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99 Cards in this Set
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Precautions for postural drainage: |
Relative Contraindications to Postural Drainage Severe hemoptysis Untreated acute conditions • Severe pulmonary edema • Congestive heart failure • Large pleural effusion • Pulmonary embolism • Pneumothorax Cardiovascular instability • Cardiac arrhythmia • Severe hypertension or hypotension • Recent myocardial infarction • Unstable angina Recent neurosurgery • Head-down positioning may cause increased intracranial pressure; if PD is required, modified positions can be used |
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Relative Contraindications to Percussion |
Relative Contraindications to Percussion Prior to using percussion in a postural drainage program, a therapist must weigh the potential benefits versus potential risks. In most instances, it is prudent to avoid the use of percussion... Over fractures, spinal fusion, or osteoporotic bone Over tumor area If a patient has a pulmonary embolus If the patient has a condition in which hemorrhage could easily occur, such as in the presence of a low platelet count, or if the patient is receiving anticoagulation therapy If the patient has unstable angina If the patient has chest wall pain, for example after thoracic surgery or trauma |
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Types of COPD |
Chronic bronchitis Emphysema Peripheral airway disease
Asthma Cystic fibrosis Bronchiectasis Bronchopulmonary dysplasia |
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Causes of Restrictive Pulmonary Disorders |
Pulmonary Causes Diseases of the lung parenchyma such as tumor, intersti- tial pulmonary fibrosis (e.g., pneumonia, tuberculosis, asbestosis), and atelectasis Disorders of cardiovascular/pulmonary origin, such as pulmonary edema or pulmonary embolism Inadequate or abnormal pulmonary development (bronchopulmonary dysplasia) Advanced age
Extrapulmonary Causes Chest wall pain secondary to trauma or surgery Chest wall stiffness associated with extrapulmonary disease (e.g., scleroderma, ankylosing spondylitis) Postural deformities (scoliosis, kyphosis) Ventilatory muscle weakness of neuropathic or myo- pathic origin (e.g., spinal cord injury, cerebral palsy, Parkinson’s disease, muscular dystrophy) Pleural disease Insufficient diaphragmatic excursion because of ascites or obesity |
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Impairments associated with COPD |
Impairments An increase in the amount and viscosity of mucus production A chronic, often productive cough Frequent episodes of dyspnea A labored breathing pattern that results in: • Increased respiratory rate (tachypnea) • Use of accessory muscles of inspiration and decreased diaphragmatic excursion • Upper chest breathing Inadequate exchange of air in the lower lobes Most difficulty during expiration; use of pursed-lip breathing Changes in pulmonary function • Increased residual volume • Decreased vital capacity • Decreased expiratory flow rates Decreased mobility of the chest wall; a barrel chest deformity develops Abnormal posture: forward-head and rounded and elevated shoulders Decreased general endurance during functional activities |
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Impairments post-thoracic surgery |
Impairments Reduced lung expansion or an inability to take a deep inspiration because of incisional pain Decreased effectiveness of the cough because of incisional pain and irritation of the throat from intubation Possible accumulation of pulmonary secretions either preoperatively or postoperatively Decreased chest wall and upper extremity mobility Poor postural alignment because of incisional pain or chest tubes Increased risk of deep vein thrombosis and pulmonary embolism General weakness, fatigue, and disorientation |
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Emphysema vs. Chronic Bronchitis
Smoking history
Age of onset
Clinical Features Barrel chest (hyperinflation of the lungs) Weight loss Shortness of breath Cyanosis Sputum
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Smoking history E: Usual CB: Usual Age of onset E: Later in life CB: Earlier in life Clinical Features Barrel chest (hyperinflation of the lungs) E: Often dramatic CB: May be present Weight loss E: May be severe in advanced disease (cachexia) CB: Infrequent; often overweight Shortness of breath E: Absent in early disease CB: Predominant early symptom; exertional onset Cyanosis E: Often absent, even late in the disease (low PO2) CB: Often dramatic Sputum E: Absent; may develop late in the disease CB: Frequent; early symptom; abundant sputum |
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Emphysema vs. Chronic Bronchitis Auscultation Decreased breath sounds Wheezing Rhonchi
Blood gases
Cor pulmonale
Polycythemia
Prognosis
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Auscultation Decreased breath sounds E: Characteristic CB: Variable Wheezing E: Usually absent CB: Variable Rhonchi E: Usually absent or minimal CB: Often prominent Blood gases E: Relatively normal until late in the disease CB: Hypercapnia and hypoxia may be present
Cor pulmonale E: Only in advanced cases CB: Frequent peripheral edema Polycythemia E: Only in advanced cases CB: Frequent Prognosis E: Slowly debilitating disease CB: Numerous life threatening episodes due to acute exacerbations |
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Normal VO2 at rest
Max VO2 |
3.5 ml O2/kg/min (1 MET! factors in body size)
Max: 50 ml O2/kg/min rest (in decently trained person) Rest to max is about a 14-15 fold increase |
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Cardiac output at rest and at max |
HR x SV = Q (cardiac output)
Rest: 60 bpm x 83 ml/bt = 5,000 ml/min (Resting Q is about 5 L)
Max: 200 bpm x 125 ml/bt = 25,000
HR goes up a lot, SV increases quite a bit. Q goes up by about 5 times. |
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Fick equation for VO2 max |
VO2 = Cardiac output x AVO2 difference (AO2 - VO2)
Can get central and peripheral adaptations with training. Central makes the most difference but requires specific high intensity training, while peripheral adaptations can occur with a variety of exercise, including long slow burn |
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Blood lactate |
A by-product of glycolysis
Does not cause muscle soreness Does have a dramatic effect on enzymes, including PFK, the rate-limiting enzyme in glycolysis
Lactate can be used as a fuel source by the heart and slow twitch muscles! |
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The Lactate Threshold |
