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Physiology of Exercise –
        PART II
Training and the Respiratory
          System
Processes of Pulmonary Functions
Pulmonary ventilation – movement
of air into and out of the lungs.
External Ventilation – gas exchange
between the blood and lungs
Transport of gases – between the
lungs and cells
Internal Ventilation – between the
blood and body cells
Measuring Pulmonary Function
Used during the training of athletes
 and in patients with pulmonary
 disease:

 Total Lung Capacity – volume of air
 in the lungs after a maximum
 inhalation.
Measuring Pulmonary Function
 Vital Capacity – maximum volume of air
that can be exhaled after a maximum
inhalation

Tidal volume – volume of air that is taken
in or out with each inhalation or exhalation

Ventilation Rate – number of inhalations or
exhalations per minute
Ventilation Rate
Breathing Rate
– During exercise the rate of ACR
  increases.
– Increases the amount of CO2 in the
  blood
– Reduces the pH of the blood
– Reduction is detected by cells in the
  walls of the arteries (chemosensors)
Ventilation Rate
Increased ventilation rate removes
excess CO2 from the body.
– Increases the rate of O2 uptake
– Allows more ACR to take place
– pH level of blood increases
When pH increases --- ventilation
rate decreases
Ventilation RATE
IT IS THE RISING
CONCENTRATION OF
CO2 IN THE BLOOD AND
NOT THE DECLINE OF
OXYGEN THAT
TRIGGERS THE NEED
FOR BREATHING.
Exercise and Ventilation
Results in increases in
ventilation rate and tidal volume.
Blood to lungs >>> higher CO2
concentration
High rate of gas exchange
– Large gradient
High rate Acr
ANcr >>> low supply of oxygen
>>> lower duration of exercise.
Effects of Training
Be able to discuss the effects of
Training on:
– Increase – ventilation rate during
  exercise
– Decrease – resting ventilation rate
– Larger – vital capacity (muscle)
Training
     &
Circulatory
  System
Measuring Heart Function:
            Heart Rate
Heart Rate – number of contractions
 per minute

Major Factors that affect Heart Rate:
  – SEX – Male or Female
  – Your overall health
  – Physical Activity
  – Emotion
  – Posture
Measuring Heart Function
Heart Rate – number of contractions
per minute
Stroke volume – volume of blood
pumped with each contraction.
Cardiac output – volume of blood
pumped out by the heart each
minute.
Venous Return – amount of blood
returning to heart per minute
Exercise and the Heart
Can Cause:
 Increase in thickness of heart muscle
 Volume of ventricles
  – LARGER STROKE VOLUME AT REST AND
    DURING EXERCISE
 Reduce cardiac output at rest – 50b/
 min.
 Greater Stroke Volume = greater
 cardiac output as heart is trained
Cardiac Output
Exercise and the Heart

Controlling Cardiac Output:
 Receptor cells – monitor blood pH
    – Measure of CO2
   Brain: Medulla – alters rate
   Pacemaker – receives impulses to
    alter rate

Reverses when CO2 levels lower.
Effects of Exercise on Circulatory
              System
Venous Return

 Increases during exercise
 Contracting Muscles exert
 pressure on veins >>> helps to
 return blood
 Allows cardiac output to increase
Effects of Exercise on Circulatory
              System
DISTRIBUTION OF BLOOD:
More during exercise:
   – Heart wall
   – Muscles
   – Skin
Less during exercise:
   – Kidneys
   – Stomach
   – Intestines
Does not change:
   – Brain
More Effects of Training and the
      Circulatory System
Increases capillary networks in
skeletal muscles
Increase in diameter of blood vessels
Decrease in blood pressure
Increase in blood volume
Decrease in recovery time for
breathing and heart rate
Erythropoietin (EPO)
 Natural hormone
 produced by kidney to
 maintain a health
 percentage of blood
 cells
 Increases amount of
 RBC in ratio volume of
 blood ---

Packed Cell Volume(PCV)
  More RBC = more O2 to
  cells
Erythropoietin (EPO)
Benefits:             Risks:
                        Increased blood
  – Treatment for       thickness
    anemia              Increased chance of
                        blood clotting
  – Replacement of    Can result in stroke
    blood due to
    injury              Lower blood plasma
                        level
                        Body may produce
                        antibodies against EPO
Exercise and Cell Respiration
Effects of Increasing Intensity of
             Exercise
General: more exercise=more O2

VO2 – volume of O2 that is absorbed
by the body/minute that is supplied
to body tissue

VO2max – maximum rate at which O2
can be absorbed and supplied to
tissue
Effects of Increasing Intensity of
             Exercise
AnCR – in intensity of exercise can
rise above VO2max.


