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Samenvatting theorie periode 2
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Samenvatting hoorcolleges en enkele werkcolleges en VT's.
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SAMENVATTING PERIODE 2ZELFMANAGEMENT, MOTIVATIE & PREVENTIE
Inhoudsopgave
Fysiologie ............................................................................................................................................................................................... 6
Lipiden .......................................................................................................................................................................................................... 6
Exogeen lipiden transport ...................................................................................................................................... 7
Endogeen lipiden transport..................................................................................................................................... 8
Energiesystemen .......................................................................................................................................................................................... 9
Vrijmaken van energie ........................................................................................................................................... 9
Glycolyse............................................................................................................................................................ 9
Citroenzuurcyclus (Krebscyclus) ............................................................................................................................. 11
Oxidatieve fosforylering: ademhalingsketen .............................................................................................................. 11
Vetzuren en aminozuren ...................................................................................................................................... 12
Bloeddruk ................................................................................................................................................................................................... 14
Bloedvaten ....................................................................................................................................................... 14
Bloeddruk ........................................................................................................................................................ 14
Bloeddruk meten ............................................................................................................................................... 15
Druk in de grote bloedsomloop .............................................................................................................................. 15
Weefselperfusie ................................................................................................................................................. 15
Hoe ontstaat weefselvocht ................................................................................................................................... 16
Lymfe .............................................................................................................................................................. 16
Oorzaken oedeem .............................................................................................................................................. 17
Systolische en diastolische druk ............................................................................................................................. 17
Bloeddruk regulatie ............................................................................................................................................ 17
Hypertensie ...................................................................................................................................................... 19
Fysiologie hart- en vaatstelsel ............................................................................................................................................................... 20
Bloedsomloop ............................................................................................................................................................................................. 20
Kleine bloedsomloop........................................................................................................................................... 20
Grote bloedsomloop ........................................................................................................................................... 20
Hartminuutvolume ............................................................................................................................................. 20
Lichaamscirculatie ...................................................................................................................................................................................... 20
Drukverdeling ............................................................................................................................................................................................. 20
Anatomie van het hart en grote vaten ....................................................................................................................................................... 21
Ventraal aanzicht ............................................................................................................................................... 22
Doorsnede: ventraal aanzicht ................................................................................................................................ 22
Richting bloedstroom ................................................................................................................................................................................. 23
Werking van de kleppen ............................................................................................................................................................................. 23
Mitralis- en de tricuspidalisklep ............................................................................................................................. 23
Aorta- en pulmonaalklep ...................................................................................................................................... 23
Bloedvoorziening van de hartspier ............................................................................................................................................................. 23
Enkele grote takken van de aorta ............................................................................................................................................................... 24
Prikkelvorming en geleiding ....................................................................................................................................................................... 24
Spanningsverschil als vector ....................................................................................................................................................................... 25
Twaalf afleidingen ...................................................................................................................................................................................... 25
Elektrocardiodiagram ................................................................................................................................................................................. 25
Hartcyclus ................................................................................................................................................................................................... 26
Regeling van de hartactie ........................................................................................................................................................................... 27
Hartfrequentie .................................................................................................................................................. 27
n. vagus en nn. accelerantes ................................................................................................................................. 27
Slagvolume ....................................................................................................................................................... 27
Inspanningsfysiologie............................................................................................................................................................................ 28
Krachtproductie .......................................................................................................................................................................................... 28
Powerstroke in het model van Hill .......................................................................................................................... 29
Organel-, cel- en weefselniveau .................................................................................................................................................................. 29
Spiervezeltype............................................................................................................................................................................................. 30
Spierniveau ................................................................................................................................................................................................. 30
Neuromusculaire overgang ........................................................................................................................................................................ 34
Ruggenmergniveau .................................................................................................................................................................................... 35
Centraal niveau .......................................................................................................................................................................................... 36
, Training ...................................................................................................................................................................................................... 37
