EPIDEMIOLOGY AND ETIOLOGY OF STROKE

            Stroke is the fourth leading cause of death and the leading cause of long-term disability among adults in the United States. An estimated 7,000,000 Americans older than 20 years of age have experienced a stroke. Each year approximately 795,000 individuals experience a stroke; approximately 610,000 are first attacks and 185,000 are recurrent strokes. 

             Women have a lower age-adjusted stroke incidence than men. However, this is reversed in older ages; women over 85 years of age have an elevated risk compared to men. Compared to whites, African Americans have twice the risk of first-ever stroke; rates are also higher in Mexican Americans, American Indians, and Alaska Natives. he incidence of stroke increases dramatically with age, doubling in the decade after 65 years of age. Twenty-eight percent of strokes occur in individuals younger than 65 years of age. Between 5% and 14% of persons who survive an initial stroke will experience another one within 1 year; within 5 years stroke will recur in 24% of women and 42% of men. Current data reveal that stroke incidence has been declining in recent years in a largely white adult cohort. he incidence of stroke deaths is greater than 143,000 annually, and strokes account for 1 of every 18 deaths in the United States. he type of stroke is significant in determining survival. Of patients with stroke, hemorrhagic stroke accounts for the largest number of deaths, with mortality rates of 37% to 38% at 1 month, whereas ischemic strokes have a mortality rate of only 8% to 12% at 1 month. Survival rates are dramatically lessened by increased age, hypertension, heart disease, and diabetes. Loss of consciousness at stroke onset, lesion size, persistent severe hemiplegia, multiple neurological deficits, and history of previous stroke are also important predictors of mortality.1,2 Stroke is the leading cause of long-term disability in the United States. Of ischemic stroke survivors 65 or older, incidences of disabilities observed at 6 months include hemiparesis (50%), unable to walk without assistance (30%), dependent in activities of daily living (ADL) (26%), aphasia (19%), and depression (35%). Stroke survivors represent the largest group admitted to rehabilitation hospitals and about a third of patients receive outpatient rehabilitation services. Another indicator of disability is the fact that approximately 26% of patients with stroke are institutionalized in a long-term care facility. Direct and indirect costs of stroke are in the billions. Atherosclerosis is a major contributory factor in cerebrovascular disease. It is characterized by plaque formation with an accumulation of lipids, fibrin, complex carbohydrates, and calcium deposits on arterial walls that leads to progressive narrowing of blood vessels. Interruption of blood flow by atherosclerotic plaques occurs at certain sites of predilection. hese generally include bifurcations, constrictions, dilations, or angulations of arteries. he most common sites for lesions to occur are at the origin of the common carotid artery or at its transition into the middle cerebral artery, at the main bifurcation of the middle cerebral artery, and at the junction of the vertebral arteries with the basilar artery

          Ischemic strokes are the result of a thrombus, embolism, or conditions that produce low systemic

perfusion pressures. The resulting lack of cerebral blood flow (CBF) deprives the brain of needed oxygen and glucose, disrupts cellular metabolism, and leads to injury and death of tissues. A thrombus

results from platelet adhesion and aggregation on plaques. Cerebral thrombosis refers to the formation

or development of a blood clot within the cerebral arteries or their branches. It should be noted that

lesions of extracranial vessels (carotid or vertebral arteries) can also produce symptoms of stroke. Thrombi lead to ischemia, or occlusion of an artery with resulting cerebral infarction or tissue death (atherothrombotic brain infarction [ABI]). Thrombi can also become dislodged and travel to a more distal site in the form of an intra-artery embolus. Cerebral embolus (CE) is composed of bits of matter (blood clot, plaque) formed elsewhere and released into the bloodstream, traveling to the cerebral arteries where they lodge in a vessel, producing occlusion and infarction. The most common source of CE is disease of the cardiovascular system. Occasionally systemic disorders may produce septic, fat, or air emboli that affect the cerebral circulation. Ischemic strokes may also result from low systemic perfusion, the result of cardiac failure or significant blood loss with resulting systemic hypotension. The neurological deficits produced with systemic failure are global in nature with bilateral neurological deficits. Hemorrhagic strokes, with abnormal bleeding into the extravascular areas of the brain, are the result of rupture of a cerebral vessel or trauma. Hemorrhage results in increased intracranial pressures with injury to brain tissues and restriction of distal blood flow. Intracerebral hemorrhage (IH) is caused by rupture of a cerebral vessel with subsequent bleeding into the brain. Primary cerebral hemorrhage (nontraumatic spontaneous hemorrhage) typically occurs in small blood vessels weakened by atherosclerosis producing an aneurysm. Subarachnoid hemorrhage (SH) occurs from bleeding into the subarachnoid space typically from a saccular or berry aneurysm affecting primarily large blood vessels. Congenital defects that produce weakness in the blood vessel wall are major contributing factors to the formation of an aneurysm. Hemorrhage is closely linked to chronic hypertension. Arteriovenous malformation (AVM) is another congenital defect that can result in stroke. AVM is characterized by a tortuous tangle of arteries and veins with agenesis of an interposing capillary system. he abnormal vessels undergo progressive dilation with age and eventually bleed in about 50% of cases. Sudden and severe cerebral bleeding can result in death within hours, because intracranial pressures rise rapidly and adjacent cortical tissues are compressed or displaced as in brainstem herniation.

