Role of Physiotherapy in Astronaut Trainning

A PROJECT ON

ROLE OF PHYSIOTHERAPY IN ASTRONAUT

TRAINING

Project submitted to

Dr N.T.R. University of health and sciences, Vijayawada towards

The partial fulfillment of the degree,

BACHELOR OF PHYSIOTHERAPY

By

M.UMA MAHESH

Reg.no.11040010

VISAKHA ACADEMY OF PARAMEDICAL SCIENCES

COLLEGE OF PHYSIOTHERAPY,

MADHURWADA, VISAKHAPATNAM

2011-2016

ACKNOWLEDGEMENT

My whole hearted thanks to the VAPMS management especially to late professor

Dr.K.S.N.R.V.Subba Rao, founder chairman, VAPMS charitable trust, Visakhapatnam for

giving me an opportunity to shape my carrier in his institution and also to

Mr.K.V.Ramesh(Tresorer),Secretary for providing necessary requirements to complete this

study.

I would like to express my sincere thanks to Dr.Sidharth Dara M.P.T Ortho, Principal

and Professor of VAPMS College of physiotherapy for his supportive guidance,

encouragement and valuable advices.

I Would like to express my heartfelt gratitude and would never forget to gratify

Dr. Venkata Ramaiah, MPT Ortho , associate professor of VAPMS college without whose

guidance, suggestions, support and continues encouragement, I would not have completed my

work successfully.

My sincere gratitude to Associate Professor Dr. K. Neeraja, MPT Cardio, Associate

Professor Dr. M. Rajani cartor, MPT Ortho, Dr.T.Sir isha, MPT Neuro, Associate

Professor, , Associate professor Dr.Ch.Sri Vidya MPT Neurology Assistant Professor,

Dr.Supriya Sudharashini MPT Orthopaedics, MPT Orhto, Assistant professor Dr., MPT

and Assistant professor Dr. P. Visweswara Rao MPT Cardio, of our college extended their

support in academic career.

I am very thankful to my clinical posting in charges during my academic year Dr. Navya

MPT Cardiology Assistant Professor, Dr.Madhuri MPT Neurology Assistant professor,

Dr.Bharath MPT Neurology ,Dr .Nisse raj MPT Neurology Assistant professor.

Last but not least I like to specially thank Mrs. R. Krishna Kumari, Librarian and my

friends who extended their help in completion of this project.

M.UMA MAHESH

SPECIAL THANKS

I would fail my duty if I do not express my gratitude’s to my loving parents, especially

my sincere thanks to Dr. M. Rajini cator sir and my friends Prathusha, K.Harish, Swathi

,Chaitanya,Prabhudas always stood behind me and without whose encouragement and support

this work could not have been completed.

`

DEDICATED

TO

MY LOVING PARENTS

&

INDIAN ASTRONAUTS

ROLE OF

PHYSIOTHERAPY IN

ASTRONAUT

ROLE OF

PHYSIOTHERAPY IN

ASTRONAUT TRAINING

PHYSIOTHERAPY IN

TRAINING

INDEX

S.NO Pg.No

1) INTRODUCTION 1-2

2) BIO-PHYSICS 3-7

3) MICRO GRAVITY EFFECTS ON HUMAN PHYSIOLOGY 8-16

4) INVESTIGATIONS 17-18

5) MEDICAL MANAGEMENT 19-20

6) PHYSIOTHERAPY MANAGEMENT 26-47 • PRE-FLIGHT PHASE

• IN FLIGHT PHASE • POST FLIGHT PHASE

7) CONCLUSION 48

8) BIBILOGRAPHY 49-52

INTRODUCTION

INTRODUCTION

Space exploration is the ongoing discovery and exploration of celestial structures in outer space by

means of continuously evolving and growing space technology1.

While the study of space is carried out mainly by astronomers with telescopes, the physical

exploration of space is conducted both by unmanned robotic probes and human spaceflight.

Human space flight started as a race between the two super powers of the world( RUSSIA AND

USA) however, already during the Cold War, human space flight became emblematic that peaceful

cooperation was possible (Soyuz-Apollo, Shuttle-Mir mission)14.

Today, human space flight is characterized by a worldwide cooperation by many countries. Future

human space flight32 endeavors will be worldwide cooperation efforts, maybe including emerging

space-faring countries (China, India), and this for several reasons: political, financial, technological

and scientific.

The human body is an extraordinary but, also, an astonishingly complex machine. Like other living

organisms, the human body has evolved by adapting.14

To Earth’s gravitational field, and the biological structure and mechanisms of the body have

developed to suit normal Earth gravity31.

The gravitational force that acts on human beings at the Earth’s surface is the result of the interaction

between Earth and the human body. As Earth is more massive, it pulls the body toward the centre of

the Earth.

Thus, on the Moon, gravity is six times weaker than on Earth. So an astronaut would weigh a sixth as

much on the lunar surface. The Moon’s gravity is six times less than the Earth’s gravity.

When in Earth orbit, the astronaut’s body is still acted on by gravity, but much more weakly because

of the distance. In addition, the speed acquired by the spacecraft to send the astronaut into space

partially counteracts the gravitational force that continues to act on the spacecraft. This is the law of

inertia. Thus, gravity disappears and the astronaut’s body becomes weightless.

“Weightless” means that there is no sensation of weight.10 The term zero gravity is also used, but to

avoid promising too much scientists have adopted the term microgravity, because the effects of

Earth’s gravitational force, and other forces, are not completely cancelled out.

2

Space research has given us a better understanding of the physical and chemical properties of matter.

This broad field of research is known as “microgravity science.”

The effects of gravity on our bodies and the biological mechanisms involved in adapting to

weightlessness are studied under real microgravity conditions. Research on astronauts has shown that

body function is disturbed in microgravity.

Effects of space travel on the human body like space sickness, 52 disorientation, migration of organic

fluids to the upper body, bone deterioration, muscular atrophy, lengthening of the spine, backaches,

gait disturbances motor performance degradation, electrical activity disturbances neuroreflexes

readjustment, motionsickness,fluid loss,electrolight changes etc.

In space the astronaut adapts to microgravity53 and we see different changes to the body when the

astronaut is back on Earth. For example, changes in the bone and muscular skeletal system. My job is

to make sure the astronaut readapts to gravity conditions on Earth as soon as possible.

The astronaut who is assigned for a mission in the preflight period to make them ‘fit for space’ and

to train all exercises he/she has to do while on the ISS.