Ziektebeelden ....................................................................................................................................................................................... 38
Metabool syndroom ................................................................................................................................................................................... 38
Verstoorde glucosemetabolisme ............................................................................................................................ 39
Verstoorde lipidentransport .................................................................................................................................. 40
Verhoogde glucosemetabolisme ............................................................................................................................ 41
Behandeling ...................................................................................................................................................... 41
Multi-factoraal probleem ..................................................................................................................................... 42
Andere interventies ............................................................................................................................................ 42
Fysiotherapeutisch proces .................................................................................................................................... 42
Limited joint mobility .......................................................................................................................................... 43
Diabetes Mellitus ........................................................................................................................................................................................ 44
Verschil tussen Diabetes Mellitus type I & type II ....................................................................................................... 44
Normale stofwisseling ......................................................................................................................................... 44
Invloed van insulineresistentie & dysfunctie -cellen van de pancreas ............................................................................. 44
Acute symptomen Diabetes Mellitus type II .............................................................................................................. 45
Voet deformiteiten ............................................................................................................................................. 45
Diagnostiek ....................................................................................................................................................... 45
Hypo & hyper .................................................................................................................................................... 46
Bloedglucose meten ........................................................................................................................................... 47
Pathofysiologie van Diabetes Mellitus type II............................................................................................................. 47
Atherosclerose ............................................................................................................................................................................................ 48
Risicofactoren ................................................................................................................................................... 48
Pathogenese ..................................................................................................................................................... 48
Voorkeursplaatsen ............................................................................................................................................. 50
Arterie naar het been deels afgesloten .................................................................................................................... 52
Been infarct ...................................................................................................................................................... 52
Acute stenose beenarterie.................................................................................................................................... 52
Klinisch beeld .................................................................................................................................................... 52
Diagnostiek PAV ................................................................................................................................................. 53
Schaal van Fontaine ............................................................................................................................................ 53
Coronaire hartziekten ................................................................................................................................................................................. 54
Angina pectoris .................................................................................................................................................. 54
Acuut coronair syndroom ........................................................................................................................................................................... 56
Verschillen angina pectoris en myocardinfarct ........................................................................................................... 57
Myocardinfarct .................................................................................................................................................. 57
Behandeling acuut coronair syndroom: PCI, dotteren .................................................................................................. 58
Behandeling acuut coronair syndroom: CABG............................................................................................................ 59
Het infarct zelf ................................................................................................................................................... 59
Veneuze circulatie van het been ............................................................................................................................ 59
Spataderen, varicosis, varices ..................................................................................................................................................................... 60
Veneuze trombo-embolie ..................................................................................................................................... 61
Hartfalen en oedeem .................................................................................................................................................................................. 63
Decompensatio cordis ......................................................................................................................................... 64
Gangpatroon ........................................................................................................................................................................................ 72
Waarom analyseren ................................................................................................................................................................................... 72
De gangcyclus ............................................................................................................................................................................................. 72
Tussenstanden ............................................................................................................................................................................................ 72
Functies fase cyclus .................................................................................................................................................................................... 73
Lichaamszwaartepunt ................................................................................................................................................................................ 73
Bewegingsanalyse ...................................................................................................................................................................................... 74
Art. talocruralis .................................................................................................................................................. 74
Art. genus......................................................................................................................................................... 74
Art. coxae ......................................................................................................................................................... 75
Frontaal art. coxae.............................................................................................................................................. 75
Terminologie............................................................................................................................................................................................... 76
Karakteristieken van het gaan .................................................................................................................................................................... 76
Afwikkeling van de voet .............................................................................................................................................................................. 76
Bewegingsanalyse ...................................................................................................................................................................................... 77
Heup, art. coxae................................................................................................................................................. 77
Knie, art. genus .................................................................................................................................................. 77
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
2
, Enkel ............................................................................................................................................................... 78
