Istoricul reabilitrii

cardio-respiratorii
Conf. Univ. Dr. Oana Cristina Arghir
Universitatea Ovidius Constanta
2017
Grecia antic
 Exerciiile fizice
Activitatea fizic 1772, medicul William
Heberden

Publicaie:
Rolul unui program de exerciii fizice 6 luni 30
minute expectoraie 30 minute util la brbaii cu
afeciuni bronho- pulmonare
Reacii ?
 Pro/Con
In 1799, medicul englez, C. H. Parry, noteaz
beneficiul activitii fizice la pacienii cu dureri
toracice.

Comunitatea medical a ripostat.

Metoda nu a fost asimilat practicii medicale.

In 1912, Herrich descrie pentru prima dat un caz de

infarct miocardic i ncurajeaz medicii s reevalueze
rolul activitii fizice la pacienii cu boal
coronarian.
 Exerciiile fizice - Harvard

Dudley Sargent (1849-1924) Harvard, 1879

Program de antrenament fizic- prescripii

George Wells Fitz 1891

Physical training, Harvard University

 Primul laborator Educaie fizic
George Fitz (1860-1934)

First lab Physical Education Harvard, 1891

David Bruce Dill (1891-1986) conducted research

Primul director al Harvard (1927-1947)

Fatigue Lab Exercise Phsysiology, 1930

 "Fatigue Laboratory"
Creat n subsolul Business School's Morgan Hall

Experimente cu studeni voluntari

Abilitatea organimului de a se adapta i

aclimatiza la condiii extreme de mediu
(cldur, frig, altitudine mare)
 Tuberculoza (TB)
Originile reabilitrii
pulmonare dateaz din
perioada n care
tuberculoza (TB) era o
boal frecvent n SUA.

Denver,

Charles Denison
 Denison si-a parasit casa din Connecticut, deoarece
suferea de hemoptizii si s-a mutat in Colorado pentru a
incepe terapia climatica de tuberculoza de care
suferea, si de care in cele din urma s-a vindecat.

In timpul recuperrii sale, a observat senzatia de bine

de cate ori fcea exerciii.

El a recunoscut de asemenea, valoarea unei alimentatii

adecvate care sa combata efectele tuberculozei si ale
insuficientei respiratorii rezultate.
 PR TB
Monografia Exerciii pentru invalizii pulmonari
Charles Denison

Program sistematic de exerciii pentru pacienii cu

invaliditate pulmonar care sufereau de efectele
reziduale ale TB,

Abordare rudimentar a exerciiilor respiratorii.

 Doi dintre cei mai
mari pionieri ai
reabilitrii pulmonare
n secolul XX au fost
Alvan Barach i
Albert Haas.

Alvan Barach:
 Pionierii reabilitrii respiratorii
Alvan Barach & Albert Haas:
Poziia toracelui reduce intensitatea dispneei
Rolul respiraiei exerciiilor respiratorii n creterea toleranei la efort
 Alvan Barach:

era fascinat de dispnee si a descoperit ca postura

aplecat in fata amelioreaza dispneea;

a observat ca respiratia cu buzele stranse precum

si alte exercitii de respiratie, pot sa amelioreze
toleranta la efort la pacientii aflati in stadii
avansate ale emfizemului.
 Alber Haas:

Interesul pentru reabilitare poate fi legat de TB de

care suferea, pe care a contractat-o n 1932, pe
parcursul pregatirii sale medicale la Budapesta;

Dupa tratamentul vremii care prevedea luni sau

chiar ani de inactivitate si odihna la pat, acesta a
cerut sa se reintoarca la studiile sale medicale;
 Alber Haas
A observat cum ridicatul i cratul unor greuti (cri)
grele) nu l-au obosit, realiznd c activitatea fizic se
asociaz foarte bine cu sentimentul de bine, creterea
n greutate i tolerarea mai bun a efortului;

A emis ipoteza conform creia, cel puin n cazul su,

exerciiile fizice erau benefice, nu duntoare;

Dup emigrarea n SUA, a elaborat exerciii respiratorii

care s amelioreze durerea i limitrile fizice ale
toracoplastiei
 Recunoatere internaional
3 fiziologiti:

A.V. Hill (1886-1977),

August Krogh (1874-1949), and

Otto Meyerhof (1884-1951), Premiul Nobel ,1922

work related to muscle or muscular exercise
 Prima monografie TB i primele
cercetri n SUA
Charles L.Denison, USA bolnav TB

Rocky Mountain Health Reports,An Analytical Study of

Chronic Pulmonary Disease - published in Boston; 1880

Exercise for Pulmonary Invalids; 1895

Alvin L.Barach, USA

Bazele fiziopatologiei bolilor respiratorii:
Oxigenoterapia Helped pioneer oxygen therapy, publ. 1921;
Exerciiul fizic sub oxigenoterapie introdus n 1938.