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

WHAT IS STROKE ?

  Stroke (cerebrovascular accident [CVA]) is the sudden loss of neurological function caused by an interruption of the blood flow to the brain. Ischemic stroke is the most common type, affecting about 80% of individuals with stroke, and results when a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients. 

Hemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in or around the brain. Clinically, a variety of focal deficits are possible, including changes in the level of consciousness and impairments of sensory, motor, cognitive, perceptual, and language functions. To be classified as stroke, neurological deficits must persist for at least 24 hours. Motor deficits are characterized by paralysis (hemiplegia) or weakness (hemiparesis), typically on the side of the body opposite the side of the lesion. he term hemiplegia is often used generically to refer to the wide variety of motor problems that result from stroke. he location and extent of brain injury, the amount of collateral blood flow, and early acute care management determine the severity of neurological deficits in an individual patient. Impairments may resolve spontaneously as brain swelling subsides (reversible ischemic neurological deficit), generally within 3 weeks. Residual neurological impairments are those that persist longer than 3 weeks and may lead to lasting disability. Strokes are classified by etiological categories (thrombosis, embolus, or hemorrhage), specific vascular territory (anterior cerebral artery syndrome, middle cerebral artery syndrome, and so forth), and management categories (transient ischemic attack, minor stroke, major stroke, deteriorating stroke, young stroke)

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

Heart Valves

HEART DISEASE

      CARDIAC ANATOMY AND PHYSIOLOGY OF HEART 

     HEART TISSUE

      CORONARY ARTERIES 

Heart Valves ;    

            Four heart valves ensure one-way blood flow through the heart. Two atrioventricular valves are located between the atria and ventricle. The atrioventricular valve, positioned between the RA and RV, is termed the tricuspid valve; the left atrioventricular valve is the mitral valve (also known as the bicuspid valve), located between the left atrium and ventricle. he semilunar valves lie between the ventricles and arteries and are named based on their corresponding vessels (i.e., pulmonic valve on the right in association with the pulmonary artery, and aortic valve on the left relating to the aorta).

           Flaps of tissue called leaflets or cusps guard the heart valve openings. he right atrioventricular valve has three cusps and is therefore termed tricuspid, whereas the left atrioventricular valve has only two cusps and hence is termed bicuspid. These leaflets are attached to the papillary muscles of the myocardium by chordae tendineae. the primary function of the atrioventricular valves is to prevent backflow of blood into the atria during ventricular contraction or systole, while the semilunar valves prevent backflow of blood from the aorta and pulmonary artery into the ventricles during diastole. Opening and closing of each valve depends on pressure gradient changes within the heart created during each cardiac cycle.

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

CORONARY ARTERIES

HEART DISEASE

        CARDIAC ANATOMY AND PHYSIOLOGY OF HEART 

      HEART TISSUE

 

Coronary Arteries ;

                The coronary arteries originate in the sinus of Valsalva located in the wall of the aorta near the aortic valve.The right coronary originates from the area near the right aortic leaflet, the left coronary from the area near the left aortic leaflet. When the aortic valve is open during systole, the origins of the coronary arteries are located behind the aortic leaflets within the wall; when the aortic valve is closed during diastole, the openings of the coronaries are clearly exposed, allowing them to be easily perfused.5 he coronary arteries therefore receive the majority of their blood flow during diastole, unlike the other arteries of the body that are perfused during systole.

                    The left coronary artery begins as the left main (LM) and then branches into the left anterior descending (LAD) and the circumflex (CX) (Fig. 13.3). he LAD may have further divisions, known as diagonal branches, that come off of the primary LAD. he LAD and its diagonal branches primarily supply the anterior and apical surfaces of the LV, as well as portions of the interventricular septum. he circumflex may also have branches, known as marginal branches. he circumflex and its marginal branches supply the lateral and part of the inferior surfaces of the LV and portions of the left atrium (LA). he right coronary artery (RCA) supplies the RA, most of the RV, part of the inferior wall of the LV, portions of the interventricular septum, and the conduction system. he posterior descending artery (PDA) is most commonly a branch of the RCA and perfuses the posterior heart. If the RCA does not perfuse the posterior heart, the CX will supply this area. When the PDA comes from the RCA, the anatomy is referred to as being right dominant; if the PDA comes from the circumflex, the anatomy is referred to as being left dominant. For physical therapists, there is no clinical importance to whether the anatomy of the myocardium is either left or right dominant.