Lactate production >> lactate re-uptake = lactate accumulation in blood Produce more than you can clear -> build up Not really an anaerobic threshold (no such thing as anaerobic threshold?) At VO2 max, you're using more oxygen than at any other time (sooooo, not anaerobic) Lactate threshold: 1.5 mmol change from resting
Can train body to improve lactate threshold shift value out (not because you produce less lactate, but because you're better able to clear it) Then you can run faster without building up lactate |
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2 types of left ventricle hypertrophy |
Both have L ventricular hypertrophy... Left: ventricle is bigger, athlete's heart (a good thing! heart is stronger and more effecient), because of preload Right: thicker myocardium (hypertrophy!), from increased afterload on the heart (hypertension), pushing harder against resistance |
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Factors that affect stroke volume |
Preload - priming heart, flow into it Heart Rate |
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Why doesn't cardiac output drop that quickly when your recovery is active? |
SV increases proportional to the intensity of an exercise, but it's higher during recovery phase. Blood flow is still coming back to the heart (venous return), greater stretch of heart (increased preload) Have to be somewhat conditioned to get this effect (otherwise HR doesn't go down during recovery) |
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Optimization of high intensity interval training in coronary heart disease |
When considering perceived exertion, patient comfort, and time spent above 80% VO2 max, mode A appeared to be the optimal HIIT format for these coronary patients
Mode A was 15sec at 100% and 15 sec at 0%
interval training was an effective means of improving cardiovascular fitness and health status in highly functional patients with coronary artery disease |
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Interval training vs. continuous training in patients with COPD |
produced similar improvements in exercise tolerance and quality of life but interval training was more well tolerated |
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Cardiovascular Interval Training Guidelines (from Dr. Drexler) |
Before starting an interval training program, a person should have a baseline level of steady state endurance training (But, in pulmonary patients, start with interval training to let them recover in between) Use heart rate to measure relative intensity of the exercise Start with shorter intervals and progress to longer intervals Start with 1:1 work to rest ratio and progress as tolerated Use active recovery (to help improve VO2 through stroke volume) Duration up to 20 min at high intensity (diminishing returns after that, as myocardium is fatigued) Only do interval training 2-3 days a week (take rest days, as with any other muscle and do steady state exercise) |
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Goals of PT in Acute and Critical Care |
Attainment of optimal oxygen transport and cardiopulmonary function Attainment of optimal musculoskeletal and neurological function TO Return the patient to pre-morbid functional level to the greatest extent possible Reduce patient morbidity, mortality, and length of hospital stay
So, PT Goals: Establish detailed baseline tests and measures Maintain or restore adequate alveolar ventilation and perfusion Prolong spontaneous breathing Minimize work of breathing Maximize work of the heart Design a positioning schedule for comfort and postural alignment Maintain or restore general mobility, strength, endurance, and coordination Maximally involve the patient in a daily routine Integrate PT goals with patient/other health care team goals and activities |
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Discharge planning in acute care setting |
Crucial part of acute care setting PTs offer recommendations on: Current status and rehab potential Discharge destination Activity tolerance Equipment needs/durable medical equipment Starts at initial evaluation Determine rehab potential Frequently reassessed Discuss with patient/caregiver Communicate with health care team/discharge planner |
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Sternal instability / dehiscence (after sternotomy) |
Incidence up to 10% Infections 1-4% In-hospital mortality up to 25 % High morbidity Prolonged hospital stay 2.8 times higher additional costs Clinically apparent 4-90 days post-op 49% after hospital d/c
Risk factors Obesity Age Diabetes COPD Use of bilateral mammary arteries Duration of surgery Prolonged mechanical ventilation Re-exploration for bleeding
Post operative activity and arm movements not cited as a risk factor! |
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Treatment for sternal instability |
Surgical debridement / reclosure / lavage Flap repair Omentum Muscle (pectoralis major, rectus abdominis…) Vacuum-assisted closure therapy Trunk stabilization exercises El-Ansary D et al, Aust J Physiother 2007;53:255-260. |
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Sternal Precautions |
No Valsalva No weight bearing through UE No lifting > 10# No shoulder flexion or abduction beyond 90° No end-range shoulder horizontal abduction or adduction or extension (no reaching behind your back)
for 6-8, -10, -12 weeks?
Surgeon makes these decisions
Even within the state of Ohio, these are not consistent
pts complain of least pain with bilateral loaded activities Rationale for limiting upper extremity motion after MS not evidence-based Strict UEM limitations may have negative sequelae
And, opening the door to get to rehab involves more force than lifting a 10 lb weight anyway |
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Satisfaction after sternal surgery and referral rates to PT |
Many patients experience lasting pain and functional deficits after sternal incision Pain present in 61% of patients 12 months after surgery 18% reported severe that affected quality of life 1 year after surgery - 36% of patients report functional status as ‘unsatisfactory’ some initial pulmonary problems (increased RR, decreased total lung capacity and chest wall expansion) but don't tend to have lasting problems
Referral rates to PT after cardiac surgery are very low About 20% actually go to PT
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Phase 1 of Cardiac Rehab - when does it begin? |
Preventative To have the patient operate within safe limits not too little and not too much Know what activities are safe
Begins when the patient is medically stable Usually POD or HD #1 Indications Medically stable post MI Stable angina CABG, PTCA, other cardiac surgery Compensated HF Cardiomyopathy Heart/lung transplant PAD End-stage renal disease At risk for CHD with diagnoses of DM, dyslipidemia, HTN |
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Phase 1 Cardiac Rehab: what does it involve?