Thomas Petty, USA

PR- 1966 Denver i Minneapolis,
 Thomas L. Petty (1932-2009)
Universitatea Colorado, Father of Modern Respirology,

Contribuii:

Primul Program Standardizat

de RP la pacieni ambulatori,
1960

A descris bazele tiinifice ale

oxigenoterapiei de lung
durat
 Thomas L. Petty
A opta conferinta despre emfizem de la
Aspen (cunoscuta ca si conferinta pulmonara
a lui Th.L.Petty)

Prima care s-a confruntat cu dezvoltarea

metodelor de tratament ale fazelor avansate
ale BPOC.
 Prima definiie, 1954
Pulmonary Rehabilitation
William F.Miller

A physiologic evaluation of the effects of

diaphragmatic breathing training in patients with
chronic pulmonary emphysema.*

*Am J Med 1954;17:471

Prima monografie Astm,1935
 Publicaii- nelegerea RP

Thomas L. Petty
Miller WF,
Taylor HD,
Pierce AK
Rehabilitation of the disabled patient with chronic
bronchitis and pulmonary emphysema*

*Am J Public Health 1963; 53:18

 Program de ngrijire la bolnavii cu BPOC
Edward M.Glaser

BPOC, 1968 Conferina HIRI- Human Interaction Research Inst.

Petty TL, Nett LM,Finigan MM.et al.

Program de ngrijire pentru pacienii cu BPOC: metode i evaluare preliminar

a pacienilor simptomatici pentru o mai bun funcionare i ameliorare a
respiraiei*.

Hodgkin JE, Glaser EM, Miller WF, et al

BPOC: Current concepts in diagnosis and comprehensive care**

*Am J Public Health 1969; 70:1109; ** JAMA 1975; 232:1243-1260

 Conceptul de reabilitare pulmonar
Aplicarea RP la pacienii cu boli pulmonare
cronice este o practic relativ recent.

nainte de 1950, ntelegerea mecanismelor

fiziopatologice a bolilor pulmonare i natura
impedimentelor funcionale era limitat.
 Prima definiie a unei Societi
profesionale, ACCP* 1974
Art de practic medical n care un program adaptat
n mod individual (personalizat), multidisciplinar este
formulat pentru un diagnostic precis, iar terapia
include suport emoional i educativ, stabilizeaz /
amelioreaz componentele fizio si psihopatologice
ale bolilor pulmonare i ncearc s obin cea mai
mare capacitate funcional ventilatorie adecvat
handicapului respirator i situaiei generale de via.

*American College of CHEST Physicians (ACCP)

Importana instruirii
 Secolul XX- Anii 1960

Mijlocul anilor 1960 a fost era terapiei

intensive,

Specialitii pneumologi au nceput s nvee

metode noi de aplicaie ale ventilaiei

A fost publicat primul studiu pe termen lung

despre folosirea oxigenului pentru hipoxemia
din BPOC.
 Secolul XX- Anii 1980

Interesul a fost susinut

La sfritul anilor 1980, Brian Make a scris un

articol de revizuire n care discuta:
rolul interveniilor ocupaionale i psihoterapeutice
a identificat i a demonstrat avantajele consecutive
reabilitrii pulmonare.
 Diseminarea RP
1974, ACCP PR

Petty TL - PR = an art of medical practice- ATS, NY, 1975

Monografie ACCP,1979

ATS, 1981 - Algoritm de ngrijire BPOC

American Association of Cardiovascular and PR, 1985

 American Association of CardioVascular & Pulmonary
Rehabilitation AACVPR

nfiinat 1985 (primul preedinte: Philip K. Wilson)

To reduce morbidity, mortality, and disability from

cardiovascular and pulmonary diseases through education,
prevention, rehabilitation, research, and aggressive disease
management.