During the in-flight period we control the exercises via video, sometimes in real time, to make sure

that the performance is perfect and the effect optimal.28

To restore the normal physiological function of the body by more physical activity is necessary to

rebuild the muscle strength, bone health and cardiovascular activity.

For this we are training each system with specific techniques to rearranging body functions normal.

The aim of this project is to present the role of physiotherapeutic intervention and its benefits to

improve the health status of astronauts along with other interventions. Along with medical

management, the Physiotherapy treatment can give to prevent muscle atrophy by strengthening and

endurance exercises. To improve cardio vascular function by ergonomics and aerobics exercises. To

maintain balance and co-ordination by adaptability training, Swiss ball exercises.

BIO-PHYSICS

Earth:-

� Earth (1 AU from the Sun) is the largest and densest of the inner planets, the only one known

to have current geological activity, and the only place where

Fig no

� Its liquid hydrosphere is unique among the terrestrial planets, and it is the only planet

where plate tectonics has been observed.

� Earth's atmosphere is radically different from those of the other planets, having been altered

by the presence of life to contain 21% free

� It has one natural satellite, the

Solar System

ATMOSPHERE

DEFINITION:-

The atmosphere is a gaseous envelope that covers the earth.

ABOUT THE ATMOSPHERE

One of the primary problems of flight related to physiology has to do with the fact that the pressure

of gases in the atmosphere change as we ascend and descend. It is essential that we have an

understanding of the gases found in the atmosphere and their

such as temperature change, also need to be understood so we can protect ourselves from these

potential hazards. 52

3

BIO-PHYSICS

(1 AU from the Sun) is the largest and densest of the inner planets, the only one known

to have current geological activity, and the only place where life is known to exist.

Fig no-01 earth

is unique among the terrestrial planets, and it is the only planet

has been observed.

Earth's atmosphere is radically different from those of the other planets, having been altered

nce of life to contain 21% free oxygen.

It has one natural satellite, the Moon, the only large satellite of a terrestrial planet in the

The atmosphere is a gaseous envelope that covers the earth. 52

ATMOSPHERE :-



understanding of the gases found in the atmosphere and their effects upon the body. Other factors,


(1 AU from the Sun) is the largest and densest of the inner planets, the only one known

is known to exist. 53

is unique among the terrestrial planets, and it is the only planet

Earth's atmosphere is radically different from those of the other planets, having been altered

Moon, the only large satellite of a terrestrial planet in the



effects upon the body. Other factors,


BENEFITS OF THE ATMOSPHERE:

� Without the atmosphere there would be no life on earth.

� The atmosphere provides protection from harmful ultraviolet (UV) rays, cosmic rays, and

meteorites. 52

� The atmosphere also protects the earth from extreme temperature variations.

� It supports animal and plant life through its gaseous content and provides rain to grow crops.

The Earth’s Atmosphere Is Divided Into Several A

Fig no -02 different level of atmosphere

� These regions start and finish at varying heights depending on season and distance from the

poles. The altitude’s started below or averages

� Troposphere — surface

18,000 metres (11 mi)

� Stratosphere — Troposphere

� Mesosphere — Stratosphere

� Thermosphere — Mesosphere

� Exosphere — Thermosphere

4

ATMOSPHERE: -

Without the atmosphere there would be no life on earth.

The atmosphere provides protection from harmful ultraviolet (UV) rays, cosmic rays, and

The atmosphere also protects the earth from extreme temperature variations.

It supports animal and plant life through its gaseous content and provides rain to grow crops.

The Earth’s Atmosphere Is Divided Into Several Altitude R

different level of atmosphere

These regions start and finish at varying heights depending on season and distance from the

poles. The altitude’s started below or averages .52

surface to 8,000 metres (5.0 mi) at the poles –

mi) at the equator, ending at the Tropopause

Troposphere to 50 kilometres (31 mi)

Stratosphere to 85 kilometres (53 mi)

Mesosphere to 675 kilometres (419 mi)

mosphere to 10,000 kilometres (6,200 mi0)

The atmosphere provides protection from harmful ultraviolet (UV) rays, cosmic rays, and

The atmosphere also protects the earth from extreme temperature variations.

It supports animal and plant life through its gaseous content and provides rain to grow crops.

ltitude Regions.

These regions start and finish at varying heights depending on season and distance from the

PHYSICS OF ATMOSPHERE

Gravity:-

Gravity is a natural phenomenon by which all physical bodies attract each other. Gravity gives

weight to physical objects and causes them to fall toward one another.

Newton’s theory of gravitation:

Newton's law of universal gravitation

with a force that is directly proportional

the square of the distance between them.

where:

• F is the force between the masses.

• G is the gravitational constant

• m1 is the first mass.

• m2 is the second mass.

• r is the distance between the centers of the masses.

Microgravity: State of a body such that the set of forces of gravitational origin to which it is

subject to have a very small resultant compared to Earth

5

PHYSICS OF ATMOSPHERE


and causes them to fall toward one another.

Newton’s theory of gravitation:

Newton's law of universal gravitation states that any two bodies in the universe attract each other

directly proportional to the product of their masses and inversely proportional to

the square of the distance between them.

is the force between the masses.

gravitational constant (6.673×10−11 N · (m/kg)2).

the distance between the centers of the masses.

of a body such that the set of forces of gravitational origin to which it is

subject to have a very small resultant compared to Earth-normal gravity.4


states that any two bodies in the universe attract each other

nversely proportional to

of a body such that the set of forces of gravitational origin to which it is

Fig no

Zero gravity (or weightlessness):

forces to which it is subject have a zero resultant.

� “Weightless” means that there is no sensation of weight

but to avoid promising too much scientists have adopted the term microgravity, because the

effects of Earth’s gravitational force, and other forces,

Fig no

� An astronaut is in free fall when orbiting Earth. The reason the astronaut floats inside the

spacecraft is that he or she is falling at the same speed as it is.

� The phenomenon of floating caused by free fall can also take place on Earth. Consider the

example of a person in an elevator that suddenly breaks free and falls from the 30th floor of

6

Fig no-03 parabolic flight for astronaut

Zero gravity (or weightlessness): State of a body such that the set of gravitational and inertial

forces to which it is subject have a zero resultant.

“Weightless” means that there is no sensation of weight4. The term zero gravity is also used,

ut to avoid promising too much scientists have adopted the term microgravity, because the

effects of Earth’s gravitational force, and other forces,52 are not completely cancelled out.

ig no -04 Gravity varies from earth to space

free fall when orbiting Earth. The reason the astronaut floats inside the

spacecraft is that he or she is falling at the same speed as it is.