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Patient and family education Risk factor modification dyslipidemia smoking cessation hypertension Diabetes control regular exercise dietary changes
Behavior modification Stress management at home and work
Prevent deleterious effects of bedrest Mobilization to prevent Muscle atrophy DVT Pneumonia Lethargy
Provide a safe discharge home Perform ADL’s Reduce fear
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PT Goals of Phase 1 Cardiac Rehab |
Evaluation of physiologic responses to self-care and ambulation/physical activities Feedback to health care team about patient’s response to activity Safe guidelines for progression of activity Patient and family education Disease entities and risk factor modification Self-monitoring techniques: upper limits of activity General activity guidelines |
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Indications for withholding PT/Phase 1 |
Resting SBP > 200 mmHg or DBP > 110 mmHg Persistent hypotension (> 20 mmHg with symptoms) Uncontrolled atrial or ventricular dysrhythmias Unstable angina Resting ST segment displacement (> 2mm) Critical aortic stenosis 3rd-degree heart block Active pericarditis or myocarditis Recent embolism Uncontrolled diabetes or other metabolic conditions
Basically, get things under control first |
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Medical record review for cardiopulmonary patients |
Patient’s diagnosis - MI, CABG, PTCA, etc? Was defibrillation required? What does the ECG report say? Use of TPA or Streptokinase ? Cardiac enzymes? ECHO? Clinical lab values? Catheterization? Medications?
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Information to get from patient/family interview |
Does the patient understand what happened to them? Did the patient have chest pressure or pain or anginal equivalents? Did the patient have any predisposing risk factors? Did the patient smoke? How long ago did they stop smoking? Is this the first admission? Is there a supportive family network? Does the patient want to return to work? Will vocational retraining be necessary? Does the patient have hobbies? |
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Aspects of PT exam for cardiopulmonary patient |
All systems review Alert and oriented ROM: passive & active Gross muscle strength Skin - normal color? Patency/pulse check Surgical sites? Breathing patterns Lung auscultation (heart auscultation doesn't affect treatment really) Balance
More concerned about pulmonary complications than cardiac |
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Interventions in Phase I cardiac rehab |
Therapeutic Exercise: Aerobic Flexibility Strengthening Breathing Functional training Balance training
Patient Education: Precautions Activity limitations Self-monitoring techniques Posture & body mechanics Energy conservation Exercise
Refer to Phase 2! |
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Exercise parameters after cardiac event/surgery |
Intensity RPE < 13 (6-20 scale) HR < 120 bpm, OR HRrest + 20-30 bpm To tolerance if asymptomatic Duration Begin: intermittent bouts 3-5 min 2:1 exercise: rest ratio (does that mean rest:exercise?)
Frequency TID - QID exercise initially BID exercise after day 1-3 Progression Duration = 10-15, increase intensity Begin with aerobic training
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Sample activity for 4-day LOS Phase 1 Cardiac Rehab |
Day 0-1 METs: 1-2 Use of bedside commode, out of bed to chair
Day 1-2 METs: 2-3 Sitting w/u, walking in room, self-care activities
Day 2-4 METs: 2-3 Out of bed, as tolerated, walk 5-10 min in hall
METs: 3-4 Walk 5-10 min BID/TID, start stair training
METs: 4-5 Treadmill walking, or stair training |
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Phase 1 CR - Modified program for "complicated" patients |
‘Complicated’ patients: Large infarction With self-care activities Resting tachycardia or inappropriate HR increase BP failing to rise or decrease EKG with > 6 PVCs/min or progressive heart block Angina or undue fatigue Need for prolonged bedrest (> 4 days)
Not gonna have a 4 day length of stay (in hospital longer), not physiologically stable. Slow everything down |
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Chest tubes |
Used after thoracic surgical procedures and medical conditions Drains fluid from the affected body cavity using water or air suction Clinical considerations: encourage mobilization; depending on suction apparatus, may be restricted in location of ambulation; shoulder elevation > 90° may be painful
Chest tube in intraplural space Feel puling at fixation with arm overhead |
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Post-op precautions after thoracic surgery (not sternal incision) |
Lifting and Reaching: avoid lifting objects > 10# for the 1 week after surgery Physical Activities Light, quick activities where your arms are above your shoulders, such as brushing your hair are OK No activities where your arms are above shoulder level for a long time, such as washing a window |
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Sample post thoracotomy program: Goals |
Goals: Strengthen the shoulder girdle and prevent of disuse General conditioning to increase endurance and overall health Maximize oxygenation and discharge supplemental oxygen Provide education to effectively manage the condition and maximize independence Minimize loss of function and morbidity Maximize pulmonary function and clearance of secretions Wean patients off pain medication Begin pre-op and continue post-op If no pre-op exercise, then meeting with PT to review post-op program |
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Sample post thoracotomy program: exercises, etc. |
Breathing exercises Lateral costal expansion Airway clearance/huffing Energy conservation Diaphragmatic breathing
Shoulder ROM exercises: Pendulum exercises AAROM Active ROM – all motions
Education Stress management Self assessment techniques Smoking cessation
Shoulder strengthening exercises – Once able to do 30 reps actively, add 1#/week Shoulder motions Shoulder shrugs Serratus anterior strengthening in supine Aerobic exercise conditioning Treadmill, arm ergometer, and stationary bike Monitor VS, SaO2, and subjective measures (Borg)
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Arterial pressures
and arterial line |
Severely ill patient Unable to hear Korotkoff’s sounds Intra-arterial catheter (‘art line’) Continuous monitoring of SBP, DBP Easy access for arterial blood gas sampling Mean arterial pressure (MAP)
MAP = (SBP + (2xDBP))/3
Normal 70-110 mmHg
Arterial line: To measure BP and arterial blood gases, and medication can go in there (most meds go into venous system, but if they want to bypass heart it'll go in arteries)
Most of you have had IVs (donate blood, etc.) Artery is very different. That's why pressure can be measured Typically displayed as MAP
Typically use radial artery
Bags of saline, bag with pressure pump, transducer (why is that important? Always needs to be at heart level. Move pressure gauge with them to avoid error.)