As intensity of Exercise increases the
fat burned (ACR) decreases
– AnCR can only use Carbohydrates as a
  respiration substrate
Muscle Fatigue

Muscle fibers contain a store of
carbohydrates --- GLYCOGEN
Glycogen is converted to glucose
– Intense or long duration exercise
When glycogen is used up…
muscle fatigue takes place
Accumulation of lactate. (AnCR)
Myoglobin
Myoglobin – oxymyo or deoxymyo-
– Globular protein
– Heme – prosthetic group
– Red pigment
– Contained in muscle
– Intracellular O2 storage
O2 is released when level in muscle is low
Allows for longer ACR – longer exercise
periods.
Other Source of ATP
Creatine Phosphate
 – Used by muscles cells only!
 – Created by excess ATP in pancreas, liver,
   kidneys
 – Direct phosphorylation of ATP from store
 – Duration: exercise up to 10 seconds
Creatine Phosphate
– Dietary supplement
    Absorbed by intestines
    Can help athletes who have naturally low levels
    Correlation: can improve maximum intensity over
    short time
Can cause water retention –
    Weight gain, HBP, cramps – dehydration
      – Inhibit performance.
Muscles,ATP, and Intensity of
            Exercise
Low Intensity Exercise
  If O2 is available, ACR can produces ATP
  continuously
  – Walking, light jogging
High Intensity Exercise
  If O2 is used faster, the body switches to
  AnCR.
  Lactate is produced – toxic
  – Produces energy for 2 minutes maximum
AnCR and Oxygen “Debt”
If lactate is present = oxygen debt
Lactate produced is passed to the
liver (accessory organ)
If large amounts of lactate are
present, large amounts of O2 are
needed to “repay the debt.”
This is why it takes TIME for the
ventilation rate to return to “normal”
after high intensity exercise.
Fitness
  AND
Training
Fitness
The physical condition
of the body that
allows it to perform
exercise of a
particular type
Training
Training = Exercises that are done to
change the physical conditioning of
the body.
Depends on:
– Frequency – how often a training session
  occurs.
– Duration – length of session
– Intensity – vigorous
Speed and Stamina
Rate at which a movement is
performed.
– Sprinting, baseball, football, swimming,
  skiing.
Ability to continue an exercise
for long periods of time
– Maximum duration.
– Rowing, long distance running
Fast Muscles
Fast muscle fibers
TWITCH
– These are the muscle fibers that are
  responsible for short, explosive and
  powerful movements.
– Fast twitch fibers are the ones that
  grow!
– Release large amounts of energy for
  short periods of time
Slow Muscles –
TONIC
– These are the muscle fibers that are
  responsible for endurance.
– They do not really respond to
  resistance training with any type of
  growth or hypertrophy.
– Release energy for longer time periods.
Fast vs. Slow
     .                Fast                    Slow
               Fast Oxidative/Glycolytic     Slow Oxidative


  Blood        Moderate to                  Very good
  supply          low
Mitochondria   Little present              Much present


 Glycogen      Little present              Much present
Myoglobin      Little present              Much present
    Cell         Anaerobic                   Aerobic
Respiration
 Stamina               Low                     High
 Strength             High                      Low
Fast vs. Slow: Types
Fast –
– extensive use of arms, hands
– sprinting, power lifting, body building


Slow –
– Use of large muscles: legs, thigh, hip,
  lower back, neck,
– posture, swimmers, LD runners, cyclists
Physiology of the
     “Warm-up and Cool Down”
Warm                            Cool
 Gentle before                    Dispense lactic acid
 Vigorous                         Allows Cardiovascular
      Heats body -distributes     system to adjust
      Raises heart rate
                                  Breathing rate returns
 Warm muscles more                to normal
 flexible
      Less likely to tear
 Warm joints more
 mobile
       less strain
Drug Use in Sports
Performing Enhancing Drugs

  Anabolic Steroid
Ethics:
  – Long term health
          Smaller testes, low sperm count,
          abnormal menstrual cycles, liver
          diseases, aggression, cancers

  – Unfair Advantage?