The phenomenon of floating caused by free fall can also take place on Earth. Consider the


State of a body such that the set of gravitational and inertial

. The term zero gravity is also used,

ut to avoid promising too much scientists have adopted the term microgravity, because the

are not completely cancelled out.

free fall when orbiting Earth. The reason the astronaut floats inside the

The phenomenon of floating caused by free fall can also take place on Earth. Consider the


7

a building. The person inside, who would be falling at the same speed as the elevator, would

float inside.

� Naturally our astronaut does not fall to Earth, despite being in free fall, because the speed

imparted to the spacecraft keeps it in orbit.6

� Both phenomena, microgravity and floating, have an impact on an astronaut’s body in space.

� Space research has given us a better understanding of the physical and chemical properties

of matter. This broad field of research is known as “microgravity science.”

� The effects of gravity on our bodies and the biological mechanisms involved in adapting to

weightlessness are studied under real microgravity conditions. 11

� Research on astronauts has shown that body function is disturbed in microgravity.

� Space agencies are therefore continuing their research in hope of eventually reducing or

eliminating some of these undesirable physical effects that appear during a stay in space.

� Results of this research will make prolonged space missions safer, at a time when

construction of the international space station is just getting under way, and may one day

allow human beings to go on to Mars.21

MICROGRAVITY

INFLUENSE ON HUMAN

PHYSIOLOGY

8

Fig no -05 physiological changes due to microgravity

PHYSIOLOGICAL CHANGES DUE TO MICROGRAVITY

MUSCULOSKELETAL

� LOSS OF MUSCLE MASS

� In space, the musculoskeletal system

muscles, which are underused, become flabby and lose tone and mass

Fig no -6 Muscle wasting due to space travel

� The astronauts are then subject to muscular atrophy. The bones, too, become weaker because of

a loss of minerals (calcium, potassium and sodium).

� This bone degradation7 can reduce bone in the lower limbs by up to 10%.

� In space, muscles in the legs, back,

longer are needed to overcome gravity, just as people lose muscle when they age due to reduced

physical activity.

� Astronauts rely on research in the following areas to build muscle and maintain body

1) Exercise may build muscle if at least two hours a day is spent doing resistance training

routines.

2) Hormone supplements (hGH) may be a way to tap into the body’s natural growth signals.

3) Medication may trigger the body into producing muscle growth

9


MUSCULOSKELETAL SYSTEM:

LOSS OF MUSCLE MASS :

In space, the musculoskeletal system continuously deteriorates.The muscles, in particular the leg

muscles, which are underused, become flabby and lose tone and mass11.

Muscle wasting due to space travel

The astronauts are then subject to muscular atrophy. The bones, too, become weaker because of

a loss of minerals (calcium, potassium and sodium).

can reduce bone in the lower limbs by up to 10%.

In space, muscles in the legs, back, spine, and heart weaken and waste away because they no


Astronauts rely on research in the following areas to build muscle and maintain body

Exercise may build muscle if at least two hours a day is spent doing resistance training

Hormone supplements (hGH) may be a way to tap into the body’s natural growth signals.

Medication may trigger the body into producing muscle growth proteins.


The muscles, in particular the leg

The astronauts are then subject to muscular atrophy. The bones, too, become weaker because of

spine, and heart weaken and waste away because they no


Astronauts rely on research in the following areas to build muscle and maintain body mass:

Exercise may build muscle if at least two hours a day is spent doing resistance training

Hormone supplements (hGH) may be a way to tap into the body’s natural growth signals.

proteins.

10

Fig no -7 muscle wasting comparing from earth and space

� LOSS OF BONE DENSITY:

� Shifting from an environment with gravity to a microgravity8 environment causes changes in

an astronaut’s body.

� One area of concern for the astronauts’ health is the loss of bone density7. On Earth, a

person’s bone density peaks around the age of 30. After the age of 35, the bone density

decreases on average by < 1% each year.

� Space travelers aren't the only ones who worry about bone loss.7

Fig no- 8 picture shows that how microgravity influence on bone growth

11

New techniques are being developed to help astronauts recover faster. Research in the following

areas holds the potential to aid the process of growing new bone10:

• Diet and Exercise changes may reduce osteoporosis.

• Vibration Therapy may stimulate bone growth.

• Medication could trigger the body to produce more of the protein responsible for bone growth

and formation.

� CIRCULATORY SYSTEM:

Fig no-9 Body fluid shift due to zero gravity

� In spaceflight, shortly after reaching orbit, astronauts experience much lower gravity than on

Earth. This is known as microgravity.12

� Therefore, the average physical exertion of astronauts on board the space shuttle and the

International Space Station (ISS) is reduced compared to pre-flight, with the exception of

challenging extravehicular activities such as a space walk.

� An astronaut’s circulatory system, 34which is accustomed to working against gravity, receives

a different set of signals and stimuli in microgravity and adapts to the new environment.17

� The heart does not need to work as hard to send blood to the upper body as it does when it

working against gravity. This causes blood volume to increase in the upper body42.

12

� During systole, ventricles contract to pump a volume of blood through the body which

increases the volume of blood in the arteries and therefore also increases the pressure in the

arteries.

� During diastole, the heart relaxes and fills with blood; therefore, the volume of blood and the

pressure in the arteries decreases.

Fig no -10 Fluids shifting from the head towards the feet

� A microgravity environment leads to changes in fluid distribution, muscle loading, and

altered signaling pathways.

� Some basic changes include alterations in blood pressure and the quantity of blood that is

pumped by the heart with each beat.

� The human heart is designed to force blood to the body, and the most difficult organ to

perfuse is the brain since it is above the heart.42

� In space your heart does not have to work against gravity to pump blood to your brain and

blood accumulates in the upper body because gravity is not there to pull it toward your feet.

� Your body takes advantage of this lack of work and begins to be less efficient as

demonstrated by the lower stroke volume.

� The heart generates slightly higher systolic and diastolic pressures because large muscle

groups (like the legs) are inactive and do not demand blood, resulting in vasoconstriction.

� Also, since the heart is less efficient some blood remains in the heart after each contraction

which slightly increases the pressure during the relaxation phase known as diastole.

13

� Taken together, the amount of blood that is being pumped out of the heart (stroke volume)

will change.