Can't bend wrist, often have a splint Walker often needs platform attachment
Never pull any lines out. Definitely don't pull out this one.
Doesn't mean you can't work with patient, but you have to know what you have to do. Get something to protect them if they don't have a splint |
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Central line |
Internal or external jugular or subclavian vein often used Route for medication or fluid administration, blood sampling Monitors central venous pressure |
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Swan-Ganz catheter |
Measure pulmonary artery pressure Pulmonary artery pressure Equal to LVEDP and left atrial pressure Pulmonary artery wedge pressure Catheter tip is wedged into the wall of the pulmonary artery
55
Can look similar to centrla line, but different
Into pulmonary artery to measure pressure That approximates left side pressuer (no valve between pulmonary artery and left atrium)
During diastole the mitral valve is open, so it can also estimate left ventricle diastolic pressure
Wedge catheter into pulmonary artery... measure of pulmonary hypertension
Wrapped in cover (like saran wrap)
If swan-ganz is in 'wedge position', don't treat them. If it moves, the pulmonary artery could rupture. But it's typically not in that position for long. |
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Intra-aortic balloon pump (IABP) |
Balloon deflated during left ventricular systole… And inflated during diastole Increasing diastolic pressure and coronary blood flow Clinical considerations No hip flexion > 70° Bed mobility and ther ex only
Any time anything goes through femoral artery, don't want to mess it up so hip flexion is limited to 70*
Big artery and easy to get to, but you can't sit up with it
These patients are often too sick for PT, or you're working on things in bed, such as breathing exercise |
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Weaning from mechanical ventilation |
Resolution of initial event Alert, cooperative, and psychologically ready Respiratory parameters FIO2 < 50% SaO2 > 90% PEEP < 5 cmH2O RR < 36 VE < 15 L/min
Terminated: respiratory distress RR > 35; dyspnea Change in level of consciousness Change in HR or BP > 20 Angina, cyanosis, cardiac arrhythmias SaO2 < 90%, any decrease in PaO2, increase in PaCO2 PT: Facilitate weaning process Optimizing airway clearance and pulmonary function Timing of PT intervention |
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what is cardiac rehabilitation? (long definition) |
“coordinated sum of interventions required to ensure the best physical, psychological and social conditions so that patients with chronic or post-acute cardiovascular disease may, by their own efforts, preserve or resume optimal functioning in society and, through improved health behaviours, slow or reverse progression of disease.”
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Difference between phase I and phase II cardiac rehab
and a word about phase III and IV |
Phase I was assessment and short-term treatment Monitoring was with lines and tubes... different in out-patient
Phase II: Community-dwelling people Everything about exercise prescription and minimum physical activity guidelines
Phase III Intermittent or no EKG Supervision Variable length may not be medically supervised (physician), but have community supervision (maybe group classes, personal trainer)
Phase IV: Community-based Unsupervised No EKG "The cardio room is now available for ppl with cardiac conditions" Social support |
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Medical personel involved in cardiac rehab |
Doctor involved because of DRUGS You want someone who can bring them back to life if they die Prescribe and administer drugs
Program director – this is where Pts fit in? Director Joannie Raniery works at UMC – took over program direction of cardiac rehab
Always a cardiac rehab nurse – may monittor ECG, operate crash cart (we could all do that), administer drugs, do exercise with them, patient education! (smoking cessation, stress reduction, diet...) Nursing may do bulk of education.
Exercise physiologists with masters degrees may work in cardiac rehab (1 year program)
Contributing staff: dietician (nutrition is very important! Cooking classes...), clinical psychologist or social worker (important for stress management and smoking cessation – success occurs when more than one health professional intervenes), pharmacist (52 y.o. man has heart attack shoveling snow... they overwhelm him with discharge instructions, then he shows up at FMC with 9,000 medications he feels like he has to take. That's a lot to go through, so a pharmacist will often give talks on what medications do. |
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What are the competences for cardiac rehab professionals? |
Take a look at Hamm article! |
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Goals of Outpatient Cardiac Rehab |
Individualized exercise program to safely elicit improvement in the patient’s cardiovascular fitness. Patient education to increase understanding of the disease and implement life-style changes. Enhance confidence at safe, functional levels of activity. Aid in risk factor reduction for secondary prevention. Assists and accelerates the return to work. Promotes psychological, behavioral, and educational improvement. |
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Prevalence of hypertension and level at which they need to be on medication |
Hypertension is estimated to be 60% of population. So, most people you see (esp. over 40) will have high blood pressure. At risk for cardiac and brain events and lots of other things. Over 150 / over 100 means they need to be on medication (so see a physician) as well as all the lifestyle change things |
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At what age do people tend to get MI's? How does that affect treatment goals? |
in their 50s People need to get back to work! |
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Components of cardiac rehab include... |
Patient and family education Risk factor reduction Psychological counseling Vocational counseling STRUCTURED, PROGRESSIVE PHYSICAL ACTIVITY (exercise!)