*J Cardiopulm Rehabil 1990; 10:418;Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF,
Mahler DA, Make B, Rochester CL, Zuwallack R, Herrerias C.
 Noi Definiii
National Institutes of Consensus Conference on
Pulmonary Rehabilitation (NHLBI),1994

A multi-dimensional continuum of services directed

to persons with pulmonary disease and their
families, usually by interdisciplinary teams of
specialists,with a goal of achieving and maintaining
the individuals maximum level of independence and
functioning in the community*

* Fishman AP. Pulmonary rehabilitation research:NIH workshop summary.Am J Respir Crit Care
Med 1994;149:825.)
 Declaraii
ATS,1981
Ad hoc committee of the Scientific Assembly on Clinical Problems
(Chair: John E. Hodgkin)

AACVPR published first systematic review of the scientific basis of

PR, 1990

ATS Statement
Standards for the diagnosis and care of patients with COPD (Am J
Respir Crit Care med 1995; 152:s84).

Ries AL, Carlin BW,Carrieri-Kohlman V, et al. Pulmonary rehabilitation: joint

ACCP/ AACVPR evidence-based guidelines. Chest 1997; 112:1363-1396.
 Ghiduri
Ries AL-
Position paper on joint ACCP/AACPR:
Scientific basis of PR*

AACVPR & ACCP first evidence-based guidelines, 1997

ACCP/AACVPR Pulmonary Rehabilitation Guidelines

Panel, Pulmonary rehabilitation: joint ACCP/AACVPR
evidence-based clinical practice guidelines. Chest
2007;131:`1S-42S.
 Algoritm BPOC.

GOLD Major revision, Nov.2006

ATS/ERS, 2006:
The impressive rise in interest
in PR is likely related to both a
substantial increase in the
number of patients being
referred as well as the
establishment of its scientific
basis by the use of well /
designed clinical trials that use
valid, reproductible and
interpretable outcome
measures Am J Respir Crit
Care Med 2006; 173: 1390-
1413
 Ansamblul de ngrijiri medicale
Assessment
Impairment
Disability
Healthcare Community Activity
Handicap Outcomes
Physiological adaptation
Capacity utilisation
Behaviour change
Disabled patient Self efficacy
Rehabilitation
Anxiety and Depression
Individual needs Health status
Healthcare Utilisation
Social Support

Content
Exercise training
Family Work
Disease education
Psychological & Sustainability
Social support Maintenance
Re-enrolment
 Home-Based Rehabilitation
RP = amalgam
a "physical exercise" component and
a "self-management" component.
 Features of successful rehabilitation,
2006

1. Multidisciplinaritate,
2. Programe personalizate- individualizate (nevoile pacientului)
3. Atenie la funcia fizic i social.
 Self-Management Ghid
ATS/ERS Statement
1. Educational component of pulmonary rehabilitation
should emphasize self-management skills
2. Self-management should include : Action plan for early
recognition and treatment exacerbation
3. Consider to teach breathing strategies
4. Transference of educational training and exercise
adherence to the home setting should be emphasized
Nici, Donner, Wouters, Zuwallack et al. ATS/ERS Statement on Pulmonary Rehabilitation.
AJRCCM 2006; 173: 1390-1413.
Guidelines for Pulmonary Rehabilitation
Programs, Fourth Edition, 2011
RP-Tipuri mixte fiziologice i adaptare comportamental
 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
for patients with chronic respiratory diseases who
are symptomaticExercise
and often have decreased daily
capacity,
life activities. Integrated
functional exerciseinto the individualized
capacity
treatment of the patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
for patients with chronicReduced
respiratory diseases who
symptoms
are symptomatic and often have decreased daily
life activities. Integrated into the individualized
treatment of the patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
Health related
for patients with chronic respiratory diseases who
are symptomatic and oftenquality
have of
decreased
life daily
life activities. Integrated into the individualized
treatment of the patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
Physical activity
for patients with chronic respiratory diseases who
are symptomatic and often participation
have decreased daily
life activities. Integrated into the individualized
treatment of the patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
for patients with chronic respiratory
Reduce diseases
health care costs who
are symptomatic and often have decreased daily
life activities. Integrated into the individualized
treatment of the patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 ATS-ERS 2006 (Update 2012 under way)

Pulmonary rehabilitation is an evidence-based,

multi-disciplinary, and comprehensive intervention
for patients with chronic respiratory diseases who
are symptomatic and often have decreased daily
Reversing systemic
life activities. Integrated into the individualized
treatment of the consequences
patient, pulmonary rehabilitation
is designed to reduce symptoms, optimize functional
status, increase participation, and reduce health
care costs through stabilizing or reversing systemic
manifestations of the disease.