                     The inner diameter (i.e., the opening) of the arteries through which the blood flows is the lumen. he size of the lumen is critical for adequate blood flow. A significant narrowing of the lumen, such as that which occurs with a fixed atherosclerotic lesion of CAD, will decrease the available blood supply to the myocardium. Lumen size may also be altered by the smooth muscle within the walls of the arteries, because smooth muscle regulates vasomotor tone of the coronary arteries. Vasodilation will increase lumen diameter as a result of relaxation of smooth muscle, and vasoconstriction will decrease lumenal diameter as a result of smooth muscle contraction. he responsiveness of arterial smooth muscle is also influenced by the integrity of the endothelium, the lining of the coronary artery that is in direct contact with the lumen. The endothelium has a number of normal functions and “plays the central role in controlling the biology of the vessel wall.”10, p. 1,265 Some of these important functions are anti-inflammatory actions, antithrombotic activity, and its influence on vasodilation. Endothelial cells release endothelial-derived relaxing factor (EDRF), which facilitates vascular smooth muscle relaxation. Nitric oxide (NO) is the most prevalent EDRF. An injury to endothelium can result in impaired NO release and a decrease in vasodilation.11 NO release is influenced by many factors, including acetylcholine, norepinephrine, serotonin, adenosine diphosphate, bradykinin, and histamine.The etiology of the clinical condition known as coronary spasm, in which smooth muscle contraction within the walls of the artery results in narrowing of the coronary artery, is not clearly understood. Coronary spasm occurs in arteries that have endothelial injury (e.g., atherosclerosis), as well as in those arteries that appear to be normal but exhibit hyperreactivity to a variety of vasoconstrictor stimuli, such as serotonin and ergonovine, and loss of EDRF.

Heart Valves

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

HEART TISSUE

HEART DISEASE

CARDIAC ANATOMY AND PHYSIOLOGY OF HEART

       HEART TISSUE ;

    The heart wall is made up of three tissue layers.The outermost layer of the heart is a doublewalled sac termed the pericardium. he two layers of the pericardium include an outer tough fibrous layer of dense irregular connective tissue termed the parietal pericardium and an inner thin visceral pericardium.5 Between these two layers is a closed space filled with pericardial fluid, which serves as a lubricant allowing the two surfaces to slide past one another. Clinically, patients may develop an infection with resultant inflammation of the pericardium termed pericarditis. he clinical signs that accompany this pathology and used to differentially diagnose pericarditis include a pericardial friction rub (an audible grating sound suggesting irritation of the pericardium) that can be auscultated with each heartbeat accompanied by constant chest pain.In some patients excessive fluid accumulation within the closed pericardial space may lead to a secondary condition known as cardiac tamponade. Tamponade involves compression of the heart caused by fluid buildup in the space between the myocardium and pericardium. In this state, patients will demonstrate compromised cardiac function and contractility due to the excess fluid within the closed space pushing against the heart.7,8 he muscular middle layer of the heart is termed the myocardium. It is the layer that facilitates the pumping action of the heart to move blood to the entire body.

             Alterations in the muscular wall of the heart are termed cardiomyopathies. here are three common classifications of cardiomyopathies: dilated, hypertrophic, and restrictive. Dilated cardiomyopathy is evidenced by ventricular dilation and altered cardiac muscle contractile function. CAD is the prime cause of dilated cardiomyopathy, causing mitochondrial dysfunction and resultant myocardial damage. Myocarditis (inflammation of the heart muscle) and alcohol abuse are additional causes of dilated cardiomyopathy. Hypertrophic cardiomyopathy presents as diastolic dysfunction with an increased ventricular mass. Chronic HTN and aortic stenosis are examples of hypertrophic cardiomyopathy. Restrictive cardiomyopathy also presents as diastolic dysfunction owing to the presence of excessively rigid ventricular walls, resulting in a decrease in compliance. he connective tissue changes of the heart associated with diabetes are an example of a restrictive cardiomyopathy. Damage to myocardial cells from cardiomyopathies and various other etiologies lead to cardiac muscle dysfunction and resultant heart failure, which will be comprehensively discussed later in this chapter. he innermost layer of the heart is termed the endocardium.

                The tissue of the endocardium forms the inner lining of the chambers of the heart and is continuous with the tissue of the valves and the endothelium of the blood vessel. Because the endocardium and valves share similar tissue, patients with infections of the endocardium are at risk for developing valvular dysfunction. Endocardial infections can spread into valvular tissue developing vegetations (a mixture of bacteria and blood clots) on the valve.9 In patients with newly developed vegetations, bronchopulmonary hygiene procedures including percussions and vibrations are contraindicated because they may dislodge, move as emboli, and cause an embolic stroke.

