussion on the individuals’ past and present activities to discover their likes and dislikes (e. Decisional balance Participants are asked to complete a decisional balance chart, which involves comparing the perceived pros and cons of being active. Patients should be encouraged to identify the benefits gained during the phase III exercise pro- gramme. Examples of benefits stated by patients include increased fitness, improved well being, increased confidence and weight management. The importance of remaining active in order to maintain these benefits should be emphasised. Then individuals should consider additional benefits they would gain by remaining active in the long term: preventing another heart attack, improving quality of life, living longer and controlling weight. Patients are also asked to explore their perceived cons (costs) of being active: examples of perceived costs of being active experienced by patients include having to make time for exercise and not liking to walk in bad weather. The aim of the decisional balance chart is to help individuals realise that the pros of being active out- weigh the cons.

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This should include periods when patients may be having a rest buy methotrexate 2.5 mg overnight delivery, to avoid postural and orthostatic hypotension 2.5mg methotrexate with visa. An inadequate warm-up generic 2.5 mg methotrexate visa, cool-down or a sudden stop results in pooling of the blood in the lower extremities purchase methotrexate 2.5 mg with visa, i order methotrexate 2.5 mg free shipping. Any sudden drop in BP from the individual’s normal range may produce dizziness or lightheadedness. Exercise prescribers and CR participants must be aware of the actions and implications for exer- cise of these medications. It is important that patients inform the instructor of the use of their GTN spray or any changes in medication. Exercises where patients move from lying to standing should be avoided, as this may induce sudden changes in BP, which can lead to postural hypoten- sion. Obesity Obesity is excess body fat for a given age or gender and can increase the risk of coronary heart disease two-fold (BHF, 2004). Body Mass Index (BMI) is an 124 Exercise Leadership in Cardiac Rehabilitation accepted method of estimating a person’s relative weight. BMI is calculated by dividing weight in kilograms by the square of height in metres. In the last ten years the percentage of obese adults has increased by more than 50%, from 14% of the population to 22% (BHF, 2004). This has many serious implications for cardiac rehabilitation, as obesity is a significant risk to the primary cause and secondary prevention of CHD. At present there is inconclusive evidence regarding the relative effectiveness of physical activity combined with diet, versus diet alone or physical activity alone (Mulvihill and Quigley, 2003). As adipose tissue contains about 7000kcal/kg, with physical activity alone it is difficult to lose much weight (BHF, 2004). Therefore, man- agement of obese participants should include advice on diet, physical activity and a behavioural modification component in order to be comprehensive and effective. The most favourable alterations in body composition will occur with low-intensity, long duration aerobic exercise and aerobic exercise combined with high repetition resistance training (Mulvihill and Quigley, 2003). If the goal is to use exercise as a strategy for obesity reduction, exercise pro- grammes require prescribed energy expenditure of 3000–3500kcal per week. This would require approximately 45–60 minutes of exercise, for example, pur- poseful walking performed at a moderate intensity (70% HRmax) on most days of the week (Mulvihill and Quigley, 2003). Frequency The frequency remains at 3 to 5 exercise sessions per week, integrating activ- ity into everyday life. Type Combined cardiovascular (CV) and RE should be included with the aim to increase lean tissue (muscle), as this is more metabolically active. For overweight patients, avoid high-impact exercises in order to prevent excess stress on joints. Alternatively, non-weightbearing activities could be Exercise Prescription 125 prescribed, e. Some obese patients may be embarrassed to do these and some exercise bikes will have a weight restriction. In addition, adipose tissue may restrict positions for stretching or the ability to partake in floor-based exercises. Therefore, the exercise leader should be aware of this and take it into account when prescribing activity to encourage adherence. When monitoring an obese patient it may be difficult to palpate a pulse at the wrist or neck areas, and RPE scales may be the mode of monitoring. Time Increase duration and frequency according to the participant’s capacity and aim to increase total energy expenditure. Special attention is required for participants who are on insulin or oral hypoglycaemic agents (OHA). Awareness by the exercise leader and participant of the potential for both hypoglycaemia and hyperglycaemia within an exercise situation is essential. Any planned new physical activity should be discussed with the diabetic CR participant and the diabetes care team (Diabetes UK, 2003). After a cardiac event, metabolic stress may induce latent diabetes or can worsen the control of pre-existing diabetes. Therefore, it is essential that diabetes is well con- trolled prior to the individual commencing exercise. If a participant is newly diagnosed with either type I or type II diabetes, it is advisable that they do not exercise alone until they are able to monitor their response to exercise. These neuropathies affect sympathetic and parasympathetic activity, and therefore HR and BP response to exercise may be altered.

