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Mikä on Käypä hoito -suositus?
Suomalaisen Lääkäriseuran Duodecimin ja Käypä hoito -johtoryhmän asettama työryhmä
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Liikunta

Käypä hoito
13.1.2016
Suomalaisen Lääkäriseuran Duodecimin ja Käypä hoito -johtoryhmän asettama työryhmä

Opi ja ota käyttöön

Koosteet

Potilaalle

Keskeinen sanoma

  • Säännöllisen liikunnan tulee kuulua pitkäaikaissairauksien, kuten valtimotautien, lihavuuden, diabeteksen, rappeuttavien tuki- ja liikuntaelinsairauksien, ahtauttavien keuhkosairauksien, muistisairauksien, depression ja useiden syöpäsairauksien, ehkäisyyn, hoitoon ja kuntoutukseen, tarvittaessa yhdistettynä muihin elintapamuutoksiin ja hoitoihin.
  • Vähäinen fyysinen aktiivisuus ja huono fyysinen kunto, erityisesti kardiorespiratorinen kunto, suurentavat ennenaikaisen kuoleman riskiä.
  • Runsas istuminen on terveydelle haitallista.
  • Oikein toteutetulla liikunnalla on vähän terveyshaittoja.
  • Aikuisten liikuntasuositukset:
    • kohtuukuormitteista kestävyysliikuntaa, kuten reipasta kävelyä, ainakin 150 minuuttia viikossa tai raskasta liikuntaa, kuten juoksua, 75 minuuttia viikossa sekä
    • lihasvoimaa ja -kestävyyttä ylläpitävää tai lisäävää liikuntaa vähintään kahtena päivänä viikossa ja nivelten liikkuvuutta ja tasapainoa ylläpitävää liikuntaa.
  • Lääkärin ja muiden terveydenhuollon ammattilaisten tehtävä on kysyä liikuntatottumuksista ja liikkumisesta, kirjata tiedot ja kannustaa liikkumaan.
  • Lääkäri arvioi liikunnan vasta-aiheet ja sairauksiin liittyvät liikkumisrajoitteet.
  • Ennen liikunnan aloittamista ja harjoittelun aikana on tärkeää havaita tapaukset, joissa potilailla on uusia rasitukseen liittyviä oireita, ja ohjata heidät tarvittaessa jatkoarvioon. Ks. interaktiivinen kaavio «http://www.terveysportti.fi/xmedia/hoi/hoi50075/liikunnan_aloittaminen.html»1.
  • Terveydenhuollon ja liikunnan ammattilaiset antavat yhteistyössä yksilölliset liikuntaohjeet ja seuraavat liikuntaohjelmien toteutumista.
  • Katso videoita terapeuttisen harjoittelun käytöstä tuki- ja liikuntaelimistön vaivojen hoidossa «http://www.kaypahoito.fi/web/kh/liikuntaharjoitteluvideot »6.

Kohderyhmä

  • Suositus on tarkoitettu kaikille terveydenhuollon ja liikunnan ammattilaisille.

Tavoitteet

Aiheen rajaus

Määritelmät

  • Ks. lisätietoa aiheesta «Liikuntaan liittyviä määritelmiä»4:
    • fyysinen aktiivisuus (physical activity)
    • liikunta (physical exercise)
    • fyysinen kunto (physical fitness)
    • liikuntaharjoittelu
    • kestävyysliikunta (aerobinen liikunta)
    • lihasvoimaharjoittelu
    • arkiliikunta ("hyötyliikunta")
    • kuntoliikunta
    • terapeuttinen harjoittelu
    • fyysinen inaktiivisuus (physical inactivity)
    • istuminen (paikallaanolo) (sedentary behaviour)

Liikunnan kuormittavuus ja rasittavuus

Taulukko 1. Kestävyysliikunnan kuormittavuuden luokittelu. Luvut pätevät keski-ikäisiin henkilöihin, joiden maksimaalinen hapenkulutus (VO 2max, "aerobinen kunto") on hyvä (≥ 12 MET eli vähintään 12 kertaa lepoaineenvaihdunta) tai huono (< 5 MET). Taulukko on täydellisenä lähteessä «Howley ET. Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc 2001;33:S364-9; discussion S419-20 »8.
1 luotettavasti mitattu maksimaalinen syke (ei iänmukainen arvio)
2 Borgin asteikko (6–20) «Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-81 »4
3 osuus maksimaalisesta hapenkulutuksesta, VO2max
Kuormittavuus-luokka % maksimaa- lisesta sykkeestä1 Koettu kuormit- tavuus (Borg)2 Hyvä suorituskyky Huono suorituskyky
MET % VO2max3 MET % VO2max3
(Hyvin) kevyt ≤ 63 ≤ 11 ≤ 5,3 ≤ 44 ≤ 2,5 ≤ 51
Kohtalainen 64–76 12–13 5,4–7,5 45–62 2,6–3,3 52–67
Raskas 77–93 14–16 7,6–10,2 63–85 3,4–4,3 68–87
Hyvin raskas ≥ 94 ≥ 17 ≥ 10,3 ≥ 86 ≥ 4,4 ≥ 88
Taulukko 2. Koetun kuormittavuuden eli Borgin asteikko «Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-81 »4.
Miltä rasitus tuntuu nyt?
6 ei lainkaan rasitusta
7 erittäin kevyt
8
9 hyvin kevyt
10
11 kevyt
12
13 hieman rasittava
14
15 rasittava
16
17 hyvin rasittava
18
19 erittäin rasittava
20 äärimmäisen rasittava