� As the flight duration increases, these changes become slightly more dramatic, and may

affect an astronaut’s other physiological functions.33

� There could even be permanent changes in the way organs and blood vessels behave.

� Resistance training (weight lifting) and cardiovascular (aerobic) exercise to minimize muscle

atrophy and cardiovascular de-conditioning are very important countermeasures

Fig no-10.1 microgravity effect on circulation

� Lack of activity and a sedentary lifestyle may lead to the same problems that astronauts face

in microgravity.

� As the heart 12becomes less efficient, other physiological functions of the body are affected.

Long term sedentary lifestyle may lead to permanent changes that may increase risks of

certain cardiac diseases.

INFLUENCE ON BLOOD CIRCULATION:

� One of the most visible effects of a space mission is no doubt the “puffy-face”, “bird-leg”

look that astronauts42 get.

� On Earth, the heart is programmed to distribute blood evenly throughout the body.

� The heart must do more work to supply the upper body, because blood is naturally drawn

downward by the force of gravity.

� The lower limbs do not have this problem, as the bl

Fig no- 11 Influence

� In space, bodily fluids no longer flow back down naturally by gravity.

� The heart is still programmed the way it was on Earth. So,

veins and arteries, the blood rushes to the person’s torso and head, and they then experience

“puffy face syndrome.”

� The veins of the neck and face stand out more than usual; the eyes become red and swollen.

� This effect is often accompanied by nasal congestion and sometimes even headaches. Astronaut’s

legs also grow thinner, because instead of dropping effortlessly down to the lower limbs, the

blood has to be pumped there by the heart.

� Particularly because of physio

sickness or space adaptation syndrome (the space version of what we call motion sickness on

Earth).

� About 40% of those who have gone into space have had dizziness or nausea.

� Both generally wear off after 2 or 3 days, as soon as the astronaut’s body has had time to adapt.

� CARDIAC RHYTHMS :

� Heart rhythm disturbances have been seen among astronauts.

14

The heart must do more work to supply the upper body, because blood is naturally drawn

downward by the force of gravity.

The lower limbs do not have this problem, as the blood coming to them is gravity

Influence of microgravity and body changes

In space, bodily fluids no longer flow back down naturally by gravity.

The heart is still programmed the way it was on Earth. So, under the pressure of the heart and the


The veins of the neck and face stand out more than usual; the eyes become red and swollen.

ffect is often accompanied by nasal congestion and sometimes even headaches. Astronaut’s


blood has to be pumped there by the heart.

Particularly because of physiological changes such as these, astronauts suffer from space


About 40% of those who have gone into space have had dizziness or nausea.

Both generally wear off after 2 or 3 days, as soon as the astronaut’s body has had time to adapt.

:

have been seen among astronauts. 27

The heart must do more work to supply the upper body, because blood is naturally drawn

ood coming to them is gravity-assisted.

under the pressure of the heart and the


The veins of the neck and face stand out more than usual; the eyes become red and swollen.

ffect is often accompanied by nasal congestion and sometimes even headaches. Astronaut’s


logical changes such as these, astronauts suffer from space


About 40% of those who have gone into space have had dizziness or nausea.

Both generally wear off after 2 or 3 days, as soon as the astronaut’s body has had time to adapt.

15

� Most of these have been related to cardiovascular disease, but it is not clear whether this was due

to pre-existing conditions or effects of space flight.12

� It is hoped that advanced screening for coronary disease has greatly mitigated this risk. Other

heart rhythm problems, such as atrial fibrillation, can develop over time, necessitating periodic

screening of crewmembers’ heart rhythms.

� Beyond these terrestrial heart risks, some concern exists that prolonged exposure

to microgravity may lead to heart rhythm disturbances.

� Although this has not been observed to date, further surveillance is warranted.

� ORTHOSTATIC INTOLARENC:

� In space, astronauts lose fluid volume—including up to 22% of their blood volume.

� Because it has less blood to pump, the heart will atrophy. A weakened heart results in low blood

pressure and can produce a problem with “orthostatic tolerance,”23 or the body’s ability to send

enough oxygen to the brain without fainting or becoming dizzy.

� "Under the effects of the earth's gravity, blood and other body fluids are pulled towards the lower

body.

� When gravity is taken away or reduced during space exploration,36 the blood tends to collect in

the upper body instead, resulting in facial edema and other unwelcome side effects.

� Upon return to earth, the blood begins to pool in the lower extremities again, resulting

in orthostatic hypotension."27

� LOSS OF BALANCE:

� Leaving and returning to Earth’s gravity causes “space sickness,” dizziness, and loss of balance

in astronauts31. By studying how changes can affect balance in the human body—involving the

senses, the brain, the inner ear, and blood pressure—NASA hopes to develop treatments that can

be used on Earth and in space to correct balance disorders53.

� Until then, NASA’s astronauts must rely on a medication called Midodrine (an “anti-dizzy” pill

that temporarily increases blood pressure) to help carry out the tasks they need to do to return

home safely.43

16

� DECREASED IMMUNE SYSTEM FUNCTIONING:

� Astronauts in space have weakened immune systems, which means that in addition to increased

vulnerability to new exposures, viruses already present in the body—which would normally be

suppressed—become active.42

� In space, T-cells (a part of white blood cells) do not reproduce properly.

� T-cells that do exist are less able to fight off infection. NASA research is measuring the change

in the immune systems of its astronauts as well as performing experiments with T-cells in space.

� PSYHOLOGICAL FACTORS:

� Alzheimer's disease (AD), also known as Alzheimer disease, or just Alzheimer's, accounts for

60% to 70% of cases of dementia. It is a chronic neurodegenerative disease that usually starts

slowly and gets worse over time. The most common early symptom is difficulty in remembering

recent events (short-term memory loss)

� OTHER PHYSIOLOGICAL CHANGES:

1. Expose to high energy cosmic waves radiation increases risk of neurodegenerative disease31.

2. Eye abnormalities may arises due to UV exposure increases the intra cranial pressure.

3. Due to microgravity, distributions of fluid to upper body result in "puffy face" appearance.

4. Nasal congestion due to fluid distribution causes anosmia (loss of smell) and diminished taste.

5. Heart stroke volume decreases as cardiovascular system adapts to microgravity. RBC count also decreases.

6. Musculoskeletal adaptation to microgravity leads to loss of muscle mass and bone density.

7. Blood plasma volume is reduced by increased kidney output , elevated calcium secretions results

in increased risk of kidney stones17.