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Initial exam for phase II cardiac rehab may include |
Risk stratification Exercise test if not previously done May not have received Phase I/inpatient CR -Not hospitalized -Procedures with short hospital stay
notes: No need to test them again if they have results from exercise test with doctor If they had a short stay, may not have gotten education at the hospital. BL (lady with bipass surgery) – 10 years prior had an exercise test that showed ischemia, they did an angioplasty in outpatient, so she didn't get much education |
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Level of supervision during exercise (in phase II) |
Patient-by-patient decision Based on -Clinical course -Exercise test results -Degree of ventricular impairment -Initial assessment Direct staff supervision with exercise -Risk stratification: guidelines for supervision Start with continual EKG -Decrease to intermittent as appropriate
notes: Supervision guidelines based on risk stratification are available from two different groups (similar) If they've been stable for a while, take of ECG and only use occasionally. Helps empower patients to realize they're getting better |
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Cardiac rehab aerobic component - intensity (how is intensity determined in phase II) |
Above the minimal level of ‘training effect’ Parameters Deconditioned patients: as low as 35% HRR Lower risk: 40-70% HRR or VO2R RPE: 11-13 initially; 14-16 Below ischemia or other signs and/or symptoms Use medication and dose during testing and exercise
Notes: Can start out low, but Intensity is the same as someone who hasn't had a cardiac event
Start lower, then bring them up
Important: want them below their ischemic threshold! Even if 152 is 50% of their heart rate reserve, if they're getting T wave inversions and angina, don't exercise them there!
Standardize dose and type of medication (same between testing and training for consistency) |
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Cardiac rehab aerobic component - type (how is type determined?) |
Multiple activities Promote total physical conditioning Ex. Treadmill, cycle and arm ergometer, rowing machines Can add ROM and/or resistance exercise as indicated Often start with treadmill walking < 2mph can provide benefits
Notes: Anything they want!
Typically start with treadmill walking because it's easy. When they're deconditioned, slow walking can be beneficial (<2 mph)
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Cardiac rehab aerobic component - length (how are frequency and time determined?) |
Frequency – 3+ days/week (Goal: 4-5 d/wk) Duration Warm-up = 5-10 minutes Conditioning = 15-45 minutes (Goal: 45 min) Cool down = 5-15 minutes Energy expenditure > 1000 kcals/wk after 3-6 months Inter-individual variation Goal: 1500 – 2200 kcals/week To change status, not just maintain, need more. Weight management 1700 kca/week? Sounds like federal guidelines, eh? |
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Example of phase II CR without an exercise test (test may be contraindicated right away) |
Component and initial recommendation
Warm-up: stretching for 5-10 min
Muscular Fitness: Resistance exercise (if indicated) 20-30 min 2d/week
Aerobic Exercise: Frequency - 1-2 times/day; 5 days a week Duration - 30-45 minutes Intensity - HR rest + 20; RPE 11-13 Mode - 2-3 METs initially: treadmill, UE or LE ergometer, stairs
Cool-Down: low level aerobic or stretching. 5-10 minutes |
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Exercise progression in Phase II CR |
Evaluate program goals on a regular basis Forms of progression Increase the duration of exercise Increase the intensity of exercise Change the mode of exercise Most progress to 85-95% of initial exercise test results
Notes: Most people progress really far – exercising at 85-95% of initial exercise test max (VO2 peak?), however, their max has increased due to training so if they were tested again they'd probably have a higher max
Progression Typically increase the duration of the intensity first, before intensity Changing type/mode of exercise helps prevent boredom and injury and can create progression
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What are the outcomes with cardiac rehab, according to Heran et al. Cochrane Review? |
Mortality: reduced long-term total mortality after 12 months Hospitalization: short-term (<12 months) lower odds of hospitalization Cost: wouldn't that be affected then? Only 2-3 studies measured cost, not sure whether it described what those costs included (was it overall long-term health costs or just initial costs?) 1 was cost over study duration (so you expect the more intensive intervention to be higher cost initially). Australia, Italy, and China in early 2000s. So, based on this paper, can't make a big statement about cost. QOL: 7/10 studies showed improvements (what about the 3 that didn't? How were they measuring) Why: able to do activities without symptoms, knowledge is power, less time in hospital, helps with depression... seeing other patients with quadruple bypass jogging on treadmill helps them realize what's possible (group setting)
Take a look at the article! |
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Should you do resistance training in cardiac rehab? For who? |
Low to moderate risk patients ? benefit in high risk Criteria for resistance training 5 weeks after MI or cardiac surgery (4 wks of CR) 3 weeks after PTCA (2 wks of CR) No evidence of: Heart failure Uncontrolled dysrhythmias Severe valve disease Uncontrolled hypertension
Notes: High risk you gotta be careful, may not be able to get to high enough intensity to induce a benefit
Hold off on resistance for a bit... start with aerobic
Textbooks says no evidence (don't use resistance training in people with heart failure) Refuted Dr. Warren thinks resistance training is critical for people with heart failure Anything uncontrolled (watch out for) |
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Resistance training exercise prescription in phase II CR |
Intensity: UE: 30-40% 1 RM LE: 50-60% 1 RM Thera-band, light weights instituted sooner Exercises: 8-10 using major muscle groups Reps: 1 set x 10-15 reps Progression UE: 2-5#/wk LE: 5-10#/wk Monitoring RPE: 11-13 Avoid Valsalva - Exhale with effort
Notes: FIRST (frequency intensity reps sets time) What's the estimation you can do if you don't want to do a 1 rep max
Theraband is a nice place to start, but can't give intensity based on it 1 rep max testing: Dr. Warren likes National Strength & Conditioning Association's protocol Imprimatur |
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Flexibility component of Phase II CR |
Part of warm-up and cool-down Focus on upper and lower trunk, neck, low back, and hip regions Static stretching 10-30 second hold
do deep breathing here too |
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Safety of (phase II?) cardiac rehabilitation |
Incidence rate 8-9 cardiac arrests/1 million patient hours 3-4 MI/1 million patient hours 1.3 fatalities/1 million patient hours
Emergency procedures Trained personnel Emergency equipment Physician
1 in a million fatalities So, it's pretty safe. That's why a physician and defibrillator are around So safe because we monitor them. Good info going in, especially with exercise test (stay below T wave inversion, etc.), good history, and team ready to address everything. Stops people from dying and going to hospital, makes them feel better, it's safe... However, compliance issue
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Compliance in cardiac rehab Pinto article |
Overall compliance 15-50% 30-60% of patients continue exercise after 1 year What has been shown/can be done to improve compliance?