CORONARY ARTERIES

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

CARDIAC ANATOMY AND PHYSIOLOGY OF HEART

HEART DISEASE

 Surface Anatomy ;

The heart lies within the left thoracic cavity. The base of the heart is located superiorly, approximately between the second and third rib; the apex is located inferiorly, approximately at the level of the fifth rib. In this position, the heart is rotated in the sagittal plane so that the right ventricle (RV) is positioned anterior to the left ventricle (LV) and tipped anteriorly, bringing the apex closer to the chest wall. In the posterior–anterior view of a chest x-ray, the RV occupies a significant portion of the frontal plane. he right atrium (RA) is generally located in the area of the second intercostal spaces and the angle of Louis. When one palpates the sternum, the angle of Louis is the “bump” that demarcates the manubrium from the body of the sternum. 

The second intercostal spaces are lateral and slightly below the angle of Louis. The second intercostal spaces are an important auscultatory landmark; the right space is known as the aortic area, the left as the pulmonic area. he apex of the normal heart is in the fifth intercostal space at the midclavicular line. In a healthy heart, this area, known as the point of maximal impulse (PMI), is where the contraction of the LV is most pronounced.

HEART TISSUE

CORONARY ARTERIES

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

HEART DISEASE

INTRODUCTION;

                    Cardiovascular disease (CVD) is a term referring to the pathological process of atherosclerosis affecting the entire arterial circulation. Coronary artery disease (CAD), also called coronary heart disease (CHD), refers to the pathological process of atherosclerosis, specifically affecting the coronary arteries.

                     CAD includes the diagnoses of angina pectoris, myocardial infarction (MI), silent myocardial ischemia, and sudden cardiac death. he pathophysiological conditions that underlie CVD are atherosclerosis, altered myocardial muscle mechanics, valvular dysfunction, arrhythmias, and hypertension (HTN). Atherosclerosis is a disease in which lipid-laden plaque (lesions) is formed within the intimal layer of the blood vessel wall of moderate and large size arteries; over time the plaque may extend into the lumen causing a decreased lumenal diameter. Atherosclerosis is also a primary contributor to cerebrovascular disease (cerebrovascular accident [CVA]) and peripheral vascular disease (PVD). Alteration in myocardial muscle mechanics involving the systolic and/or diastolic properties of the myocardium results in an impairment of left ventricular (LV) function. Heart failure is a clinical diagnosis caused by impaired LV functioning and is referred to as congestive heart failure (CHF) when it is accompanied by signs and symptoms of edema (i.e., congestion). here are many causes of heart failure, including myocardial scarring and remodeling as a result of an MI, cardiomyopathy (involving an enlarged, thickened, and/or hardened heart muscle) from various causes, or impaired valvular function, especially within the mitral and aortic valves. Arrhythmias are caused by a disturbance in the electrical activity of the heart, resulting in impaired electrical impulse formation or conduction. Arrhythmias may present as benign or malignant (i.e., life threatening). Examples of malignant arrhythmias are sustained ventricular tachycardia (V-tach) and ventricular fibrillation (V-fib). An example of a common benign arrhythmia in the elderly is atrial fibrillation (A-fib) with a controlled ventricular response involving a ventricular rate between 60 and 100 beats per minute (bpm). HTN is the most prevalent CVD in the United States and one of the most powerful contributors to cardiovascular morbidity and mortality. HTN occurs when the systolic blood pressure is consistently greater than 140 mm Hg or the DBP is equal to or greater than 90 mm Hg. CVD remains the leading cause of death and disability in the United States. According to the American Heart Association’s Heart Disease and Stroke Statistics 2011 Update, an estimated 82,600,000 American adults (more than 1 in 3) have one or more types of CVD.1 Currently, HTN occurs in 76,400,000 individuals, CHD affects 16,300,000, and heart failure is seen in 5,700,000 patients.1 he average annual rates of first cardiovascular events rise from 3 per 1,000 men at age 35 to 44 years to 74 per 1,000 at age 85 to 94. For women, comparable rates occur 10 years later in life with a narrowing gap with advancing age.1 On average, 2,200 Americans die of CVD each day with an average of 1 death every 39 seconds.2 In every year since 1900 except 1918, CVD accounted for more deaths than any other major cause in the United States.3It is also important to note that the United States is in the midst of a demographic shift with a remarkable increase in the diversity of the American population. By 2050, there will be a decrease in the white non- Hispanic population to 52.5% from 75.7% in 1990. Hispanic population will increase to 22.5%, a change in African Americans to 15.7%, and Asian and Pacific Islanders will account for 10.3% of the population.4 hese statistics will have a major impact on the epidemiology, pathophysiology, and treatment of CVD in the forthcoming years. within the United States and worldwide, we are faced with major challenges as CVD dominates as a major cause of death and disease. his chapter provides a review of normal anatomy and physiology of the cardiovascular system and its relevance to physical therapist practice followed by a discussion of various pathologies and pertinent physical therapy implications.