8. Stresses of spaceflight, including ionizing radiation, results in compromised immune system function.

9. Fluids redistribution from leg to upper body results in 10-30% decreased leg circulations.

10. Sleep disorder.

INVESTIGATIONS

17

Examination:

PRE FLIGHT :-

Physical examinations include-

• Abdominal Organs and Gastrointestinal System

• Blood and BloodForming Tissue Diseases

• Body Build

• Dental

• Ears and Hearing

• Endocrine and Metabolic Disorders

• Upper Extremities

• Lower Extremities

• Miscellaneous Conditions of the Extremities

• Mental Health

• Eyes and vision

• General and Miscellaneous Conditions and Defects

• Genitalia and Reproductive Organs

• Head

• Heart and Vascular System

• Height and Weight

• Lungs, Chest Wall, Pleura, and Mediastinum

• Mouth

• Neck

• Neurological Disorders

• Nose, Sinuses, and Larynx

• Skin and Cellular Tissues

• Spine and Sacroiliac Joints

• Systemic Diseases

• Tumors and Malignant Diseases

• Urinary System

18

POST FLIGHT:-

• Blood tests

• Brain CT –to detect any bleeding ,tumour,anurysums.

• Electrocardiogram (ECG)- to know the heart functioning.

• Magnetic resonance imaging(MRI)- to know any changes occer in brain.

• Muscle biopsy-to assess for muscle atrophy.

• Electromyography(EMG)-to analyzed to detect medical abnormalities and biomechanics of

human.

• Bone scan- To know density of bone .

MEDICAL INTERVENTIONS

19

MEDICAL INTERVENTIONS

• Exercise to maintain muscle strength and function

• Sleep cap

• Medication, including hormone replacement therapy.

FOR IMPROVING THE BONE HEALTH:

� Bone and calcium metabolism have been a concern for space travelers, literally since before

human space flight was a reality.43

� Vitamin D is a concern for space travelers, in part because their dietary sources of vitamin D

are insufficient, and in part because they lack ultraviolet light exposure.

� Vitamin D stores decline during flight if supplemental intake of this vitamin is inadequate.

� Recent studies have documented that supplementation with 800 IU vitamin D/day will

maintain vitamin D stores in astronauts on 6-month space missions.

� Although vitamin D is likely not a countermeasure for space flight-induced bone loss,

vitamin D deficiency will surely exacerbate the problem.

FOR IMPROVING THE MUSCLE HEALTH:

� Treatment will depend on the diagnosis and the severity of your muscle loss. Any underlying

medical conditions must be addressed.

� Common treatments for muscle atrophy include:

1) In severe cases of muscular atrophy, the use of an anabolic steroid such as methandrostenolone is

administered to patients as a potential cure.

2) Novel classes of drugs, called SARM (selective androgen receptor modulators) are being

investigated with promising results. 47

3) They would have fewer side-effects, while still promoting muscle and bone tissue growth and

regeneration.

� SURGERY may be necessary if your tendons, ligaments, skin, or muscles are too tight and

prevent you from moving.

• Surgery may be able to correct it if your muscle atrophy is due to malnutrition.

20

TO IMPROVE CADIOVASCULAR SYSTEM:

Medication:

Over-the-counter and prescription medications37 are readily available, such as

1. Dramamine (dimenhydrinate),

2. Stugeron (cinnarizine), and

3. Bonine/Antivert (meclizine).

4. Scopolamine is effective and is sometimes used in the form of transdermal patches (1.5 mg)

or as a newer tablet form (0.4 mg).

� The selection of a transdermal patch or scopolamine tablet is determined by a doctor after

consideration of the patient's age, weight, and length of treatment time required.

TO IMPROVE VESTIBULAR SYSTEM:

� Many pharmacological treatments which are effective for nausea and vomiting in some medical

conditions may not be effective for motion sickness. 47

� For example,

1. metoclopramide and

2. prochlorperazine,

� Although widely used for nausea, are ineffective for motion-sickness prevention and treatment.

� This is due to the physiology of the CNS vomiting centre and its inputs from the chemoreceptor

trigger zone versus the inner ear.

� Sedating anti-histamine medications such as promethazine work quite well for motion sickness,

although they can cause significant drowsiness.

� As astronauts frequently have motion sickness, NASA has done extensive research on the causes

and treatments for motion sickness. One very promising looking treatment is for the person

suffering from motion sickness to wear LCD shutter glasses that create a stroboscopic vision of 4

Hz with a dwell of 10 milliseconds.53

MANAGEMENT

MANAGEMENT

21

ASSESSMENT

NAME:………………………………………………………………………………………………….

AGE:……………SEX:…………………OCCUPATION:…………………………………………….

I.PNO…………………………………OPNO……………….DOA:………ADDRESS………………

………………………………………………………………………………….………………………

…………………………………………………………………………………………………………

…………………..PhoneNo……………………………………………………………………………

CHIEF COMPLAINTS-

HISTORY OF PRESENT ILLNESS:

MEDICAL HISTORY-

FAMILY HISTORY-

PERSONAL HISTORY-

SOCIOECONOMIC STATUS-

HAND DOMINACE-

OBSERVATION -

a) Built :

b) Posture :

c) Attitude of limbs :

d) Trophical movements :

e) Facial Expressions :

f) External Appliances :

g) Deformity :

h) Gait/mode of locomotion :

22

ON EXAMINATION

Higher cortical function :

Consciousness/unconsciousness(GCS Score) :

Orientation :

Memory :

Attention :

Calculation :

Emotion :

Problem Solving :

Judgement :

Speech and language :

Perceptual disorders :

CRANIAL NERVE EXAMINATION:

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

IX.

X.

XI.

XII.

