1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 11 Activity Tolerance and Fatigue

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Benefits of Regular Exercise Slowing or halting the progression of atherosclerotic coronary artery disease Lowering low-density lipoproteins (LDL) Increasing high-density lipoproteins (HDL) Providing better regulation of blood glucose in persons with diabetes Improving activity tolerance in persons with cardiac and respiratory diseases Improving self-esteem and quality of life

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Components of Exercise Cardiopulmonary fitness Muscle strength Flexibility Endurance Availability of energy substrates to meet the increased energy demands imposed by increased physical activity Motivation and mental endurance

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Exercise Aerobic or Endurance Exercise –The use of oxygen for transforming substrates such as glucose, fatty acids, and amino acids into energy –A change in muscle length (contraction and elongation) such as walking and running –Results in muscles that use oxygen more efficiently –The body can do more work with less cardiac and respiratory effort.

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Exercise (cont.) Isometric or Resistance Exercise –Muscles contract against an immovable force without changing length. –Involves activities, such as weight lifting and high- resistance exercises –Improves overall muscle strength and tone and builds muscle mass

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following types of exercise will, over time, utilize more energy? –A. Aerobic –B. Anaerobic –C. Isometric

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Aerobic Rationale: Aerobic exercise will use more energy stores and result in greater weight loss.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiopulmonary Responses to Exercise Circulatory functions of the heart and blood vessels Gas exchange functions of the respiratory system –Supply oxygen and energy substrates to the working muscle groups –Exchange oxygen and carbon dioxide with the atmosphere

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychological Responses to Exercise Improve self-esteem Remedy depressive moods Enhance quality of life

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins General Recommendations for a Balanced Diet 55% complex carbohydrate sources 30% fat sources (mainly polyunsaturated fats) 15% protein

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of Aerobic Exercise Maximal oxygen uptake (VO 2 max) –Cannot be exceeded –Can be improved Measurement of VO 2 max

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Activity Tolerance Pencil-and-paper tests –For example, human activity profile Ergometry –For example, the bicycle ergometer and the treadmill ergometer Metabolic equivalents

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Activity Intolerance and Fatigue Activity intolerance—not having sufficient physical or psychological energy reserve to endure or complete an activity Fatigue—depletion of reserves that makes it impossible to complete an activity –Normal –Symptomatic

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Exercise Tolerance and the Elderly –Gains in cerebral function –Improved balance and coordination Physical benefits –Overall health and physical fitness –Enhanced maximal aerobic capacity –Prevention of a decline in the basal metabolic rate

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Exercise Tolerance and the Elderly (cont.) Psychological benefits –Greater sense of well-being –Increased opportunities for social interactions –Lower rates of mortality –Fewer years of disability

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Definitions of Fatigue Acute –Lasting less than 4 weeks Chronic –Present for 50% of the day or lasting 1 to 6 months or longer

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Origins of Fatigue Physiological –Environmental factors –Drug-related incidents –Physical exertion Psychological Pathological –Treatment-related causes Unknown Causes –Chronic fatigue syndrome

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Used to Determine the Diagnosis of Fatigue Underlying physiologic basis Origin or cause Temporal patterns over time

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiological Basis of Fatigue Diaphragmatic and Motor Mechanisms –Force and duration of muscle work exceed muscle energy stores. Neurologic Mechanisms –Involve the loss of maximal capacity to generate force during exercise

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Fatigue is a subjective feeling that you have when you feel tired.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Fatigue is rooted in physiological change.

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute and Chronic Fatigue Chronic fatigue differs from acute fatigue in terms of onset, intensity, perception, duration, and relief. Chronic fatigue is much more complex and difficult to diagnose.

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Problems Related to Chronic Fatigue Epstein-Barr virus Human herpes virus 6 Enterovirus Other infectious agents Anxiety and depression

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cancer-Related Factors Causing Fatigue Infection Medications Metabolic disorders Anemia Cachexia Stress Pain

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Diagnosis of Chronic Fatigue Syndrome Fatigue longer than 6 months’ duration, not relieved by rest Significant reduction in activities

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Diagnosis of Chronic Fatigue Syndrome (cont.) Presence of at least four of following symptoms: –Impaired memory or concentration –Sore throat –Tender cervical or axillary lymph nodes –Muscle pain

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Diagnosis of Chronic Fatigue Syndrome (cont.) Presence of at least four of following symptoms (cont.): –Multijoint pain –New headaches –Unrefreshing sleep, postexertional malaise

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Criteria for Diagnosis of Chronic Fatigue Syndrome (cont.) Exclusionary diagnosis –Active medical condition explaining fatigue –Past or current diagnosis of major depressive disorder –Alcohol or other substance abuse

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Theories of Pathogenesis of CFS Infections Psychological disorders Dysfunction in the hypothalamic–pituitary–adrenal axis Alteration in the autonomic nervous system

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Manifestations of Chronic Fatigue Syndrome –Wheezing –Splenomegaly –Myalgias and arthralgias –Heme-positive stool with subsequent negative sigmoidoscopies Physical problems –Complaint of fatigue –Low-grade fever –Nonexudative pharyngitis –Palpable and tender cervical lymph nodes –Mildly enlarged thyroid gland

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Manifestations of Chronic Fatigue Syndrome (cont.) Psychological Problems ―Impaired cognition ―Mood and sleep disturbances ―Balance problems and visual disturbances ―Various degrees of anxiety and depression

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins CFS Treatment Treatment tends to remain symptomatic with a focus on management rather than cure. –Education –Emotional support –Treatment of symptoms –Overall management of general health –Structured activity program

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Immobility and Bed Rest Generalized weakness Orthostatic intolerance Atelectasis Pneumonia Pulmonary emboli Thrombophlebitis

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Immobility and Bed Rest (cont.) Muscle atrophy Osteoporosis Urinary retention Constipation Impaired sensory perception

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiovascular Response to Bed Rest Redistribution of blood volume from lower body to central circulation Deconditioning of the heart Reduction in total body water

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Contributing to the Development of Deep Vein Thrombosis (DVT) The Virchow triad for thromboembolic disease combines to predispose a person to thrombus formation: –A redistribution of circulating volume leads to a decreased intravascular volume, which contributes to increased blood viscosity and a hypercoagulable state. –Venous stasis due to absence of the lower extremity muscle pumping effect –Application of external pressure from the mattress against the veins

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulmonary Changes Due to Bed Rest Decreased tidal volume and functional residual capacity Tendency of alveoli to collapse –Resultant areas of decreased pulmonary ventilation

38. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Muscle and Bone Changes Due to Bed Rest Muscle mass is reduced due to disuse atrophy. Bone mass is reduced because of an imbalance of activity between osteoclasts and osteoblasts.

39. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Progression of Physiological Responses The body responds in a characteristic pattern to the effects of the supine position and bed rest (see Figure 11.3). Milestones –First 3 days of bed rest –Day 4 to 7 –Day 8 to 14 –After 15 days

40. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Interventional Treatment of Immobility- Related Degeneration Should address physical and psychosocial needs Goals of care –Decrease risk for complications –Provide diversional activities to offset sensory deprivation –Repositioning schedule –Prophylactic DVT intervention