Document freely available at www.ersnet.org

 RP n Romnia

1983, Monografia Tudor

Sbenghe Reabilitarea
medical pentru bolnavii
cronici pulmonari

2009, Tratat de reabilitare

pulmonar prof.dr. Voicu
Tudorache
 Iai -1978
Prof. Dr. Doc. Ioan Lungu,
Prof. Dr. George-Ioan Pandele

1 Martie 2007:
Reabilitare cardio pulmonar

Conf. Dr. Paraschiva Postolache,

postgraduated in SUA, Australia,
Israel, France
 Echipa PR
Paraschiva Postolache, PhD, FCCP 3 PR pulmonologist physicians:
Head of Clinical PR Department Laura Ciobanu postgraduated in GB
Clementina Cojocaru
Ana-Maria Mantea postgraduated in
France

Octavian Petrescu, MD, PhD, specialized in

lung function special testing in Germany
and France

1 MD counseling for cessation smoker

10 nurses
2 kinetotherapists (postgraduated in
France)
balneo-physiotherapists
2 inhalotherapists
1 psycholog
2 nutritional assessment nurses
1 priest.
 Clinica Iai

Implemented programms in-patient, out-patient or

home-care
10 Postgraduated courses for physicians nurses,
kinethoterapists (2006 - 2010)
6 meetings for patients with pulmonary diseases
6 meetings with smokers patients
Scientific papers published in international journals
Timioara- nainte de reabilitarea cldirii
Timioara Cardio and Pulmonary Rehabilitation center

1st master of cardio-pulmonary

1st PR book edited in Romania, 2009
Implemented programms in-patient,
out-patient or home-care suported by
Insurance Romanian System
Postgraduated courses for physicians
(2008) , nurses
Scientific papers published in
international journals
 Center of Pulmonary Rehabilitation
Pneumology Institute Marius Nasta Bucureti

Founded in 2009
Research Project REABILUM +
donation
5 labs of PR in Bucuresti
Effort cardio-respiratory testing
lab

Research Project Manager:

Prof. Dr. Miron Alexandru BOGDAN

Colab.:
Diana Ioni, MD, FCCP-
Pulmonologyst PR postgraduated
in France
Kinetotherapist
Nurse
Psycholog
Center of Pulmonary Rehabilitation
Pneumology Institute Marius Nasta Bucureti
Integrated into the individualized treatment
of the patient
Conclusions: PR continues in our days
 Medicina bazat pe dovezi
Managementul pacientilor cu boli respiratorii
cronice a crescut simtitor

Interveniile RP au demonstrat cu certitudine

reducerea dispneei,
cresterea performanei exercitiilor i
mbuntirea calitii vieii.
Future of PR
ANATOMIA TORACELUI
 Toracele

Reprezint partea superioara a trunchiului,

Separat de abdomen printr-un muschi numit diafragm,

continand principalele organe ale respiratiei.

Se intinde de la radacina gatului la partea de sus a

abdomenului.

Se articuleaza cu cele doua membre superioare prin

articulatiile scapulohumerale.
 Anatomia toracelui
Linii de delimitare: - Linii orizontale
Anterioare
Claviculara
Bimamelonara
Xifoidiana
Subcostala
Posterioare
Cervicotoracica (C7)
Bispinoscapulara (T3)
Bianguloscapulara (T12)
Subcostala (L1)
 Anatomia toracelui
Linii de delimitare: - Linii orizontale

Anterioare
Claviculara
Bimamelonara
Xifoidiana
Subcostala
 Anatomia toracelui

Linii de delimitare: - Linii orizontale

Posterioare
Cervicotoracica (C7)
Bispinoscapulara (T3)
Bianguloscapulara (T12)
Subcostala (L1)
 Anatomia toracelui
Regiuni anatomo-topografice:
I. Anterioara (l. mediosternala - l. axilara
anterioara)

II. Laterala (intre liniile axilare ant. si post.)

III. Posterioara (l. axilara post. - l. scapulara)

IV. Vertebrala (intre liniile scapulare)

 Anatomia toracelui
Regiuni anterioare:
Reg. sternala
Reg. infraclaviculara
Reg. mamara (pectorala)
Reg. clavi-deltopectorala
Reg. infrapectorala
(hipocondrica)
 Anatomia toracelui
Regiuni posterioare:

Regiunea scapulara:
Reg. supraspinoasa
Reg. infraspinoasa
Regiunea infrascapulara
 Toracele este compus din:
invelis cutanat si muscular,
doi plamani,
esofagul,
inima si vasele care pleaca
de la ea sau care se
despart.
 Repere osteo-musculare externe:
Claviculele,
Incizura jugular,
Sternul;
Unghiul Louis la nivelul inseriei coastelor ll;
Arcurile costale, coastele i apofiz xifoid;
Apofizele spinoase ale vertebrelor toracale,
Spina scapulei, marginea medial i unghiul inferior al
scapulei
Mamelonul,
Marginile inferioare ale mm.Latisimus dorsi, pectoralis
major
 Liniile CONVENIONALE DE ORIENTARE

linia mediosternal linia median

anterioar

linia parasternal

linia mamelonar linia

medioclavicular
 Liniile CONVENIONALE DE ORIENTARE

linia scapular
linia paravertebral
linia median posterioar
 Liniile CONVENIONALE DE ORIENTARE

linia axilar anterioar

linia medioaxilar
linia axilar posterioar
 Limitele toracelui

Superior: o linie trasat pe

marginea superioar a
sternului,
claviculelor,
procesele acromiale ale
omoplatilor (scapule)
pn la apofiza spinal a
vertebrei C Vll.

Inferior: procesul xifoid,

marginile arcurilor costale Xll,
pn la apofiza spinal a
vertebrei Th Xll.
 MALFORMATIILE CONGENITALE
TORACICE
1. Pectus excavatum
- Se constata un aspect de
plnie, datorat depresiunii
sternului si cartilajelor costale
inferioare.

Poate fi simetric sau asimetric.

Se asociaz cu:
scolioza,
malformatii congenitale
cardiace
astmul bronsic.
 MALFORMATIILE CONGENITALE
TORACICE
2. Pectus carinatum
Apare mai rar dect pectus
excavatum
16,7% din toate malformatiile
peretelui toracic.

Consta de fapt intr-un spectru

de malformatii toracice (patru
categorii) din care cea mai
frecventa este

forma clasica, caracterizata

prin protruzia anterioara a
corpului sternal si protruzia
simetrica a cartilajelor costale
joase.
 Musculatura peretelui toracic:

Musculatura extrinseca

Musculatura intrinseca
 Musculatura extrinsec
M. pectorali mare si mic
M. subclavicular
M. dintat anterior
M. latissimus dorsi
M. trapez
M. supraspinos
M. infraspinos
M. subscapular
Mm. rotund mare si mic
 Musculatura intrinsec:

Stratul superficial - mm. intercostali externi +

membr. intercostala externa

Stratul intermediar - m. intercostali interni +

membr. Intercostala interna

Stratul profund mm. subcostali, mm.

intercostali intimi, m. transvers toracic, mm.
ridicatori ai coastelor (scurti si lungi)
 Musculatura toracelui

Actiune: formeaza o centura musculara ce solidarizeaz

coastele ntre ele asigurnd unitatea cutiei toracice.
 MUSCHII TORACELUI
Muschii intercostali ocupa spatiul dintre doua coaste succesive.
Ei sunt dispusi n 2 planuri:
- intercostalii interni, cu fibre oblice de jos in sus si dinspre
anterior spre posterior
- intercostalii externi cu fibre oblice de sus in jos si dispuse
dinspre exterior spre interior.

Muschii intercostali interni sunt coboratori ai coastelor

(expiratori), iar muschii intercostali externi sunt ridicatori ai
coastelor (inspiratori).
 MUSCHII TORACELUI
Muschii supracostali (ridicatori ai coastelor) se intind de la
procesul transvers al unei vertebre dorsale pana la coasta situata
cu unul sau doua etaje mai sus.

Actiune: participa la rotatia vertebrelor sau la ridicarea coastelor

in functie de punctul fix situat pe coaste sau pe coloana
vertebrala.
 MUSCHII TORACELUI

Muschii subcostali se insera pe fata mediala a primei coaste si pe

fata mediala a celei de a doua sau a treia coaste subiacente.

Muschiul transvers al toracelui ia nastere de pe fata posterioara a

sternului si de pe apendicele xifoid.

Fibrele sale formeaza fascicule spre cartilajele costale 2 - 6.

Actiune: coboara coastele (expirator).

 Importana kinetoterapiei
Bolile cronice cardio-respiratorii au o prevalen
crescut n practica curent

Povara lor va crete n deceniile urmtoare ca i

consecin a mbtrnirii populaiei.

Reabilitarea cardio-respiratorie a devenit o

component indispensabil a tratamentului
bolnavilor cu boli respiratorii i/sau cardio-
vasculare.