SENSORY EVALUATION :

23

Superficial :

Deep :

Combined cortical sensation :

MOTOR ASSESMENT :

Muscle Tone :

Muscle Power/Voluntary control :

Developmental Reflexes :

Milestones Assesment :

REFLEXES :

Superficial :

Deep :

MUSCULOSKELETAL ASSESSMENT:

AROM :

PROM :

T/C/D’S :

CO-ORDINATION TESTS :

BALANCE ASESSMENT :

• Sitting balance :

• Static :

• Dynamic :

• Standing balance :

• Static :

• Dynamic :

BLADDER /BOWEL CONTROL :

24

POSTURE ASSESMENT :

GAIT ASSESSMENT :

OTHER SYSTEM ASSESSMENT :

CARDIO RESPIRATORY SYSTEM :

A. CHEST EXAMINATION:

They are 4 phases:

-inspection

-auscultation

-palpation

-percussion

B.OBJECTIVE FOR CHEST EXAMINATION ;

a) Pulmonary problems

Eg: cough, sputum, dyspnoea, chest pain

b) Co existing signs of pulmonary disease

Eg: symptoms of chest pain

c) Determine the need for further evaluation procedures

Eg: X-ray, E.C.G and PFT

d)Indentify R goals & formulate plan to track progress

Eg; proper guidelines & scales

SKIN CHANGES :

FUNCTIONAL ASSESSMENT :

25

INVESTIGATION :

CLINICAL IMPRESSION :

DIFFERENTIAL DIAGNOSIS :

PROBLEM LIST :

AIMS :

GOALS

STG: LTG:

MEANS OF TREATMENT :

FOLLOW UP:

26

PHYSIOTHERAPY MANAGEMENT

AIMS:

1. TO IMPROVE MUSCLE STRENGTH

2. TO IMPROVE ENDURENCE

3. TO IMPROVE BALANCE AND CO-ORDINATION

PHYSICAL ACTIVITY IMPORTANCE:

� Physical activity is an overarching concept which is expressed in many forms, for example;

play, physical education, daily activities including walking, going up and down stairs, cycling

to work, movement activities, exercise, and sports.28

� Physical activity can be defined as "all physical motion produced by skeletal muscles

resulting in a substantial increase of energy consumption beyond the normal level" .

� Moderate physical activity is defined as an activity that requires three to six times as much

energy as the energy used at rest.

� Exercise is physical activity that is planned, structured and repeated, aiming to improve or

maintain physical fitness.

PRE-FLIGHT PHASE

27

PRE-FLITE PHASE

� MOTOR FITNESS:

Motor fitness training develops the endurance, strength, power, balance, agility and flexibility to

climb efficiently on steep and challenging terrain.52

STRENGTH AND POWER TRAINING:

In addition to leg strength, mountaineering requires a strong core (back and stomach) as heavy

pack weights add a new dimension to climbing. Strength training principles are essentially the

same for upper and lower bodies. Strength training can involve body weight exercises as well as

routines using traditional weights.21

CORE STRENTHENING EXERCICES:

Core strength exercises strengthen your core muscles, including your abdominal muscles, back

muscles and the muscles around the pelvis. Strong core muscles make it easier to do many

physical activities.

• Core exercises build abs and other core muscles.

DEEP (FULL) SQUATS:-

Full squats push the knee joint past 90 degrees. Whether they are done with or without weights (a

barbell or a weight held across the shoulders or in the hands) this can strain the ligaments, cartilage

and muscle of the knee joint and lower back, and create problems with the tracking (movement) of

the kneecap. Suggestions include: Fig no- 12.

• Perform half-squats instead (45-degree bend of the knee).

• Use a mirror to check when your knee joint is at 90 degrees. You could also ask someone else

to watch you or seek instruction from a qualified fitness professional.

28

a) b)

Fig no- 12 a)deep squat with weights b) full squat

DOUBLE LEG RISES: -

Avoid double leg raises. This exercise involves lying on your back and raising both legs at the same

time. This places enormous stress on the lower back.

Another potentially harmful variation is to lie on your stomach and lift both legs at the same time.

Fig no-13 double leg rise

An alternative is to perform the exercise one leg at a time, making sure your hips remain stable

throughout the movement. Keep the other leg bent, with your foot on the ground. Blow shown

diagram.

BEHIND THE NECK PRESS:-

The ‘behind the neck presses or ‘latpulldown behind the neck’ should be avoided, especially if you

have been told you have instability in the front of your shoulder.

29

Fig no-14 neck press strengthening of back muscles

Push-ups:-

Push-ups can range in difficulty from very easy to so difficult that few people can do them.

Adjusting the difficulty level is simply a matter of changing hand placement and body level to alter

leverage and load. 52

Fig no-15 picture showing the which muscles are strengthen by push ups

Keeping the body upright and the hands in line with the shoulders scales the pushup for people who

are just beginning their fitness journey. Placing the feet high and moving the hands lower, toward the

hips, increases the loads dramatically and can challenge world-class athletes.

30

Decline push-up:-

To do push-ups with little or no resistance, start in a standing position, arms-length from a wall.

Extend the arms in front of you at shoulder height to place your hands on the wall slightly wider than

shoulder-width. These push-ups (or, more literally, push-outs) are appropriate for beginners and

those who are rehabilitating injuries. With the body almost completely vertical, these can be used to

restore and build mobility in the arms and shoulders, to teach the plank body position, and to work

toward a horizontal push-up on the floor.

Fig no-16 pushups with no resistance

Even with this simple movement it is important to keep a rigid body and full range of motion

(ROM). Each rep should bring the chest and face as close as possible to the wall and finish with the

arms completely straight and the shoulders fully extended.

The degree of difficulty can be additionally fine tuned by adjusting the distance of the feet from the

wall. Obviously, the farther out they are - and the more acute the angle of the body - the more

difficult they will be.

L-sit/V-sit:-

L-sits can be performed on the ground, with legs extended straight in front of you and hands flat on

the floor on either side of the legs. This requires a conscious effort to push the shoulders down to lift

the body high enough to perform the L on flat ground. ( Fig;17)You can also do a straddle L, with

hands on the ground between your legs.

31

Fig no- 17, L- sit/v sit for the triceps and abs

STANDING AND TOE TOUCH :-

Avoid standing toe-touches altogether. Bending down to touch the toes, with straight legs, can

overstretch the lower back muscles and hamstrings, and stress the vertebrae, discs and muscles of the

lower

Back and hamstrings. Adding a twisting movement to the toe-touch can cause damage to the joints.

Alternative stretches for the abdominal muscles or the lower back muscles and hamstrings include:

• Stretch the hamstrings and lower back muscles by placing one foot on a low bench or chair,

with both legs slightly bent so as not to stress the knee joints and, keeping your back straight,

gently reach forward with your arms.

• An alternative hamstring stretch involves lying on your back with both knees bent. Straighten

one leg by lifting it towards the ceiling, keeping the knee slightly bent. Support this leg by

clasping both hands behind the knee. Hold. Repeat for the other leg. You should feel the

stretch on the back thigh of the straight leg.