Drie rockers ................................................................................................................................................................................................ 78
Verschillen gaan en lopen ........................................................................................................................................................................... 78
Verhouding stand en zwaai ................................................................................................................................... 78
Bipedale fase .................................................................................................................................................... 78
Zwaartepunt ..................................................................................................................................................... 79
Staplengte en frequentie ...................................................................................................................................... 79
Comfortabele loopsnelheid ......................................................................................................................................................................... 79
Subjectieve en objectieve ganganalyse....................................................................................................................................................... 79
Subjectieve ganganalyse ...................................................................................................................................... 79
Objectieve ganganalyse ....................................................................................................................................... 79
Hulpvraag bij afwijkende gang ................................................................................................................................................................... 80
Veel voorkomende strategieën standfase................................................................................................................................................... 80
Initial contact met gehele voet .............................................................................................................................. 80
Onvoldoende invering knie bij loading response ........................................................................................................ 80
Overdreven kniestabiliteit in single leg stance ........................................................................................................... 80
Trendelenburg ............................................................................................................................................................................................ 81
Duchenne.................................................................................................................................................................................................... 81
Veel voorkomende strategieën zwaaifase .................................................................................................................................................. 81
Mogelijke oorzaken ............................................................................................................................................ 81
Perifeer arterieel vaatlijden ........................................................................................................................................................................ 81
Basisprincipes looptraining ......................................................................................................................................................................... 81
Hoe gaat de fysiotherapeut te werk ........................................................................................................................................................... 81
Preventie, beweegprogramma’s en voorlichting .................................................................................................................................... 82
Preventie .................................................................................................................................................................................................... 82
Doel preventie ................................................................................................................................................... 82
Indeling gericht op doelgroepen ............................................................................................................................ 82
Indeling gericht op fase van de ziekte ...................................................................................................................... 83
Beweegprogramma .................................................................................................................................................................................... 83
Definitie van een KNGF-standaard Beweeginterventie ................................................................................................. 83
Doelstelling van een KNGF-standaard Beweeginterventie ............................................................................................. 83
Rol van preventie ............................................................................................................................................... 83
Gecombineerde leefstijlinterventie (GLI) .................................................................................................................. 84
Voorlichting ................................................................................................................................................................................................ 84
Plaats van voorlichting ......................................................................................................................................... 84
Ziektepercepties ................................................................................................................................................ 84
IPQ-K............................................................................................................................................................... 85
Common Sense Model of Self-regulation.................................................................................................................. 85
Ziekteperceptie en coping .................................................................................................................................... 85
Van ziekteperceptie naar voorlichting ..................................................................................................................... 85
Voorlichtingsbijeenkomst ..................................................................................................................................... 85
Beweeginterventies .................................................................................................................................................................................... 86
WHO (World Health Organisation): niet overdraagbare aandoeningen ............................................................................ 86
Beweeginterventie ............................................................................................................................................. 86
Bewegen .......................................................................................................................................................... 87
Belang van bewegen ........................................................................................................................................... 88
Fysiotherapeut .................................................................................................................................................. 88
Beweegprogramma ............................................................................................................................................ 89
AGE: Advanced Glycation Endproducts .................................................................................................................... 89
Polyneuropathie ................................................................................................................................................ 89
Cardiovasculair risicomanagement ........................................................................................................................................................ 90
Zorgstandaard ............................................................................................................................................................................................ 90
Doel zorgstandaard: ............................................................................................................................................ 90
Doel richtlijn: .................................................................................................................................................... 90
Zorgstandaard cardiovasculair risicomanagement 2013 ............................................................................................... 90
Patiëntengroep .................................................................................................................................................. 90
NHG 2019 ................................................................................................................................................................................................... 90
Chronic care model ..................................................................................................................................................................................... 91
Inhoud zorgstandaard ................................................................................................................................................................................ 91
Lichamelijke activiteit .......................................................................................................................................... 91
Stress .............................................................................................................................................................. 91
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
3
, Risicofactoren ............................................................................................................................................................................................. 92