Yleiset liikuntasuositukset

Liikunnan aiheiden ja liikuntakelpoisuuden arviointi

Liikuntakelpoisuus

Äkillisen sydäntapahtuman vaara liikunnan aikana

Kohonnut verenpaine

Liikunta kohonneen verenpaineen hoidossa

Dyslipidemiat

Lihavuus

Liikunta lihavuuden hoidossa

Tyypin 2 diabetes

Liikunta tyypin 2 diabeteksen ehkäisyssä

Liikunta tyypin 2 diabeteksen hoidossa

Sepelvaltimotauti

Liikunta sepelvaltimotaudin ehkäisyssä

Liikunta sepelvaltimotaudin hoidossa ja kuntoutuksessa

Aivoinfarkti ja aivoverenvuoto

Liikunta aivoinfarktin ja aivoverenvuodon ehkäisyssä

Liikunta aivohalvauksen hoidossa ja kuntoutuksessa

Ääreisvaltimotauti

Liikunta ääreisvaltimotaudin ehkäisyssä

Liikunta ääreisvaltimotaudin hoidossa ja kuntoutuksessa

Sydämen vajaatoiminta

Liikunta sydämen vajaatoiminnan hoidossa ja kuntoutuksessa

Sydämen rytmihäiriöt

Eteisvärinä

Muut rytmihäiriöt

Ahtauttavat keuhkosairaudet

  • Terveillä keuhkojen toimintakapasiteetti on huomattavan suuri ja maksimaalisessa rasituksessakin ventilaatioon jää reserviä.
  • Keuhkojen toiminnan heikkenemisen tai vaihtelevan heikentymän vaiheet astmassa:
    • Lievä heikkeneminen ei vielä välttämättä vaikuta suorituskykyyn, joten liikuntaa voi harrastaa terveiden tavoin.
    • Kohtalaisen vaikea heikkeneminen aiheuttaa hengenahdistusoireita kevyessä tai kohtuukuormitteisessa liikunnassa, joten se rajoittaa tai heikentää suorituskykyä.
    • Vaikea heikkeneminen aiheuttaa hengenahdistusoireita jo arkiaskareissa ja rajoittaa selvästi liikuntaa.
  • Potilaan on tärkeää liikkua säännöllisesti niin raskaasti, että saavutetaan mahdollisimman suuri hengästymisen aiheuttava rasitustaso, jotteivät oireet rajoittaisi arkipäivän liikkumista.
  • Keuhkojen toimintakykymittauksilla voidaan arvioida kapasiteetin pienentymisen merkitystä ja tarkentaa liikuntaa rajoittavat tekijät. Ks. lisätietoa aiheesta «Keuhkojen toimintakokeet keuhkopotilaalla»17.