• For an alternative lower-back stretch, sit cross-legged on the floor then slowly lean forward,

keeping your back straight while reaching your arms out to the floor. Hold.

Fig no- 18 toe touching

32

SIT –UPS:-

Two common but potentially harmful variations of the sit-up include anchoring the feet (where

your training partner holds your feet) or keeping the legs straight along the floor.

The hands are held behind the head or neck, and the upper body lifted. These types of sit-ups strain

the lower back and tend to target the muscles of the hips and thighs rather than the abdomen.

Suggestions include:

Fig no-19 sit ups training

• Avoid this style of sit-up altogether.

• Perform abdominal curls instead. Lie on your back with your knees bent, feet flat on the floor

and arms folded across your chest or alongside your body. Breathe out and curl your ribcage

towards your pelvis.

Hollow rock:-

The starting position is lying on the back in a hollow. A hollow position for this purpose is one in

which the pelvis is turned under (i.e., tail tucked), legs are lifted slightly off the floor, lower back is

touching the ground, head and shoulders are lifted slightly off the floor, and arms are held by the

ears, off the ground.

From this position, rock smoothly back and forth, keeping the body tight, the hip angle constant (no

pinking of the hip), and the lower back rounded.

33

Any thumping in the motion shows that the hollow position has been compromised, which indicates

that the trainees abs are not strong enough to keep the pelvis turned under in this position. Continued

training will alleviate this deficiency.

Fig no-20 hallo rock moves

BURPEE:-

To do a burpee in its most basic form, start from standing, squat with your hands on the floor, and

jump your feet back to put you in a prone position with straight arms (as at the top of a push-up).

Then bring your legs forward into a squat again and return to standing. This basic version is also

sometimes called a squat thrust.

Fig no-21 procedure to perform the burpee

34

Several modifications can be made to the burpee to increase its demands: add a push-up in the prone

position, add a jump at the end as you return to standing, perform the burpee under a bar and jump up

to do a pull-up in each rep, etc. Be creative with burpees and see what variations you can come up

with.

JUMPING JACK :-

Most people have done jumping jacks in a PE class at some point. They are an excellent way to

warm up, and they can be included in a conditioning set either as a station where fatigued muscles

are allowed to recover while metabolic demands are kept high, or as a significant component of a

metabolic conditioning circuit. Jumping jacks should be practiced both with arms and legs in concert

(legs straddling while arms are swung upward) and in opposition (legs straddling while arms are

brought down).

Fig no - 22 showing the changing leg by sequence

HANDSTAND AND PRESS HANDSTAND:-

Handstand pushup benefits are many. Some might even call it one of the greatest exercises

ever invented.fig 23

1. Strengthens the triceps, shoulders and chest

2. Strengthens many stabilizer muscles

3. Requires coordination and balance

4. Can be an effective muscle builder

5. Provides the benefits of inversion

6. It’s an impressive skill few people can do

7. Can be handled very progressively

Handstand and press handstands are excellent exercises for developing strength

Fig no

ANTI- GRAVITY TREADMILL TRAINING

• In weightlessness at anti gravity

Then a normal thread mill which can

• Activates proprioceptors.

Fig no

35


Fig no-23 hand stand and press

GRAVITY TREADMILL TRAINING :-

In weightlessness at anti gravity treadmill, it makes running on treadmill more effective

mill which can be adapted to the zero gravity. 28

Fig no-24 Anti gravity thread mill


on treadmill more effective.

36

UNDER WATER STENGTH TRAINING:

• HydroWorx’s patented underwater treadmill is revolutionizing physical therapy, sports

medicine and conditioning. This proprietary feature comes standard in all of our therapy

pools. The powered underwater treadmills are integrated into the pool floor and feature a

polished stainless steel frame that is professionally welded for durability and safety. Our

endless rubberized treadmill belts offer excellent traction and may be utilized with bare feet

or shoes.50

Fig no-25.1 under water thread mill

• When a person runs on an underwater treadmill, his or her body undergoes greater exertion

due to the viscosity of the water. This leads to greater hip, leg and foot strength, as well as

improvements in core muscle groups throughout the body.

Fig no-25.2 An underwater treadmill also provides resistance for range of motion exercises and for

stretching and therapeutic exercises.

37

CARDIOVASCULAR FITNESS:-

• Cardiovascular training uses both aerobic exercises 12 and interval training and functions as

the foundation for your ability to climb for long periods of time.

• A variety of aerobic exercises work well for training, including climbing and descending

hills, stairs or stadium bleachers, skiing, running and cycling.

• Build your aerobic training over time, beginning with shorter sessions and increasing to

longer workouts.

• By the time your climb approaches you should feel comfortable with an aerobic exertion that

is similar to any day of your anticipated climb.33

Fig no:-26 aerobics exercises

38

ENDURANCE TRAINING:-

Endurance is a motor skill like strength and balance and can be developed with training. In short,

endurance training is a focus on continually increasing the intensity of your training and not

becoming complacent in your routine or your level of fitness20. This will build a more durable body

and allow you to climb strongly for an extended period of time as well as adapt to the unanticipated

physical challenges of the climb.51

Fig no-27 training under parabolic flight.

39

� HYPOXIC MANAGEMENT

IHT or Intermittent Hypoxic Training involves short intervals of breathing (4-6 minutes) of

hypoxic20 air interspersed with intervals (4-6 minutes) inhaling ambient air.

Improve breathing economy and the ability.

Fig no-28 under clinical test

INTERMITTENT HYPOXIC TRAINING

Intermittent Hypoxic Training system (IHT) enables athletes, injured athletes, and sedentary

individuals to enhance performance, increase fitness while injured, and pre-acclimatize to high

altitudes.

IHT involves short intermittent inhalations (3-5 minutes) of hypoxic air (10% O2, 20,000ft/6000m)

interspersed with inhalations of ambient air (2-5 minutes).

IN-FLIGHT PHASE

40

IN FLIGHT

when they are in space station ,all astronauts are required to exercise 2-5 hours per day six

days a week in orde to prevent muscle atrophy14 and bone mineral density and cardio vascular

losses.