  – Criminal Profit?
Physiology of Exercise
       Injuries
Sprains and Strains
Sprain: The stretching and/or tearing
of ligaments.
Strain – stretching and/or tearing of
tendons or muscles.
Jacqueline Crews and her foot!
Dislocations
Abnormal movement of a joint.
Bones move out of alignment
If the dislocation is partial, it's called
subluxation. The joint is loose and
may slide partially out of place.
Shoulder
Other Dislocations
Other Dislocations
Separations
A separated shoulder: collarbone
(clavicle) and shoulder blade
(scapula) meet.
ligaments are torn.
Outer end of the collarbone slips out
of place.
Shoulder Separation
Shoulder Separation
Disc Damage
Abnormal movements or heavy loads
cause the soft center of a disc to
“bulge” out through a tear in the wall
of the disc
Herniated Disc
Herniated Disc
Arthroscopy
A surgical procedure where a doctor
uses a camera to view and repair a
joint
Treatment of tissue injury :
            R.I.C.E.
Swelling              Rest
– Excess buildup of   Ice –
  fluid
                          reduce blood flow-
Causes                    heat
– Tears in blood          Reduce swelling
  vessels                 Reduce pain

– Infection           Compression
– Inflammation            Reduces swelling
                      Elevation
                          Removes excess
                          fluid