Pinto BM, et al. Maintenance of exercise after phase II cardiac rehabilitation. Am J Prev Med. 2011;41(3):274 –83. No downside, so should be 100% compliance...
Pinto: Called once a week or once every 2 weeks, asked them about exercise log and stages of change (transtheoretical model) On average, they were meeting the physical activity guidelines! So, more motivated group than normal. Selection bias. Study was underpowered. Needed 144 ppl, only had 130ish. More risk of Type 2 error – fail to find a significant difference when one is there. Very reasonable intervention (at least our class thinks so... the previous year said if they can't bill for it it's not going to happen) – we think the benefits are worth the time for an assistive personnel to call. (billing for phone calls is difficult, but maybe possible as long as you make sure you're not breaking laws, such as practicing in a state you're not licensed in) |
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Criteria for discharge from Phase II Cardiac Rehab |
Life-long changes = life-long support? Criteria Goals and desired outcomes met Unable to continue 2° medical or psychosocial complications Failure to progress toward goals Non-adherence to HEP Lack of willingness or ability to participate Reimbursement Often dictates participation Almost always dictates length of time enrolled Most insurance companies reimburse to some degree Medicare: 12 weeks or 36 visits for patients with MI, CABG, or stable angina
Notes: Discharge when they transfer to self management
Or, non-compliance and failure to progress toward goals
Medicare: 3 groups, 3x a week for 12 weeks, doesn't cover cardiac rehab for other conditions Aspirin should be given to every Medicare patient (>65) to reduce/prevent heart attack
SOAPBOX: When we discharge from PT, we need to remember basic principles of exercise physiology. OVERLOAD. When you discharge a patient with a home exercise program without giving them a progression, that is not appropriate. Disservice to patient if you don't provide that (~month of progression). Goal is to discharge to self management. So, using heart rate for aerobic exercise works because it changes along with progression. (self regulates). This is incumbent on the profession. |
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Exercise considerations for special cardiac patient populations - Myocardial Ischemia |
May be inappropriate with angina at < 3 METs May benefit from pre-exercise NTG Prolonged warm-up and cool-down THR: > 10 beats below anginal threshold UE exercise more angina provoking Intermittent, shorter duration may be useful 4-6 d/wk with 5-10 min/session Decrease or discontinue when angina > 2 (1-4 scale)
Notes: If they have angina at really low levels, exercise intervention is inappropriate. Don't want to work above ischemic threshold. Need medical management first. May benefit from pre-exercies nitroglycerine. Tell them to bring it to PT.
Stay below anginal/ischemic threshold
If they're at 3 or 4 on anginal scale, stop.
Signs AND symptoms are taken into consideration. Figure out validity of their anginal scale |
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Exercise considerations for special cardiac patient populations - Heart failure
Is it efficacious? What is the mechanism? Is it safe?
What is an appropriate exercise prescription?
Keteyian SJ et al. Exercise training in congestive heart failure: risks and benefits. Prog Cardiovasc Dis. 2011;53:419-28. |
Mechanisms that this paper reviews that induces changes in people Peripheral adaptations – cellular metabolism and enzymes Some show central adaptations as well: some increased ejection fraction/Q In general, the heart is getting worse over time because it's progressive, so induce changes in parts that won't necessarily get worse, i.e. peripheral People often are limited by shortness of breath, rather than muscle fatigue, so enhancing... wait, what were we saying here? If we can decrease muscle fatigue, we can allow them to exercise at a higher level
It is safe! Heart failure: acute is uncompensated, chronic is compensated (what is definition of congestive heart failure?) Classes of heart failure: 1-4. IV have symptoms at rest so they need medical management, not an increase in oxygen demand.
Appropriate exercise prescription: about the same as federal guidelines, standard recommendations for everybody. Except pacemakers? |
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Exercise considerations for special cardiac patient populations - pacemakers |
Variations in exercise prescription based on pacemaker category
Fixed rate: SBP for exercise intensity TSBP = (SBPmax – SBPrest) * 50-80%) + SBPrest Monitor throughout exercise Very low intensity to start
Rate responsive Consider upper and lower limits of the pacemaker May require adjustment
Notes: Fixed rate – that sounds scary. Wouldn't do exercise with these people. Not used that much anymore.
Rate responsive pacers are more common. Set at a range (so know what that is) that heart rate can move between.
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Exercise considerations for special cardiac patient populations - cardiac transplant |
Transplanted heart is denervated Delayed cardiac output increase Stroke volume increases initially with HR at higher intensities Post-exercise HR increases and remains elevated Peak O2 consumption = 50% of normal Exercise test to volitional fatigue Low sensitivity to ECG for ischemia Intensity 50-75% VO2peak RPE: 11-15 MET load
Notes: Decrease in cardiac output. Won't have same adaptations or responses to acute bouts of exercise.