CARDIAC ANATOMY AND PHYSIOLOGY OF HEART 

HEART TISSUE

     CORONARY ARTERIES

 

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

WEIGHT LOSS EXERCISES

INTRODUCTION;

           There are two things that you must do to lose weight and one of those we have already covered pretty extensively and that is to eat right and fill your body with good, clean water. The other thing you have to do is get your body moving. You don't have to purchase a gym membership to get exercise. In fact, there are several things you can do on a daily basis that will help to kick start your body into losing weight and there are several exercises you can do on your own to lose weight.

TIP 1:

 When you begin working out, whether at home or in a gym, don't be discouraged if you don't see results right away. It takes more than a week to get your body into shape and to begin making progress. Many people make the mistake of believing that their exercising isn't working when it just takes a little bit of time.

If you push your body too much when you first get started exercising you can end up with injuries. Your bones, joints and ligaments are not prepared for the exertion you are putting on them. Don't think that if you really push yourself hard for a few workouts that you'll lose money, unfortunately the body doesn't work this way. Slow and steady wins the race when it comes to exercising.

TIP 2:

 Check your weight when you start exercising, but don't use it as a guide to how much weight you are losing. Your weight fluctuates throughout the day. If you check your weight every day, you may only end up getting discouraged.

TIP 3:

 The best way to know if you're losing weight is by the fit of your clothes. If you start to feel as though you're floating in your clothes then you know you're eating and exercising is doing you some good. Another way to know if you're losing weight is if you can begin moving where you usually buckle your belt, of course tighter is better.

TIP 4:

 When you periodically check your weight and the fit of your clothes, reward yourself. Buy yourself some new running shoes or a new pair of jeans. This will help to keep you motivated as you pursue your weight loss goals.

TIP 5:

 Take a day off from exercising to provide your body with a chance to rest and repair. Your body needs a day off once a week.

TIP 6:

 Three days of 30 minute exercise will help you to maintain your weight, but you need at least 4 days of 30 minute exercise to begin to lose weight and 5 days a week is even better.

TIP 7:

 Collect information on exercise and easy things you can do from your own home. There is tons of extensive research available on exercise and you can choose what will assist you the most to meet your weight loss goals. Browse the Internet or pick up some books on health and exercise from your local bookstore or library to learn more and how to burn off the desired number of calories you are trying to burn each week.

TIP 8:

 Try to find an exercise buddy. This should be someone who is as committed to exercising and losing weight as you are. One of the advantages of finding a committed partner is that you have someone to keep feeling responsible to them. The knowledge that someone is waiting on you makes it easier for you to get out of bed and go exercise with them. You wouldn't want to stand up your exercise buddy would you?

TIP 9:

 When your body tells you it has had enough, take a break. When you have worked out for a considerable amount of time, you will start receiving signals from your body. This is particularly important when you are just getting started in your exercise routine.

TIP 10:

 If you decide to increase the length of your workouts, do so gradually. The same is true for the intensity of your workouts.

TIP 11:

 Select an exercise routine that suits your lifestyle. Everybody has a different lifestyle and a different profession. There is no set time that you should or should not workout. If you like to workout late before you go to bed because it is relaxing to you then do it. If you like to workout early in the morning because it helps you wake up then that's great too. Some people like to workout on their lunch break to take a break from the stress of their job or because that is the only time they have available.

TIP 12:

 Don't stand around, walk around. If you can walk around then do it. People who are pacers are actually doing themselves a lot of good because they are constantly moving. Pacing also helps you think.

TIP 13:

 Don't sit if you can stand. If you can stand comfortably, you will burn more calories doing so than if you were to sit.

TIP 14:

 Don't lie down if you can sit. Same concept as the two above.

TIP 15:

 The couch and the television are anti-weight loss. If you are inclined to become a couch potato, don't sit on it. In fact, if you have to, put a not so comfortable chair in front of the television so you won't spend so much time in front of it. The same is true for the computer if you're a computer junkie. Some people have a more comfortable chair in front of their computer than they do in front of their television. (This is, of course, if you don't work from home and need to work hours at a time in front of your computer because your chair is very important then.)

TIP 16:

 If you have a job where you sit the whole time, stand up and stretch every half hour or so. Most of today's jobs are in front of a computer and require you to sit. If you have a job like this make it a point to move every so often.

TIP 17:

 Walk around while you're on the telephone. You'll get a good workout if it is a long conversation.

TIP 18:

 Use the stairs instead of the elevator or escalator. These are great conveniences, but they make us very lazy. Also, it may be quicker to take the stairs than to wait on an elevator to open.

TIP 19:

 Quit smoking. Smoking does not contribute to your weight exactly, but it does lead to erratic eating behaviors and increases caffeine dependence.

TIP 20:

 10 minutes of cardio a day is good for most, you can get this by other methods than running.

TIP 21:

 If you can't run for a physical reason, then try 15 minutes of brisk walking to keep fit.