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Physiology of exercise 2009

  • 2. Training and the Respiratory System
  • 3. Processes of Pulmonary Functions Pulmonary ventilation – movement of air into and out of the lungs. External Ventilation – gas exchange between the blood and lungs Transport of gases – between the lungs and cells Internal Ventilation – between the blood and body cells
  • 4. Measuring Pulmonary Function Used during the training of athletes and in patients with pulmonary disease: Total Lung Capacity – volume of air in the lungs after a maximum inhalation.
  • 5. Measuring Pulmonary Function Vital Capacity – maximum volume of air that can be exhaled after a maximum inhalation Tidal volume – volume of air that is taken in or out with each inhalation or exhalation Ventilation Rate – number of inhalations or exhalations per minute
  • 6. Ventilation Rate Breathing Rate – During exercise the rate of ACR increases. – Increases the amount of CO2 in the blood – Reduces the pH of the blood – Reduction is detected by cells in the walls of the arteries (chemosensors)
  • 7. Ventilation Rate Increased ventilation rate removes excess CO2 from the body. – Increases the rate of O2 uptake – Allows more ACR to take place – pH level of blood increases When pH increases --- ventilation rate decreases
  • 8. Ventilation RATE IT IS THE RISING CONCENTRATION OF CO2 IN THE BLOOD AND NOT THE DECLINE OF OXYGEN THAT TRIGGERS THE NEED FOR BREATHING.
  • 9. Exercise and Ventilation Results in increases in ventilation rate and tidal volume. Blood to lungs >>> higher CO2 concentration High rate of gas exchange – Large gradient High rate Acr ANcr >>> low supply of oxygen >>> lower duration of exercise.
  • 10. Effects of Training Be able to discuss the effects of Training on: – Increase – ventilation rate during exercise – Decrease – resting ventilation rate – Larger – vital capacity (muscle)
  • 11.
  • 12. Training & Circulatory System
  • 13. Measuring Heart Function: Heart Rate Heart Rate – number of contractions per minute Major Factors that affect Heart Rate: – SEX – Male or Female – Your overall health – Physical Activity – Emotion – Posture
  • 14. Measuring Heart Function Heart Rate – number of contractions per minute Stroke volume – volume of blood pumped with each contraction. Cardiac output – volume of blood pumped out by the heart each minute. Venous Return – amount of blood returning to heart per minute
  • 15. Exercise and the Heart Can Cause: Increase in thickness of heart muscle Volume of ventricles – LARGER STROKE VOLUME AT REST AND DURING EXERCISE Reduce cardiac output at rest – 50b/ min. Greater Stroke Volume = greater cardiac output as heart is trained
  • 17. Exercise and the Heart Controlling Cardiac Output:  Receptor cells – monitor blood pH – Measure of CO2  Brain: Medulla – alters rate  Pacemaker – receives impulses to alter rate Reverses when CO2 levels lower.
  • 18. Effects of Exercise on Circulatory System Venous Return Increases during exercise Contracting Muscles exert pressure on veins >>> helps to return blood Allows cardiac output to increase
  • 19. Effects of Exercise on Circulatory System DISTRIBUTION OF BLOOD: More during exercise: – Heart wall – Muscles – Skin Less during exercise: – Kidneys – Stomach – Intestines Does not change: – Brain
  • 20. More Effects of Training and the Circulatory System Increases capillary networks in skeletal muscles Increase in diameter of blood vessels Decrease in blood pressure Increase in blood volume Decrease in recovery time for breathing and heart rate
  • 21. Erythropoietin (EPO) Natural hormone produced by kidney to maintain a health percentage of blood cells Increases amount of RBC in ratio volume of blood --- Packed Cell Volume(PCV) More RBC = more O2 to cells
  • 22. Erythropoietin (EPO) Benefits: Risks: Increased blood – Treatment for thickness anemia Increased chance of blood clotting – Replacement of Can result in stroke blood due to injury Lower blood plasma level Body may produce antibodies against EPO
  • 23. Exercise and Cell Respiration
  • 24. Effects of Increasing Intensity of Exercise General: more exercise=more O2 VO2 – volume of O2 that is absorbed by the body/minute that is supplied to body tissue VO2max – maximum rate at which O2 can be absorbed and supplied to tissue
  • 25. Effects of Increasing Intensity of Exercise AnCR – in intensity of exercise can rise above VO2max. As intensity of Exercise increases the fat burned (ACR) decreases – AnCR can only use Carbohydrates as a respiration substrate