SPAV ........................................................................................................................................................................................................... 92
Doelstellingen KNGF-richtlijn ................................................................................................................................. 92
Behandeldoelen ................................................................................................................................................. 92
Ondersteunen CVRM bij sPAV ............................................................................................................................... 92
Aangrijpingspunten voor fysiotherapeutische interventies ......................................................................................................................... 93
Zelfmanagement ........................................................................................................................................................................................ 93
Noodzakelijke voorwaarden ....................................................................................................................................................................... 93
Fysiotherapie en preventie ......................................................................................................................................................................... 94
Aangrijpingspunten voor fysiotherapeutische interventies bij preventie .......................................................................... 94
Gedragsdeterminanten ........................................................................................................................................ 94
Theorieën......................................................................................................................................................... 94
Methoden ........................................................................................................................................................ 94
Model stoppen met roken........................................................................................................................................................................... 95
Motiverende gespreksvoering ............................................................................................................................................................... 96
Motivatie .................................................................................................................................................................................................... 96
Stages of Change ........................................................................................................................................................................................ 96
Motiverende gespreksvoering .................................................................................................................................................................... 97
Verandertaal en behoudtaal ....................................................................................................................................................................... 97
Schaalvragen .............................................................................................................................................................................................. 98
Weerstand en reparatie reflex .................................................................................................................................................................... 98
Gesprekstechnieken .................................................................................................................................................................................... 98
Reflectie .......................................................................................................................................................... 98
Bevestigen ........................................................................................................................................................ 99
Symptom limited test ......................................................................................................................................................................... 100
Inspanningsketen ..................................................................................................................................................................................... 101
Typische verloop van de lactaatcurve ....................................................................................................................................................... 101
Fietsergometrisch onderzoek .................................................................................................................................................................... 101
ECG ........................................................................................................................................................................................................... 102
Afwijkingen ECG ....................................................................................................................................................................................... 102
Wat beperkt normaal de maximale inspanning ........................................................................................................................................ 103
Gaswisselingsstoornissen leiden tot een lage PaO2 .................................................................................................................................. 103
Beperkingen.............................................................................................................................................................................................. 104
Fietstest interpretatie ............................................................................................................................................................................... 104
Voorbeeld tabel ........................................................................................................................................................................................ 105
Gedragsverandering............................................................................................................................................................................ 106
ASE-model ................................................................................................................................................................................................ 106
I-Change Model ........................................................................................................................................................................................ 107
Stages of Change ...................................................................................................................................................................................... 107
Nudging .................................................................................................................................................................................................... 107
Zelfmanagement................................................................................................................................................................................. 108
Waarom is zelfmanagement belangrijk .................................................................................................................................................... 108
Veranderingen gezondheidszorg .............................................................................................................................................................. 108
Functie als fysiotherapeut ........................................................................................................................................................................ 108
Belangrijk bij zelfmanagement ................................................................................................................................................................. 108
Zorgstandaarden en integrale bekostiging ........................................................................................................................................... 109
Wat komt er op ons af .............................................................................................................................................................................. 109
Behandeling diabetes mellitus type II in het ziekenhuis ............................................................................................................................ 109
Wat kost deze zorg ................................................................................................................................................................................... 109
Bestaande zorgstandaarden ..................................................................................................................................................................... 109
Zorgstandaarden en zorgmodules ............................................................................................................................................................ 109
Verschil zorgstandaard en richtlijn ........................................................................................................................................................... 109
Functie zorgstandaard .............................................................................................................................................................................. 110
Integrale zorg ........................................................................................................................................................................................... 110
Transparantie en kwaliteit voor mensen met diabetes mellitus type II ..................................................................................................... 110
De diabetesgroep; ketenzorg .................................................................................................................................................................... 110
De multidisciplinaire diabeteszorggroep .................................................................................................................................................. 110
Meetbare kwaliteit van de ketenzorg ....................................................................................................................................................... 111