TIP 22:

 You can walk anywhere if you have time. If work or the grocery store is not far away, consider walking there or riding a bike. It may take you longer, but you're getting your workout in at the same time.

TIP 23:

 Hide the remote control from yourself. Remote controls are also evil when it comes to losing weight. If you didn't have a remote, you may not even turn on the television, which means you might find more active things to do. Get up and change the channel if you don't have a remote or go for a walk instead of watching TV.

TIP 24:

 Do your own fetching. If you need something from the kitchen, the TV channel changed, the mail or newspaper from the driveway, walk and get it yourself. Adding a little walking to your day will do wonders for you.

TIP 25:

 Walk along or climb the escalator with it or just take the stairs.

TIP 26:

 Walk around during commercial breaks or do simple exercises like crunches or bending over and touching your toes. Do anything to get your body moving more and to keep your blood pumping.

TIP 27:

 Turn on some music and dance. Again, the more you get moving the better you will feel and the more weight you will lose.

TIP 28:

 If you take public transportation, get off a block before your stop and walk the remainder of the way. This is a good way to squeeze in a walk before and after work or on the way to another destination.

TIP 29:

 Do pelvic gyrations to get your midsection in shape. Of course, you wouldn't do these with anybody around, but they are a good step in getting your body prepared for more serious stomach crunches. It is also good on the back muscles and keeps you loose instead of tight.

TIP 30:

 Suck in your stomach when you walk. Walk properly, but do your best to keep that stomach tucked in. You will soon begin to feel those muscles tightening.

TIP 31:

 Do breathing exercises to tone your midsection. It is amazing how breathing properly and with your entire diaphragm can actually help to tighten your abdominal muscles. Most people breathe way too shallow as it is and oxygen is good for the brain.

TIP 32:

 Experiment with yoga. Yoga is a great way to lose weight and reduce your stress levels. Yoga teaches you how to control your muscles and gain more control of your individual muscles groups.

TIP 33:

 Lift weights. Strength training burns more fat than people give it credit. When you work on building muscle, they begin to burn fat to fuel muscles growth. Do be aware that when you gain muscle, your scale may not be an accurate tool in determining weight loss because muscle weighs more than fat.

TIP 34:

 Massage your partner. You can exert yourself a little bit and at the same time you will be able to complement them on the weight they have lost if they have been working out with you.

TIP 35:

 Take the stairs two at a time instead of one at a time. This causes you to have to exert yourself more and increases your heart rate.

TIP 36:

 Take your dog on a walk. Chances are that if you're not getting enough exercise, neither is your pet. Or, let your dog take you on a walk. For once in his life, let him lead you where he wants to go and as fast as he wants to get there. It could be a good workout for the both of you.

TIP 37:

 Join a dancing class. This could be ballroom dancing where you learn dances like the tango, salsa or fox trot. These dances are fast paced and will get you moving. Even slow ballroom dancing is a lot of exercise and will definitely tone your legs. Or, you can take an aerobic dance class. How many dancers do you know that are overweight?

TIP 38:

 Lean against the wall so that your face is close and then use your hands to push your body away. Do this three or four times to stretch.

TIP 39:

 Swim whenever you can. Swimming is a great way to get your cardio exercise and it's low to no impact on your joints, which is great for people who have osteoporosis or joint problems.

TIP 40:

 Try playing tennis or basketball. Playing games are a great way to get into shape. It's also more fun to workout with someone else in a competitive atmosphere. You will be more driven to push yourself and you'll burn more calories, just don't overdo it.

TIP 41:

 Always start your workout with a warm up of about 5-10 minutes and end with a cool down of 5-10 minutes. Your body needs to reach a certain heart rate level before it will respond well to the rest of the workout.

TIP 42:

 Don't carry your wireless phone or cell phone with you. If it rings, go walk for it. There are so many conveniences in life and we always have everything we need at our fingertips, but this is obviously bad for the waistline.

TIP 43:

 If you're standing around, stretch your legs a bit by standing up on your toes and then gradually drop to your heals. You can also flex your buttock muscles as well, but maybe when nobody else is looking.

TIP 44:

 Before going to bed, undress and stare at yourself in front of the mirror. Take note of what areas you need to improve on and what areas are your best assets. Taking a self-inventory can keep you motivated in your workout endeavors. Also, don't forget to complement yourself on any new muscle tone you may have or other improvements you've made.

TIP 45:

 Don't slouch in your chair. Try to sit up straight and erect at all times. Slouching is bad for your back and gives you a flabby figure. Make it a point to always sit and stand with good posture.

TIP 46:

 Most people would like to target their stomachs and get rid of that area all together. Unfortunately, we can't spot reduce. But, one thing you can do is a breathing exercise to help tighten those stomach muscles.