  • 26. Muscle Fatigue Muscle fibers contain a store of carbohydrates --- GLYCOGEN Glycogen is converted to glucose – Intense or long duration exercise When glycogen is used up… muscle fatigue takes place Accumulation of lactate. (AnCR)
  • 27. Myoglobin Myoglobin – oxymyo or deoxymyo- – Globular protein – Heme – prosthetic group – Red pigment – Contained in muscle – Intracellular O2 storage O2 is released when level in muscle is low Allows for longer ACR – longer exercise periods.
  • 28. Other Source of ATP Creatine Phosphate – Used by muscles cells only! – Created by excess ATP in pancreas, liver, kidneys – Direct phosphorylation of ATP from store – Duration: exercise up to 10 seconds Creatine Phosphate – Dietary supplement Absorbed by intestines Can help athletes who have naturally low levels Correlation: can improve maximum intensity over short time Can cause water retention – Weight gain, HBP, cramps – dehydration – Inhibit performance.
  • 29. Muscles,ATP, and Intensity of Exercise Low Intensity Exercise If O2 is available, ACR can produces ATP continuously – Walking, light jogging High Intensity Exercise If O2 is used faster, the body switches to AnCR. Lactate is produced – toxic – Produces energy for 2 minutes maximum
  • 30. AnCR and Oxygen “Debt” If lactate is present = oxygen debt Lactate produced is passed to the liver (accessory organ) If large amounts of lactate are present, large amounts of O2 are needed to “repay the debt.” This is why it takes TIME for the ventilation rate to return to “normal” after high intensity exercise.
  • 32. Fitness The physical condition of the body that allows it to perform exercise of a particular type
  • 33. Training Training = Exercises that are done to change the physical conditioning of the body. Depends on: – Frequency – how often a training session occurs. – Duration – length of session – Intensity – vigorous
  • 34. Speed and Stamina Rate at which a movement is performed. – Sprinting, baseball, football, swimming, skiing. Ability to continue an exercise for long periods of time – Maximum duration. – Rowing, long distance running
  • 35. Fast Muscles Fast muscle fibers TWITCH – These are the muscle fibers that are responsible for short, explosive and powerful movements. – Fast twitch fibers are the ones that grow! – Release large amounts of energy for short periods of time
  • 36. Slow Muscles – TONIC – These are the muscle fibers that are responsible for endurance. – They do not really respond to resistance training with any type of growth or hypertrophy. – Release energy for longer time periods.
  • 37. Fast vs. Slow . Fast Slow Fast Oxidative/Glycolytic Slow Oxidative Blood Moderate to Very good supply low Mitochondria Little present Much present Glycogen Little present Much present Myoglobin Little present Much present Cell Anaerobic Aerobic Respiration Stamina Low High Strength High Low
  • 38. Fast vs. Slow: Types Fast – – extensive use of arms, hands – sprinting, power lifting, body building Slow – – Use of large muscles: legs, thigh, hip, lower back, neck, – posture, swimmers, LD runners, cyclists
  • 39. Physiology of the “Warm-up and Cool Down” Warm Cool Gentle before Dispense lactic acid Vigorous Allows Cardiovascular Heats body -distributes system to adjust Raises heart rate Breathing rate returns Warm muscles more to normal flexible Less likely to tear Warm joints more mobile less strain
  • 40. Drug Use in Sports
  • 41.
  • 42.
  • 43. Performing Enhancing Drugs Anabolic Steroid Ethics: – Long term health Smaller testes, low sperm count, abnormal menstrual cycles, liver diseases, aggression, cancers – Unfair Advantage? – Criminal Profit?
  • 45. Sprains and Strains Sprain: The stretching and/or tearing of ligaments. Strain – stretching and/or tearing of tendons or muscles.
  • 46. Jacqueline Crews and her foot!
  • 47.
  • 48. Dislocations Abnormal movement of a joint. Bones move out of alignment If the dislocation is partial, it's called subluxation. The joint is loose and may slide partially out of place.
  • 52. Separations A separated shoulder: collarbone (clavicle) and shoulder blade (scapula) meet. ligaments are torn. Outer end of the collarbone slips out of place.
  • 55. Disc Damage Abnormal movements or heavy loads cause the soft center of a disc to “bulge” out through a tear in the wall of the disc
  • 58. Arthroscopy A surgical procedure where a doctor uses a camera to view and repair a joint
  • 59.
  • 60.
  • 61. Treatment of tissue injury : R.I.C.E. Swelling Rest – Excess buildup of Ice – fluid reduce blood flow- Causes heat – Tears in blood Reduce swelling vessels Reduce pain – Infection Compression – Inflammation Reduces swelling Elevation Removes excess fluid

