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Examples of muscular endurance exercises Muscle/group Exercise Gastrocnemius Standing single calf raises Gluteals Standing single hip extension Upper trapezius and deltoid Upright row holding weighted pole Lateral dorsi and rhomboids Seated row with elastic band Triceps Standing press backs or seated dips Gluteal medius and minimus Standing hip abduction Biceps Bicep curls holding dumbbells Lateral rotator cuff Seated shoulder rotations with elastic band Quadriceps buy generic atrovent 20 mcg, hamstrings and gluteal Wallslides maximus Pectorals and triceps Chest press (band around back under arms) Class Design and Use of Music 139 Station 1 Station 2 Station 3 Station 4 Station10 Station 9 Station 5 Station 8 Station 7 Station 6 Figure 5. Room Arrangement In its basic format, a circuit is usually arranged around the perimeter of the room (see Figure 5. Alternative layouts, which may better suit the dimensions of the exercise room, are shown in Figures 5. Using different room arrangements pro- vides variety, while still using the same stations. Often circuit classes are held in physiotherapy departments, where other equipment is stored. This is helpful when there are several beginners in the class as it keeps it simple for both the participants and the instructor. One group goes round the perimeter stations in a clockwise direction, while the other group goes round the perimeter stations in an anticlockwise direction. This means that participants exercise with a different person at each station, rather than going round the whole circuit with the same person. This can be a useful way of getting the group to mix and it can promote better self-pacing and less competiveness, since the exercise partner is constantly changing. The line at the far end (line E) will not be able to 140 Exercise Leadership in Cardiac Rehabilitation Stations 1 and 2 Stations 5 and 6 Stations 3 and 4 Stations 9 and 10 Stations 11 and 12 Stations 7 and 8 Figure 5. After all five exer- cises have been completed the exercise leader gets the group to perform an active recovery walk and then changes the line exercise for the second circuit. This circuit relies on at least one participant in each group acting as a line leader. Station Duration Aerobic stations can vary between 30 seconds and three minutes, with the duration dictated by participants’ functional capacity.

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Even though fatigue is common and potentially disabling discount atrovent 20mcg free shipping, it is clear that people who have MS are not fragile. Although rest may be helpful, the idea that fatigue leads to increased demyelination has not been proven. The idea that MS progression occurs if a person does not rest a great deal is also without merit. You need to listen to your body, but there always are times when a little extra push is necessary, and this is not a cause for fear. In summary, the approach to fatigue in MS involves identifying the type of fatigue and treating it specifically. Occupational therapists may be helpful in teaching the concept of energy conservation to those who have moderate or severe fatigue of differing varieties. Efficiency in performing activities of daily living, which include dressing, grooming, toileting, eating, and so forth, may increase the energy available for other activities. PRINCIPLES OF ENERGY CONSERVATION • Balance activity with rest and learn to allow time to rest when planning a day’s activities. Make a daily or weekly schedule of activities to be done and spread heavy and light tasks throughout the day. Taking time out for five- or ten-minute rest periods during an activ- 27 PART II • Managing MS Symptoms ity may be difficult at first, but it may significantly increase overall functional endurance. Focus on items that are priorities or that must be done, and learn to let go of any guilt that may be associ- ated with not finishing tasks as the result of fatigue. MINIMIZING FATIGUE BY CONSERVING ENERGY The following are some specific suggestions for common tasks and groups of tasks that most of us need to do regularly. They take advantage of the principles described previously and are designed to conserve energy expenditure. Kitchen and Cooking Arrangements • tore items that are used most often on shelves or in areas where they are within easy reach, to minimize the need to stretch and bend. Sit whenever possible while preparing meals or washing dishes, and use a large stool with casters that roll to eliminate at least some walking.

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The "centrifugal" arterial system: (1) the radicu- lomedullary artery trusted atrovent 20 mcg, (2) the ventral spinal axis, and (3) the sulcocommissural arteries. This network gives rise to radial/coronal arteries (vasa co- rona), which extend around the circumference of the cord and have anastomoses to the ventral spinal axis. The radial/coronal arteries give off perforating branches to the cord all along their course. These short perforating branches extend axially, into the white matter and a portion of the gray matter of the dorsal horns. The perforating branches of the radial/coronal arteries have in- tramedullary anastomoses with branches of the sulcocommissural ar- teries dorsolaterally, ventrolaterally, and ventrally. There are also short, extramedullary longitudinal (craniocaudal) anas- tomoses between the radial/coronal arteries. These anastomoses are rel- atively small, however, and cannot provide adequate craniocaudal sup- ply in the case of arterial occlusion. The dorsolateral pial network must therefore be regarded primarily as an axial system of arterial supply. Somatic Arterial Supply The metameric/segmental artery is centered at the level of the inter- vertebral disc, the corresponding nerve, and the myelomere (cord). Therefore, the vertebral body is fed by two consecutive segmental ar- teries on each side (for a total of four). However, extensive anasto- moses within the substance of the vertebrae often permit all or most of the vertebral body to be seen from one arterial injection. The somatic arteries anastomose on the posterior surface of the ver- tebral body, making a characteristic hexagon or diamond-shaped net- work on anterior–posterior angiography (Figures 1. Usually a hemivertebral blush is seen from one segmental arterial injection; this effect is evident only 25% of the time.