Integrale bekostiging ................................................................................................................................................................................ 111
Waarom......................................................................................................................................................... 111
Voordelen ...................................................................................................................................................... 111
Nadelen ......................................................................................................................................................... 111
Knelpunten ..................................................................................................................................................... 112
Aandachtspunten ............................................................................................................................................. 112
En nu? ........................................................................................................................................................... 112
Gezondheid naar gedrag ..................................................................................................................................................................... 113
De kosten voor gezondheidszorg .............................................................................................................................................................. 113
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
4
, Nederland en Europa ........................................................................................................................................ 113
Verdeling van zorgkosten in Nederland .................................................................................................................. 113
Zorguitgaven in de toekomst ............................................................................................................................... 113
Trendscenario ........................................................................................................................................................................................... 113
Definitie WHO........................................................................................................................................................................................... 113
Definitie Machteld Huber ......................................................................................................................................................................... 113
Wie heeft (volgens bovengenoemde publicatie van de OECD) procentueel gezien in Europa naar verhouding de allerhoogste zorgkosten
in 2012? Welk percentage wordt hier gesteld? ........................................................................................................................................ 114
Welke deelsectoren vormen de grootste zorguitgaven? ........................................................................................................................... 114
Ons zorgstelsel.......................................................................................................................................................................................... 114
Wetten...................................................................................................................................................................................................... 115
De Wet Langdurige Zorg (Wlz).................................................................................................................................................................. 115
Voor wie ........................................................................................................................................................ 115
Door wie ........................................................................................................................................................ 115
Belangrijkste veranderingen in het kort ................................................................................................................. 116
Voorbeelden ................................................................................................................................................... 116
De Zorgverzekeringswet (Zvw).................................................................................................................................................................. 116
Voor wie ........................................................................................................................................................ 116
Door wie ........................................................................................................................................................ 116
Belangrijkste veranderingen in het kort ................................................................................................................. 116
Voorbeelden ................................................................................................................................................... 116
De Wet maatschappelijke ondersteuning 2015 (Wmo2015) .................................................................................................................... 116
Voor wie ........................................................................................................................................................ 116
Door wie ........................................................................................................................................................ 116
Belangrijkste veranderingen in het kort ................................................................................................................. 117
Voorbeelden ................................................................................................................................................... 117
De Jeugdwet ............................................................................................................................................................................................. 117
Voor wie ........................................................................................................................................................ 117
Door wie ........................................................................................................................................................ 117
Belangrijkste veranderingen in het kort ................................................................................................................. 117
Voorbeelden ................................................................................................................................................... 117
De Participatiewet .................................................................................................................................................................................... 117
Voor wie ........................................................................................................................................................ 118
Door wie ........................................................................................................................................................ 118
Belangrijkste veranderingen in het kort ................................................................................................................. 118
Anatomie............................................................................................................................................................................................ 119
Thorax ...................................................................................................................................................................................................... 119
Het sternum.................................................................................................................................................... 119
De thorax ....................................................................................................................................................... 119
Projectiepunten hart ......................................................................................................................................... 119
Bijlage 1: NNGB + Beweegnorm........................................................................................................................................................... 120
NNGB ........................................................................................................................................................................................................ 120
Beweegnorm ............................................................................................................................................................................................ 120
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
5
,Fysiologie
Lipiden
Lipiden zijn vetachtige stoffen en zijn onoplosbaar in water. Een ander woord voor lipiden is vetten.
De bekendste voorbeelden van lipiden zijn cholesterol en tryglyceriden.
Cholesterol heeft verschillende functies in het lichaam. Deze functies zijn niet altijd slecht.
Functies van cholesterol zijn:
o Opbouwen en versterken cel- en vaatwanden
o Regelen van essentiële communicatie tussen de cellen
o Repareert beschadigd weefsel
o Speelt belangrijke rol in de hersenen en het zenuwstelsel
o Bouwsteen voor veel hormonen, zoals oestrogeen, progestagenen, androgenen, cortisol en
aldosteron
o Aanmaak van antistoffen (immuunsysteem)
o Maakt het mogelijk vitamine D aan te maken uit zonlicht
o Zorgt dat celwanden doorlaatbaar zijn voor belangrijke stoffen (zoals vitamines)
90% van cholesterol wordt in het lichaam door de lever aangemaakt. 10% van de cholesterol komt
via voeding binnen, wordt opgenomen via de darmen en wordt vervoerd naar de lever.
Tryglyceriden zijn de meest voorkomende vetten in het lichaam. Het bestaat uit 3 vetzuurmoleculen
gekoppeld aan een glycerolmolecule. Normaal gesproken bevindt zich kleine deeltjes van
tryglyceride in de bloedbaan en wordt gebruikt als brandstof.
Tryglyceriden krijg je binnen via voedsel en via de lever. Het lichaam van iemand die meer calorieën
tot zich neemt dan nodig is, zet deze om in tryglyceride, dat wordt opgeslagen in de vetcellen.