• In weightlessness at zero gravity it moves running ona treadmil more effective

• The treadmil features a rotating belt with or without resistance44

Fig no- 29, T2 treadmill (Normal thread mill without whistles or fancy bells)

• Like treadmil the stationary bike appears to be a no- trils version of one that might befound in

a recreation gym, the only component it lacks and hardles a seat the later of which isn't

needed in space as long as the individual feet's anchored to the bike53. To keep them in place,

they were cycling shoes that clips to the bike pedals.[fig no-30]

Fig no - 30 cycle Ergo meter

41

ADVANCED RESISTIVE EXCERCISE DEVICE (ARED):-

• Advanced resistive exercise device which resembles the proto type of a bow flex or a

similarly at home gym with a bench weight resistance levels provided by two vacuum

cylinder.41

• The high load is needed because we have to compensate for no body weight in zero gravity.

• Although daily strength training is non-negotiate in space, astronauts are able to choose their

cardiac workout.53

Fig no- 31weights lifting with resistence

Fig no-32 Advance resistive exercise device with combination ofwholebody vibration

specially designed for astronauts in space.

42

ELECTRICAL STIMULATION TO MUSCLES:-

Electrical muscle stimulation37 at zero gravity to prevent the muscle atrophy and

Demineralization of bone.

Fig no-33 electrical stimulation for the quadriceps and Doris flexors.

POST-FLIGHT PHASE

43

POST FLIGHT PHASE

Astronauts returning from challenging long-duration missions face one more challenge when they

get back to Earth - standing up and walking.

Upon returning to normal gravity, astronauts often suffer from balance problems that lead to

dizziness and difficulty standing, walking and turning corners.

Tilt Table:-

Astronauts after the space travel , they may get dizzy when they stand up 39(orthostatic

hypotension—see Dizziness or Light-Headedness When Standing Up). A tilt table may be used to

help astronauts. This procedure may retrain blood vessels to narrow (constrict) and widen (dilate)

appropriately in response to changes in posture43. People lie face up on a padded table with a

footboard and are held in place with a safety belt. The table is tilted very slowly, determined by how

well people tolerate it, until they are nearly upright. The slow change in posture enables the blood

vessels to regain the ability to constrict. How long the upright position is maintained depends on how

well people tolerate it, but it should not exceed 45 minutes.The tilt-table procedure is done once or

twice a day. Its effectiveness varies depending on the type and degree of disability.13

Fig no-34 tilt table

44

Adaptability Training System:-

National Space Biomedical Research Institute (NSBRI) scientists51 in a project to develop techniques

to help astronauts adapt quickly to a new gravity environment and to overcome balance disturbances.

This concept will also have benefits for non-astronaut populations such as the elderly or people with

balance disorders.

They use a system that consists of a treadmill mounted on a base that can be actively moved in

different directions to simulate balance disturbances called an Adaptability Training System.

The treadmill has a projection screen in front of it that shows an image of a room or hallway that

moves as the user walks. Disturbances are simulated by tilting the treadmill in one direction as the

image is tilted in another.

Fig no-35 treadmill with front facing projection screen.

"At first, people find it difficult to walk on the treadmill since its movement and images are out of

sync. But over time, they learn to walk on it efficiently. We call this concept 'learning to learn,'"

In order to perform everyday activities, the brain interprets information provided by the body's

sensory systems: the eyes, the inner ear balance43 organs, the skin and muscle movement receptors.

The problems for astronauts occur during the transition period in which the brain is trying to adapt to

a new gravity environment - either returning to Earth or in the future adjusting to lunar or Martian

gravity.

45

"In space, information from the sensory systems is different, particularly when you take away

gravity. The brain reinterprets that information, makes adjustments and allows you to do the

activities you need to do in space,"

The down side to that is when you return to Earth, the sensory systems are not used to a normal

gravity environment."

An astronaut has been in space on a typical two-week shuttle mission, it may take several days to

recover. For six-month stays aboard the ISS, it could take at least several weeks to return to normal.

Adaptability Training System that induces balance disturbances through support surface movement

and changes in visual information. The system consists of a treadmill mounted on a base that can be

actively moved in different directions paired with a virtual scene projected in front of the subject

providing a variety of balance challenges as the user walks.

To Build Up Atrophied Muscles-

� Progressive exercise program.

Step 1

Begin with isometric exercises to improve circulation and increase strength in the atrophied muscle.

Isometric exercises involve simply contracting the muscle for a few seconds at a time. For example,

contracting your quadriceps with your leg straight would begin to improve quad strength just as

contracting your biceps while your arm remains in a relaxed, bent position would begin to rebuild

atrophied arm muscle. Gradually increase the contraction time and repetitions as your strength

improves.fig no- 36

Fig no-36 isometric exercise for quadriceps

46

Step 2

Progress to range of motion exercises that involve joint movement but do not use outside resistance.

For atrophied quadriceps muscles, for example, sit in a chair and simply straighten your leg to

engage the atrophied muscles. These types of exercises can be performed several times throughout

the day to keep your blood flowing and muscles limber.

Fig no-37 range of motion exercise for quadriceps

Step 3

Use light resistance such as small hand weights or resistance tubing to begin rebuilding your lost

muscle mass. Resistance needs to be added gradually, adding too much too quickly can result in

injury. A leg extension with a resistance band is an example exercise for atrophied quadriceps

muscles.

Fig no-38 light resistence exercises through theraband

47

Step 4

Add more resistance, moderately, in the form of heavier free weights or weight machines. Include

more functional movements into your exercise program. Squats and step-ups will help to continue to

build up atrophied quadriceps muscles while overhead presses will strengthen atrophied muscles in

the upper body.

Fig no-39 weight training

48

CONCLUSION

Space science is a specialized field, astronauts need a special preparation to overcome the varied

changes in the gravitational pull at various levels of ascent and duration of the stay in specified

situations in the space stations.

1. Bone demineralization

2. Muscle atrophy

3. Circulatory problems

4. Respiratory complications

A specialized physiotherapy rehabilitation team needed to train certain conditions like strength

training, muscle, balance, coordination and cardio respiratory conditions etc.

The whole topic deals with the physiotherapeutic measures to shorten the microgravity effects on

astronauts. Physiotherapy helps to improve the muscle strength, endurance, co-ordination and

balance. To shorten the complications of micro gravity on astronaut through the physiotherapy

intervention. Physical Therapy focuses on to restore overall function to get them moving faster and

feeling better. Physiotherapist will provide you with a customized recovery program that will restore

you to your maximal potential, and get you moving faster. The ultimate goal is to enable our patients

to manage their own physical well-being independently.

BIBILOGRAPHY

49

BIBILOGRAPHY

This bibliography is intended to be instructive but is not exhaustive. All these documents may

be consulted (and, in the case of videos, reproduced) at the Canadian Space Resource

Centers.

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50

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