Keuhkoahtaumatauti

Astma

Hengitystieinfektiot

Osteoporoosi

Taulukko 3. Yleinen liikuntasuositus ja tarkennettuja liikuntaohjeita ikääntyneille terveydentilan ja liikuntatavoitteiden mukaan ( «Savela S, Komulainen P, Sipilä S, Strandberg T. Ikääntyneiden liikunta – minkälaista ja mihin tarkoitukseen?. Duodecim 2015;131:1719-25 »119, mukailtu).
Toimintakyky
Kognitio
Depressio-oireet
Gerastenia
(hauraus-raihnausoire-yhtymä)
Monipuolinen liikuntaharjoittelu, johon sisältyy
  • progressiivista lihasvoimaharjoittelua 40–80 % 1 RM, asteittain vaikeutuvaa tasapainoharjoittelua ja toiminnallista harjoittelua (kävely, askelharjoituksia, pelejä ym.) sekä
  • kestävyysliikuntaa 3 x/viikko, yhteensä 45–60 minuuttia/kerta
Sarkopenia
(lihaskato)
Lihasvoimaharjoittelu:
  • 2–3 x/viikko,
  • 60–80 % 1 RM:stä suurille lihasryhmille
  • 8–12 toistoa/lihasryhmä
Kaatumisten ja murtumien ehkäisy
  • Progressiivinen lihasvoimaharjoittelu 60–80 % 1 RM, 10–15 toistoa, 2–3 x/viikko sekä
  • tasapaino- ja liikkumiskykyharjoittelua vähintään 2 x/viikko.
  • Lisäksi reipasta kestävyysliikuntaa vähintään 2,5 tuntia viikossa.
Luuston vahvistaminen
  • Progressiivinen lihasvoimaharjoittelu 70–80 % 1 RM, 2–3 sarjaa, 8–12 toistoa/sarja, 2–3 x/viikko sekä
  • tasapaino- ja ketteryysharjoittelua
  • Lisäksi reipasta kestävyysliikuntaa päivittäin ≥ 30 minuuttia/kerta
Osteopenia Kuten luuston vahvistamisliikunta, mutta progressiivinen lihasvoimaharjoittelu 50 % 1 RM
Osteoporoosi
  • Selän lihasten vahvistaminen ja ryhdin parantaminen pienellä tai kohtalaisella teholla sekä
  • tasapainoa kehittävää harjoittelua 2–3 x/viikko
  • Lisäksi reipasta kestävyysliikuntaa päivittäin ≥ 30 minuuttia/kerta
Asteikolla 0–10 (0 = istuminen ja 10 = maksimikuormitus) kohtuullinen kuormitus vastaa lukemia 5–6 ja raskas kuormitus lukemia 7–8. 1 RM (repetition maximum, yhden toiston maksimi) on suoritus, jonka henkilö pystyy tekemään yhden kerran.

Polvi- ja lonkkanivelrikko

Liikunta nivelrikon ehkäisyssä

Liikunta nivelrikon hoidossa

Epäspesifinen alaselkäkipu

Liikunta epäspesifisen alaselkäkivun ehkäisyssä

Liikunta epäspesifisen alaselkäkivun hoidossa

Fibromyalgia

Liikunta fibromyalgian ehkäisyssä

Liikunta fibromyalgian hoidossa

Nivelreuma

Liikunta nivelreuman hoidossa

Depressio

Liikunta depression hoidossa

Syöpä

Kolorektaalisyöpä

Liikunta kolorektaalisyövän hoidossa

Rintasyöpä

Liikunta rintasyövän ehkäisyssä

Liikunta rintasyövän hoidossa

Eturauhassyöpä

Keuhkosyöpä

Raskaus

Taulukko 4. Raskaudenaikaisen liikunnan ehdottomat ja suhteelliset vasta-aiheet «ACOG Committee Obstetric Practice. ACOG Committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Obstet Gynecol 2002;99:171-3 »239, «Royal College of Obstetricians and Gynaecologists 2006. Exercise in pregnancy, statement No 4. »240.
Ehdottomat Suhteelliset
Ennenaikaisen synnytyksen uhka (hoitoa vaativa kohdun supistelu) Uhkaava keskenmeno ensimmäisen raskauskolmanneksen aikana
Selvittämätön verenvuoto emättimestä Monisikiöinen raskaus
Äidin yleissairaus, joka vaatii liikunnan rajoituksia Pre-eklampsia
Etinen istukka loppuraskaudessa
Ennenaikainen lapsivedenmeno
Todettu kohdunkaulan heikkous
Sikiön kasvun hidastuma
Istukan ennenaikainen irtoaminen

Raskausdiabetes

Liikunta raskausdiabeteksen ehkäisyssä

Liikunta raskausdiabeteksen hoidossa

Ikääntyneet

Ikääntyneiden liikuntasuositukset

Liikunta fyysisen toimintakyvyn parantamisessa ja säilyttämisessä

Gerastenia

Liikunta kaatumisten ehkäisyssä

Kognitiiviset toiminnot

Liikunta ja kognitiiviset toiminnot

Liikunnan turvallisuus

Suomalaisen Lääkäriseuran Duodecimin ja Käypä hoito -johtoryhmän asettama työryhmä

Liikunta-suosituksen historiatiedot «Liikunta, Käypä hoito -suosituksen historiatiedot»36

Puheenjohtaja:

Rainer Rauramaa, LKT, LitM, liikuntalääketieteen erikoislääkäri, liikuntalääketieteen professori, johtajaylilääkäri; Terveysliikunnan ja ravinnon tutkimussäätiö, Kuopion liikuntalääketieteen tutkimuslaitos

Kokoava kirjoittaja:

Katriina Kukkonen-Harjula, LKT, dosentti, liikuntalääketieteen ja terveydenhuollon erikoislääkäri; vanhempi tutkija, lääkäritutkija UKK-instituutti ja Etelä-Karjalan sosiaali- ja terveyspiirin kuntoutuksen vastuualue, (Käypä hoito -toimittaja)

Jäsenet:

Jari Arokoski, LT, dosentti, fysiatrian erikoislääkäri, kliininen opettaja; Itä-Suomen yliopiston lääketieteen laitoksen kliininen yksikkö, kirurgia (ml. fysiatria), KYS:n fysiatrian klinikka

Hannele Hohtari, LKT, naistentautien ja synnytysten erikoislääkäri, osastonlääkäri; HUS:n Jorvin sairaala

Eeva Ketola, LT, yleislääketieteen erikoislääkäri, eMBA, johtajalääkäri; Järvenpään sosiaali- ja terveyskeskus

Jyrki Kettunen, TtT,dosentti, ft, vanhempi tutkija; Yrkeshögskolan Arcada Ab, Helsinki

Pirjo Komulainen, FT, ft, tutkija; Terveysliikunnan ja ravinnon tutkimussäätiö, Kuopion liikuntalääketieteen tutkimuslaitos

Urho Kujala, LT, liikuntalääketieteen erikoislääkäri, liikuntalääketieteen professori; Jyväskylän yliopiston terveystieteiden laitos

Jari Laukkanen, LT, dosentti, kardiologian erikoislääkäri, osastonylilääkäri; Keski-Suomen keskussairaala, sisätaudit

Liisa Pylkkänen, LT, dosentti, syöpätautien ja sädehoidon erikoislääkäri, ylilääkäri; Suomen Syöpäyhdistys

Salla Savela, LT, geriatrian erikoislääkäri, osastonlääkäri; Oulun kaupunginsairaala

Kai Savonen, LT, LitM, TtM, dosentti, liikuntalääketieteen ja terveydenhuollon erikoislääkäri, erikoislääkäri; Terveysliikunnan ja ravinnon tutkimussäätiö, Kuopion liikuntalääketieteen tutkimuslaitos

Heikki Tikkanen, LT, kliinisen fysiologian ja liikuntalääketieteen erikoislääkäri, liikuntafysiologian professori; Itä-Suomen yliopiston terveystieteiden tiedekunta, lääketieteen laitos

Asiantuntijat:

Arto Hautala, FT, dosentti, ft, yliopistotutkija; Oulun yliopiston tieto- ja sähkötekniikan tiedekunta

Timo Lakka, LT, sisätautien erikoislääkäri, lääketieteellisen fysiologian professori; Itä-Suomen yliopiston terveystieteiden tiedekunta, lääketieteen laitos

Hilkka Virtapohja, TtM, ft, OMT; Hintsa Performance

Sidonnaisuudet

Jari Arokoski: Ei sidonnaisuuksia

Hanne Hohtari: Ei sidonnaisuuksia

Eeva Ketola: Ei sidonnaisuuksia

Jyrki Kettunen: Ei sidonnaisuuksia

Pirjo Komulainen: Palkkio artikkelin käsikirjoituksesta (Liikuntatieteellinen Seura ry), Luentopalkkio (UKK-Instituutti; Huoltoliitto/ Siilinjärven kuntoutumiskeskus, Kunnonpaikka)

Urho Kujala: Ei sidonnaisuuksia

Katriina Kukkonen-Harjula: Luentopalkkio (MSD Finland)

Jari Laukkanen: Apuraha (Sydäntutkimussäätiö, Suomen lääketieteen säätiö, Jane ja Aatos Erkon säätiö)

Liisa Pylkkänen: Ei sidonnaisuuksia

Rainer Rauramaa: Lisenssitulo tai tekijänpalkkio (Kustannus Oy Duodecim)

Salla Savela: Apuraha (Duodecim, Suomen Geriatrit RY), Asiantuntijapalkkio (Liikunta & Tiede Lehti), Luentopalkkio (Duodecin)

Kai Savonen: Luentopalkkio (Orion, Spira), Koulutus/kongressikuluja yrityksen tuella (GSK, MSD, Synthes)

Heikki Tikkanen: Apuraha (Tekes, Opetus- ja Kulttuuriministeriö), Johtokunnan tms jäsenyys (Lääkäriliitto), Luentopalkkio (Fysi Ry, Hengitysliitto Heli), Lisenssitulo tai tekijänpalkkio (Kustannus Duodecim Oy)

Vastuun rajaus

Käypä hoito -suositukset ovat parhaiden asiantuntijoiden laatimia yhteenvetoja yksittäisten sairauksien diagnostiikan ja hoidon vaikuttavuudesta. Ne eivät korvaa lääkärin tai muun terveydenhuollon ammattilaisen omaa arviota yksittäisen potilaan parhaasta mahdollisesta diagnostiikasta ja hoidosta hoitopäätöksiä tehtäessä.

Tiedonhakukäytäntö

Systemaattinen kirjallisuushaku on hoitosuosituksen perusta. Lue lisää artikkelista khk00007

Kirjallisuutta

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