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This application is cur- rently running on a SGI Onyx2 In®nite Reality machine (Fig buy methotrexate 2.5 mg without prescription. In this application the spaceball is used to walk (navigate inside or outside of the colon) and the HMD is used for viewing the colon cheap 2.5mg methotrexate otc. The 3-D model of the colon is currently in an Inventor ®le format and has been reconstructed from CT images of the Visible Human Male Dataset buy 2.5mg methotrexate with visa. The reconstruction was made with the Analyze software package developed at the Mayo Biomedical Imaging Resource Laboratory (24 methotrexate 2.5 mg free shipping, 92) methotrexate 2.5mg low cost. Currently, the application supports the following modes and features: 110 VIRTUAL REALITY AND ITS INTEGRATION INTO A TWENTY-FIRST CENTURY Mode 1. Free ¯ythrough using the input devices that give the user the ability to examine the inner and the outer surface of the colonic wall. This is helpful when the user detects a tumor on the inner surface and wants to see if the tumor extends to the other surface. The mode gives the impression of relating to the user and keeps him or her inside the colon. It is helpful for quick examination of the colon and does not warn the user when he or she is stuck on the colonic wall. The three features allow the viewing position to be reset to an initial position and increase and decrease the scale. Much less patient discomfort results because there is no need to reposition the patient. The radiation dose used in virtual endoscopy is one half of one quarter of the average exposure in barium enema and an unlimited number of viewing angles can be exploited. There is also no need for sedation, and the patient can resume normal activities immediately after the CT scanning procedure. In addition, by adopting a virtual medical worlds interface, the pragmatics of de®ning and creating virtual envi- ronments are abstracted from the practitioner. A practitioner then has a choice, depending on the availability of supportive hardware, on how to visu- alize patient data. This chapter was not concentrated with the speci®cs of vir- tual reality techniques and did not provide detailed explanations of its use. It outlined a possible framework for how these advanced imaging techniques could be integrated into a general telemedical information society. Presently, the cost of VR hardware and software has restricted its usage to only a few medical institutions. However, it is envisaged that as these costs are reduced, the technology will become more widespread. Surgery planning programs such as VRASP are already available to allow a surgeon to practice an operation on a virtual model of the patient and then use this virtual operation to assist during the real operation. It seems quite REFERENCES 111 possible that this approach could be taken even further so that a surgeon could be in one location and either a robot or another, less specialized, surgeon could perform the operation at another location (112±118). This approach could be used in specialized cases, natural disasters, isolated regions, and even military situations. It is also possible that VR techniques could be used for telepresence to create a virtual practitioner to guide a less quali®ed practitionerÐa VR form of teleconferencing. However, with the introduction of any new technology the factors of its safe and healthy use need to be considered along with its ethics (119). Clearly, there are many diverse potential uses of VR techniques; and even through VR is in its development stages, it is providing another tool to aid practitioners not only in training but also in diagnosis and treatment planning (120, 121). It is my opinion that only if such techniques can be truly integrated into a uniform frameworkÐincluding telecommunications, computing, and data managementÐwith all other forms of medical imaging techniques and developing technologies (e. Applied virtual reality for simula- tion of endoscopic retrograde cholangio-pancreatoraphy (ERCP). Virtual endoscopy of the head and neck: diagnosis using three-dimensional visualisation and virtual representation. Towards performing ultrasound-guided needle biopsies from within a head-mounted display. The dimensionally integrated dental patient record: digital dentistry virtual reality in orthodontics. Paper presented at the 12th International Symposium on the Creation of Electronic Health Record System and Global Conference on Patient Cards.

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