Cholesterol en tryglyceriden lossen niet op in water, en dus niet in
bloed. Toch wil je dat deze stoffen opgenomen worden. Dat gebeurt
door een soort “pakketjes”. Er zijn 4 soorten van deze “pakketjes”: LDL
(Low-Density lipoproteïne), HDL (High-Density lipoproteïne), VLDL (Very-
Low-Density lipoproteïne) en Chylomicronen. Deze transportdeeltjes
worden gemaakt in de lever en de darm. Elke vorm heeft een andere
samenstelling.
Een transportdeeltje bestaat uit tryglyceriden, cholesterol, fosfolipiden en proteïne en worden
onderscheiden op grond van hun dichtheid. Onderscheid op basis van gewicht (density) heeft te
maken met verhoudingen.
o Hoe meer lipiden (vet) en minder eiwit: minder gewicht/
dichtheid
o Hoe minder lipiden (vet) en meer eiwit: meer gewicht/
dichtheid
Hoe meer lipiden ze bevatten, des te lager de dichtheid.
Lipiden zijn lichter dan eiwit.
Chylomicron is hierdoor de lichtste en HDL de zwaarste.
Chylomicron is belangrijk voor het vervoeren van vetten, doordat
het grootste deel van het chylomicron bestaat uit vetten.
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
6
,Bij verwerking van cholesterol en tryglyceriden in het lichaam is de lever het centrale orgaan. De
lever maakt goede connecties met de bloedvaten van het maagdarmstelsel, door het eten varieert
het bloed van samenstelling, de lever kan het stabiel houden door deze connecties. De lever heeft
een rol bij de controle van de hoeveelheid vet in het lichaam.
Een algemeen gezond cholesterolgehalte ziet er als volgt uit:
o TC: totale cholesterolgehalte: lager dan 5 mmol/L
o LDL-gehalte: lager dan 3 mmol/L
o Tryglyceridengehalte: lager dan 2 mmol/L
o HDL-gehalte: hoger dan 1 mmol/L
We maken hierbij gebruik van de 5-3-2-1 regel:
5 lager, 3 lager, 2 lager, 1 hoger
Exogeen lipiden transport
Vetrijk voedsel neem je op, tryglyceriden en
cholesterol komen via de darmen terecht in
de bloedvaten. De lymfevaten hebben hier
een belangrijke rol in. Het transport vindt
plaats via de chylomicronen.
Chylomicronen worden meegenomen in de
bloedbaan. In de bloedbaan bevindt zich
het enzym lipoproteïne lipase, dit enzym
zorgt ervoor dat het chylomicron kleiner
gemaakt wordt en stoffen vrijkomen. Het
chylomicron geeft inhoud af aan spier- en
vetweefsel, dit is met name tryglyceride.
Het chylomicron is kleiner geworden door
de afgifte en belandt op een receptor. Hier
wordt het chylomicron uitgescheiden door
middel van galzouten.
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
7
, Endogeen lipiden transport
Rode baan:
De lever maakt vetten vrij, de lipiden
transporteren met VLDL en komen uit in het
bloedvat. Door het enzym lipoproteïne lipase
wordt VLDL kleiner gemaakt. Door de afgifte
van tryglyceriden wordt VLDL, LDL. LDL levert
cholesterol aan de perifere weefsels. Het
overige LDL dat in het bloedvat terechtkomt
wordt geresorbeerd naar de lever, via twee
wegen kan het terug komen in de lever.
Groene baan:
De groene baan gaat direct terug naar de
lever.
Blauwe baan:
LDL komt terecht in het bloedvat en blijft daar rondcirculeren. De lever produceert HDL, en stuurt
een kleine HDL weg het bloedvat in. HDL wordt in het bloedvat groter, wanneer het groot genoeg is
neemt het LDL mee en gaat terug naar de lever.
Het enzym CETP verzamelt alles en zorgt ervoor dat het terug gaat richting de lever.
PERIODE 2: ZELFMANAGEMENT, MOTIVATI E & PREVENTI E
Sanne Eek hof
8
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