Breathe in air as strong as you can and tuck your stomach at the same time as much as you can. Hold it for a few seconds and then slowly let it out. Don't let it out so fast that your belly flops out. This is not good. Try to breathe like this whenever you think about it, about 50-60 times a day is ideal. This will help you to lose at least an inch within 20 days or so.

TIP 47:

 Use a chart, such as the one below to assist you in your weight loss endeavors. This chart shows you how many calories each of these common exercises burn, based on 20 minutes.

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

LOSE WEIGHT BY CHANGING COOKING STYLE

INTRODUCTION; 

           Here are a few tips that will help you to lose those first ten pounds by simply changing how you prepare your food. How food is cooked has just as much to do with how healthy it is or is not.

TIP  1:

 Instead of frying in oil or fat, try baking those items instead. Baking does not require all the fat and oil that frying requires and your food is not soaking in those substances while it cooks.

TIP 2:

 Use non-stick frying pan spray so you don't use oil. Also, pans that are non-stick don't require as much, if any oil.

TIP 3:

 Boil vegetables instead of cooking them. You can also steam them, as this is probably the healthiest way to eat foods like cabbages, cauliflower, broccoli and carrots.

TIP 4:

 Be leery of no fat and low fat food items. There are many of these food items on the market, but they are not exactly healthy. Many of these food items use some sort of chemical or carbohydrate to sweeten them so that they taste better. However, the body turns these chemicals and carbohydrates into sugar in the body, which means they are still getting turned into fat.

TIP 5:

 Don't fall victim to crash diets. These are bad for you and do more harm than good in the long run. The short term results are typically that you will lose a few pounds, but once you give them up then everything comes back and your weight is worse the second time around. You cannot survive on a crash diet and you eventually get to a point where you have to give it up.

TIP 6:

 Chew your food at least 8 to 12 times whether it is liquid food, sweets or ice cream. This adds saliva to the food that digests the sugar. When food isn't eaten properly and is just swallowed, you fill your stomach with food that isn't ready to be digested and it then does not yield the health benefits that you need.

TIP 7:

 When you are cooking with oil, use a good Extra Virgin Olive Oil. It is more expensive than vegetable oil, but the health benefits are much better and it is worth the cost. Olive oil has been associated with a reduced risk in coronary heart disease and helps to increase the elasticity of the arterial walls which reduces the chance for heart attack and stroke.

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)

EAT WELL AND LOSE THE WEIGHT

INTRODUCTION;

            when most people think about losing weight and eating, they think about dieting. Well, unfortunately, all of the fad diets out there tend to cause people to gain weight. Why? Because they starve them to death and the person eventually breaks down and eats everything in sight because they are so darn hungry. They also deprive them of the foods that they love. This is not a way to lose weight, nor is it a way to live. You only cause yourself stress, which actually causes you to gain weight!

So, in eating right there a few tips that you can follow each and every day and they're not going to deprive you of the foods that you love, but treat those foods as luxury items so you enjoy them that much more.

TIP 1:

          Eat fresh fruit and vegetables that have high water content. These are foods like tomatoes, watermelons, cantaloupe, kiwi, grapes – you get the idea. All of those fresh and flavorful juicy fruits and veggies are good for you. These items contain about 90 to 95% water, so you can eat a lot of these and they will fill you up without adding on the pounds.

TIP 2;

          Eat fresh fruit instead of processed fruit. Anything that is processed as more sugar. Processed and canned fruits also do not have as much fiber as fresh fruits.

TIP 3:

         Increase your fiber intake as much as you can. This usually means eating more fruits and veggies.

TIP 4:

         Veggies are your friends when it comes to shedding pounds. There are tons of options here and you may even want to try some you haven't had in the past. The leafy green varieties are the best and you always want to work in a salad when you can. Salads are packed with nutrients as long as you don't pour too much dressing on and load them with too much cheese. The leafy greens also have a lot of natural water.

TIP 5:

        Be intelligent about what you eat. Don't eat just to eat. Animals eat on instinct; people eat when they know their body really needs it. Don't be an impulse eater.

TIP 6: 

         Watch everything you consume from the food itself to what you top it with. Garnishments and condiments can sabotage a healthy meal because they are typically high in fat.

TIP 7:

           Get a handle on the sweet tooth. This doesn't mean you can't have your sweets; just don't eat them as a meal. Always remember that these sweets end up adding to an area that you don't want them to add to. Don't deprive yourself either though, because then you'll eat twice as many as you should.

TIP 8:

         Set meal times and stick to them. Try to have your meals at specific times and eat them at that time. An eating pattern will help you to control what you eat and when you eat it. Also, it really is better to have 5 small meals a day rather than just one or two huge meals. Just eating once a day makes your body feel as though it is starving, which packs on fat instead of using it as fuel. Also, don't wait until your starving to eat. This only makes you overeat until you're stuffed.