Stroke volume increases first. Very unfit, in general, so start them low. Can use same criteria for VO2 because their VO2 is low. Heart rate might not be the best for monitoring in this population. Because of denervation, don't see same ECG changes. Don't expect ischemia because they just got a brand new heart. Typically exercise to fatigue. |
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Exercise prescription in the outpatient setting Exercise considerations for special populations - peripheral arterial disease |
Benefits Improved pain-free and maximal walking distance Increased frequency of physical activity Positive changes in quality of life measures Significant increase in VO2 and CV risk factor profile Not associated with improvements in LE blood flow ACSM exercise prescription: Mode: intermittent weight bearing exercise Intensity: 40-70% VO2max Frequency: 3-7 d/wk Duration: 20-40 min
Notes: Really nice benefits
Only difference is type or mode of exercise – intermittent exercise. Walk until claudication scale is up to 3-4, stand until it goes down to 2, then walk again. Otherwise everything is the same. |
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Exercise prescription in the outpatient setting Exercise considerations for special populations - Diabetes |
Benefits Insulin-like effect Improved insulin activity and sensitivity (decreased A1C) Decreased insulin/hypoglycemic agent requirements CV risk factor reduction Hypoglycemia (<80 mg/dL) Hyperglycemia can occur (Type 1) Autonomic neuropathy: use RPE Avoid exercise with glucose > 300 mg/dL
Notes: See insulin-like effect with exercise
Present similarly to someone with cardiovascular disease (and have high incidence of)
Careful, hypoglycemia can occur with Type I diabetes. Ask them to test glucose before and after exercise to be able to monitor diet and injections |
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Exercise prescription in the outpatient setting Exercise considerations for special populations - Renal Disease |
Renal Disease:
Exercise tolerance with hemodialysis: significantly below normal Benefits Increase physical work capacity Increase HDL cholesterol Increase hematocrit values Scheduling around dialysis Weakest day before and day after dialysis Intermittent exercise – 1:2 or 1:1 (work: rest) initially Variable HR response; use RPE
Notes: Look similar to someone with cardiovascular disease
Some people really bad right before dialysis, some really bad right after (fatigue, tachycardia, etc.) Figure out what schedule will work for the patient, depending on how they respond. (pretty consistent with the same patient once he/she stabilizes) Interval training can be very helpful for them.
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What is the definition of pulmonary rehabilitation? |
"Pulmonary Rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patients, PR is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease." (American Thoracic Society and European Thoracic Society, 2006) |
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What did Sandeland et al. find about the activity level of people with COPD? (and what's the significance for pulmonary rehab) |
Ppl with COPD are half as active as other people Using oxygen made them half again as active (instead of increasing their activity) Oxygen is like carrying a heavy laptop bag... ppl with dyspnea don't like the extra burden of carrying that around Also, if they feel ok at rest with their oxygen they don't want to increase their oxygen demand. Then at risk for all the other things from sedentary lifestyle These ppl really need rehab! One program in Flagstaff (not a huge population with COPD because of the elevation and younger skewing population)
Pulmonary rehab is important in this population because they're not getting enough exercise/activity, which puts them at risk for things |
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Pulmonary vs. cardiac rehab |
Less well defined Inpatient care progressing to outpatient General phases similar More likely to be referred when medically stable Rather than in response to an acute event
Notes: People aren't technically admitted to it from a hospital event (no official “phases”) Similar to cardiac (you can tell what someone's in by whether they have an ECG) Also, are symptomatic, while people in cardiac rehab have usually been treated after an event and are no longer symptomatic |
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Does Medicare cover pulmonary rehab? |
Effective January 1, 2010 Coverage (Part B) Patients with moderate to very severe COPD Referred by the physician who is treating COPD Must be furnished in a physician’s office or a hospital outpatient setting Requires direct supervision Billed with HCPCS G0424 Limited to 36 sessions (extra with MD referral) Session must be at least 31 minutes
Notes: Yay! Yay! ...boo. (“we don't need no direct supervision”)
Not something pts bill for very often
36 visits, but if physician says additional visits are “medically necessary” then it's covered
Generally hour-long visits |
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To be covered by medicare, pulmonary rehab must include these 5 components documented in the medical record: |
Must include these 5 components documented in the medical record: Physician-prescribed exercise, including aerobic exercise Must be part of each session Individualized education and training E.g., respiratory problem management and smoking cessation counseling A psychosocial assessment An outcomes assessment An individualized treatment plan |
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What is the picture you get of people with COPD?
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They are very limited. Often depressed and isolated. (smoking used to be their social event, so quitting leads to losing social support. Also, you're not always pleasant to be around when you're struggling to be functional. And they're older and often not working... losing social network through death) Being able to work with psychosocial aspect and offer support is important |
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Does PT have a role in Pulmonary Rehab, and what are the clinical competencies for a pulmonary professional, found by Nici et al.? |
PR professionals should have knowledge of exercise physiology, prescription, testing, etc.
Also, education for lifestyle change – smoking cessation, psychosocial aspects, etc.
Infeasible for one person to be an expert in all of these things. (smoking cessation is a whole big thing by itself) |
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What are the goals of pulmonary rehab?