Editor's Notes

  1. Type II A Fibres These fibres, also called fast twitch or fast oxidative fibres, contain very large amounts of myoglobin, very many mitochondria and very many blood capillaries. Type II A fibres are red, have a very high capacity for generating ATP by oxidative metabolic processes, split ATP at a very rapid rate, have a fast contraction velocity and are resistant to fatigue. Such fibres are infrequently found in humans. Type II B Fibres These fibres, also called fast twitch or fast glycolytic fibres, contain a low content of myoglobin, relatively few mitochondria, relatively few blood capillaries and large amounts glycogen. Type II B fibres are white, geared to generate ATP by anaerobic metabolic processes, not able to supply skeletal muscle fibres continuously with sufficient ATP, fatigue easily, split ATP at a fast rate and have a fast contraction velocity. Such fibres are found in large numbers in the muscles of the arms.
  2. Type I Fibres These fibres, also called slow twitch or slow oxidative fibres, contain large amounts of myoglobin, many mitochondria and many blood capillaries. Type I fibres are red, split ATP at a slow rate, have a slow contraction velocity, very resistant to fatigue and have a high capacity to generate ATP by oxidative metabolic processes. Such fibres are found in large numbers in the postural muscles of the neck
  3. FAST – SPRINTER SLOW – MARATHON FAST – DOWNHILL SKIIER SLOW – CROSS COUNTRY SKIIER MIDDLE DISTANCE – About 50% Fast – speed, agility, quickness, power The average person has approximately 60% fast muscle fibre and 40% slow-twitch fibre (type I). There can be swings in fibre composition, but essentially, we all have three types of muscle fibre that need to trained
  4. Anabolic steroids , or anabolic-androgenic steroids ( AAS ), are a class of steroid hormones related to the hormone testosterone . They increase protein synthesis within cells, which results in the buildup of cellular tissue ( anabolism ), especially in muscles . Anabolic steroids also have androgenic and virilizing properties, including the development and maintenance of masculine characteristics such as the growth of the vocal cords and body hair. The word anabolic comes from the Greek anabolein , "to build up", and the word androgenic from the Greek andros , "man" + genein , "to produce". Anabolic steroids were first isolated, identified and synthesized in the 1930s, and are now used therapeutically in medicine to stimulate bone growth and appetite, induce male puberty , and treat chronic wasting conditions, such as cancer and AIDS . The American College of Sports Medicine acknowledges that AAS, in the presence of adequate diet, can contribute to increases in body weight, often as lean mass increases, and that the gains in muscular strength achieved through high-intensity exercise and proper diet can be additionally increased by the use of AAS in some individuals. [2] Serious health risks can be produced by long-term use or excessive doses of anabolic steroids. These effects include harmful changes in cholesterol levels (increased low-density lipoprotein and decreased high-density lipoprotein ), acne , high blood pressure , liver damage , and dangerous changes in the structure of the left ventricle of the heart. LONG TERM HEALTH ISSUES: Anabolic steroid use has been implicated in early heart disease, including sudden death, the increase of bad cholesterol profiles (increased LDL, lower HDL), an increase in tendon injuries, liver tumors, testicular atrophy, gynecomastia (abnormal enlargement of breasts in males), male pattern baldness, severe acne, premature closure of growth plates in adolescents, emotional disturbances and other significant health risks.
  5. When you have the misfortune of wrenching your shoulder upward and backward, you may dislocate it out of its socket. This condition is both painful and incapacitating. The force required is often that of a fall or a collision with another person (both of which can occur with many sports). Because of how your shoulder fits together, most shoulder dislocations happen at the lower front of the shoulder. The bones of the shoulder are the socket of the shoulder blade (scapula) and the ball at the upper end of the arm bone (humerus). The socket on the shoulder blade is fairly shallow, but a lip or rim of cartilage makes it deeper. The joint is supported on all sides by ligaments called the joint capsule, and then the whole thing is covered by the rotator cuff. The rotator cuff is made up of 4 tendons that are attached to muscles that start on the scapula and end on the upper humerus. They reinforce the shoulder joint from above, in front, and in back, which makes the weakest point in the rotator cuff in the lower front. Subluxation versus dislocation: A subluxation occurs when 2 joint (articular) surfaces have lost their usual contact. A 50% subluxation means the normally opposing articular surfaces have lost half their usual contact. A 100% subluxation means the articular surfaces have lost all of their contact. A dislocation is the same as a 100% subluxation.
  6. When your shoulder is dislocated , your arm will look out of position. You will have severe pain, particularly if muscle spasms are present. If the dislocation is a partial dislocation (subluxation), you may have the sensation that your upper arm bone can slip out of its socket. Your doctor may order an x-ray to confirm the diagnosis and check for fractures. A shoulder separation will involve pain and tenderness. Sometimes a bump will appear in the mid top of your shoulder. Your doctor may order an x-ray to confirm the diagnosis and check for fractures. An MRI ( def. ) may be ordered to make sure there are no other injuries.
  7. Rest the injured area. If moving the injured area causes pain, this is the body's way of saying stop. Rest the affected area. Do not use or bear weight (such as standing or walking) until evaluated by a healthcare provider. Sometimes resting an injured area means not participating in any physical activity or just the activity that caused the injury. For example, some walking may be allowed, but no running. If necessary, the provider may suggest using crutches or a cane so that less weight is put on the injured foot or leg. Ice applied to the injured area will help to prevent or reduce swelling. Swelling causes more pain and can slow healing. Apply a cloth-covered ice pack to the injured area for no more than 20 minutes at a time, 4 to 8 times a day. A one-pound package of frozen corn or peas makes a good ice pack. It is lightweight, conforms to the injured area, and is inexpensive and reusable. Applying ice more than 20 minutes may cause cold injury. When making an ice pack with a plastic bag, make sure all the air is out of the bag before closing it. Areas with little fat and muscle, such as fingers or toes, should only have ice on them for about 10 minutes. Frozen gel packs are colder than ice, so they should only be left on for 10 minutes. Compression (use of a pressure bandage) also helps to prevent or reduce swelling. Wrap the injured area with an elastic bandage, but not so tightly that the blood is cut off. It should not hurt or throb. Fingers or toes beyond the bandage should remain pink and not become "tingly." The elastic bandage should be taken off every 4 hours and reapplied. Elevation means raising the injured area above the level of the heart. The affected part should be elevated so it is 12 inches above the heart, to help reduce swelling. Prop up a leg or arm while resting it. It may be necessary to lie down to get the leg above the heart level. Elevation can be done with several pillows.