TIP 9:

         Eat only when you are hungry. Be sure to drink a glass of water first to determine if you really are hungry or if you are really thirsty. Many people have the tendency to eat when they see food. It doesn't mean they are hungry; they just want to eat it. Don't eat anything you're offered unless you really are hungry. If you feel you must eat it out of being polite, just nibble, don't have a meal.

TIP 10:

           Try not to snack between meals, but if you must have a snack make sure it is a healthy one. If you travel a lot try to find healthy snacks and not junk food.

TIP 11:

          Veggies make great snacks. They can get you through the hunger pangs if you are having them. Carrots are great because they satisfy hunger and they are packed with nutrients.

TIP 12:

            Counting calories is a good idea for those must have food items. If it is a packaged food item, then it will have the calories on the packaging. Be sure to pay attention to serving sizes in terms of calories as well. An Otis Spunkmeyer muffin is intended to be two servings, so you have to double the calories listed. This is where food producers get tricky and you can't fall in their trap.

TIP 13:

           Work off the extra calories by the end of the week. If you feel you have splurged too much this week, be sure to get to the gym or go walking a little longer to work off those extra calories you have consumed.

TIP 14:

           Stay away from all things fried. If it is breaded, it is better that it is baked. Fried foods are immersed in fat and oil. Even after the excess has oil has been drained away, there is still oil absorbed into the food item itself.

TIP 15:

           Don't skip meals. You should have, at the very least, three meals a day, but preferably five small meals. This will keep you from getting hungry during the day and overeating out of starvation.

TIP 16:

           Just like fruits, fresh vegetables are better than those that are canned. It is even better if you can eat your veggies raw. When you cook them, you cook away the nutrients. If you must cook them, try to boil them to the point that there is still some crispness to them. Also, don't soak them in butter. If you can buy organic and pesticide free veggies, that is even better.

TIP 17:

           Don't eat more than one egg per day. It is best if you can reduce your egg intake to three a week.

TIP 18:

          Chocolates should be treated as luxury items. Buy the good stuff and only eat them every once in awhile. If you really savor each morsel, you'll experience that much more joy in eating them and they will taste even better.

TIP 19:

          Eat foods from all of the food groups each day. This is a great way to ensure you are getting all the nutrients your body needs and it helps to ward off any diet deficiencies. Also, don't eat the same foods all the time. Experiment so that you don't get bored with same old diet.

TIP 20:

          Try to eat breakfast within an hour of waking up. This is the best way to give your body the jump start it needs. Don't wait until you are really hungry.

Breakfast is important, but you don't need to stuff yourself. The idea is that you're breaking the fast from not easting all night.

TIP 21:

          Your diet should include all aspects of the food groups including carbohydrates. In fact, your diet needs to be about 50-55% carbs. Carbs are a great source of energy. Those diets that prohibit carbohydrates are actually harming you and only making you crave them that much more. Your diet should cause you to be deficient in anything.

TIP 22:

            Proteins should make up only 25-30% of your diet. Far too much emphasis is put on meat as the main part of your meal. In actuality, it should be considered more of a side dish rather than the main course.

TIP 23:

           Fats should make up 15-20% of your meal. This is really all the fat your body needs. A lot of this is going to be in your diet in the form of cream, sugar and the like.

TIP 24:

           Eat more white meat than red meat. White meat includes chicken, fish and some other fowl. Red meat includes beef and pork.

TIP 25:

           Try to go as vegetarian as you can. This really is a healthier lifestyle, even if you can't cut meat out completely. The more fruits and veggies you can eat the better. The more meat you cut out, the more fat you can cut out of your diet as well. However, protein is important, so be certain that your option allows you to maintain good protein levels.

TIP 26:

           White bread is good, but high fiber multigrain breads are much better. These breads are another way to add more fiber to your diet and they also have a good protein level.

TIP 27:

             Pork does not assist in weight loss in any way. The less pork you eat, the better off you will be when trying to lose weight. Pork has a high fat content and includes food items such as bacon, ham and sausage.

TIP 28: 

            Limit your sugar intake as much as possible. If you must have sweetener in your coffee and tea, try to find an artificial sweetener that you don't mind the taste of. However, these things are not all that healthy either and should be limited as well.

TIP 29:

           Try grazing five to six times a day. These are those small meals we discussed earlier. Some people lose weight better when they never feel hungry and grazing on healthy food items can do this for you. Plus, it keeps your metabolism working, which will burn fat naturally.

TIP 30:

            Don't worry about cheating, but don't cheat for a meal. Eat sweets and your favorite cheat food for the flavor only. If you want dessert after dinner, share one with the whole family. You'll get the flavor, but not the pounds.

TIP 31:

            Watch your fat intake. Each fat gram is 9 calories. If you know your total calories then you can figure the amount of fat in those items.

TIP 32:

            Take it easy on the salt and try to cut what you use in half. Salt is one of the main causes of obesity.

MORE DETAILS VISTS PHYSIOTHERAPY CLINIC (ROYAL-PHYSIO)