How can you make these unrealistic goals more realistic? Eliminate dyspnea Normal lifestyle/activities Discontinue supplemental O2 |
Individualized goals Realistic given nature of progressive disease Make the most impact on daily life
So, Eliminate dyspnea Normal lifestyle/activities Discontinue supplemental O2
becomes... Strategies to relieve dyspnea Increase activity tolerance Improve SaO2 with exercise
The primary goal of pulmonary rehab is to transfer responsibility away from the hospital/clinic to the patient/caregiver
notes:
With chronic diseases it's often unrealistic to expect to eliminate dyspnea or discontinue o2... Studies have shown that intensive rehab can reverse the disease, but that's pretty intense and usually it's more about adapting |
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Outcomes with pulmonary rehab: Is it efficacious? What is the evidence for benefits? Is it safe? Is it cost effective? What is the most appropriate exercise prescription?
Ries AL, et al. Pulmonary rehabilitation: Joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest 2007;131;4S-42S. |
What works: Upper and lower extremity exercise (aerobic) Resistance training Education on self-management EXERCISE TRAINING is a MANDATORY intervention!
What doesn't work: (lacks evidence) Anabolic steroids Nutritional counseling Inspiratory muscle training (benefits at first but not for routine) Psychosocial aspects alone
Hard to measure quality of life
>12 weeks produced greater benefits (moderate recommendation to have longer program) |
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Candidates for pulmonary rehabilitation
In addition to disease presence…
Symptoms and functional limitations clinically apparent with 1+ of the following:
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In addition to disease presence… Reduction in functional status or health-related quality of life Symptoms, disability, and handicap Symptoms and functional limitations clinically apparent with 1+ of the following: FEV1 and/or FVC < 65% of predicted value (moderately severe COPD) Resting and/or exercise hypoxemia (SaO2 < 90%) |
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Conditions appropriate for Pulmonary rehab |
COPD (only thing medicare covers it for) Persistent asthma Bronchiectasis Cystic fibrosis Lung cancer Ventilatory dependency Pediatric patients with respiratory disease Obesity-related respiratory disease Pre- and post surgery Thoracic and abdominal surgery Lung transplantation Lung volume reduction surgery
Interstitial diseases Pulmonary fibrosis Occupational or environmental disease Sarcoidosis
Chest wall diseases Kyphoscoliosis Ankylosing spondylitis
Neuromuscular diseases Parkinson’s disease Post-polio syndrome Amyotrophic lateral sclerosis Diaphragmatic dysfunction Multiple sclerosis Post-tuberculosis syndrome |
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Exercise intolerance and pulmonary disease |
Exercise intolerance Dyspnea and/or fatigue Anxiety and lack of motivation “I just can't do it” (SIGN you see is hypoxemia → increased HR and RR) Exercise training = best intervention to improve exercise intolerance!
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Factors contributing to exercise tolerance (in pulmonary patients) |
Factors contributing to exercise tolerance: Ventilatory limitations (lungs don't work normally!) Gas exchange limitations (Lungs don't work! hypoxemia) Cardiac dysfunction (needs to work harder, but often deconditioned, may have co-morbid cardiac dysfunction) Skeletal muscle dysfunction (one of the biggest things we can address! And we can induce peripheral adaptations!) Respiratory muscle dysfunction (train to use diaphragm rather than accessory muscles)
(increase efficiency, etc.) |
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Exercise testing in pulmonary rehab |
Testing Steady-state endurance test vs. GXT (graded takes longer. Goal is improvements in endurance usually, rather than changing aerobic capacity. This is a group you like o2 sat, RPE and 6 minute walk test all together! Things Dr. Warren doesn't usually like) |
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Intensity and duration of exercise training in Pulmonary Rehab |
Intensity: symptom dependent 60% maximal aerobic capacity Interval training – delays onset of blood lactate accumulation (lactate is normal by-product that is normally cleared and sent to liver. Problem occurs when you can't clear it quickly enough... changes pH, start holding onto CO2, changes ability for muscles to contract. Can't work as well!) Same as with other populations usually Duration: up to 20 minutes
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Interval training in patients with COPD |
Skeletal muscle adaptations to interval training in patients with advanced COPD
Findings: CSA in type I and Iia fibers increased in both groups Changes in ability to get work done in interval training group
Dr. Drexler may have shown us these articles
Interval vs. Continuous training Improvements in dyspnea, anxiety, depression, sF-36 in both groups At same submaximal work rate, people in interval group were working less (more efficient! Have bigger margin of submaximal work before they get to maximal)
3 min intervals are efficient (study was mostly women btw) IT may be better for ppl with COPD |
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Strength training in patients with COPD |
Strength Training: May be easier to tolerate vs. aerobic Greater potential: increased muscle mass and strength Sessions: 2-4 sets of 6-12 reps at 50-85% 1RM Eccentric exercise Unfavorably alters breathing pattern
notes: May be easier to tolerate (less exercise induced hypoxemia) Start them at lower intensity with more sets typically – avoid valsalva and eccentric exercise. But, certainly can get up to higher intensity 2-4 sets at 10-12 rep max
Awesome Dutch paper is posted on Bblearn – standards for people with COPD for exercise. Goes through all impairments, other things that occur, and what should be done for each one. |
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Exercise considerations for patients with asthma |
Asthma They do fine. Use Pre-exercise bronchodilation, prolonged warm-ups, and avoid environmental irritants Often not ventilatory-limited Able to train at high-intensity Minimize bronchospasm Pre-exercise bronchodilators Gradual warm-up |
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Exercise considerations for patients with cystic fibrosis |
Cystic fibrosis Avoid cross-contamination with bacterial pathogens – they tend to colonize with pseudomonas aeruginosa, don't let people catch things from each other Maintain protein and caloric intake to meet metabolic demand (can't eat too much! McDonalds should market to them) Maintain adequate fluid and salt intake Performance athletes have close relationship with nutritionist. (absorption issues – need to take A, D, E, and K b/c of difficulty absorbing fat soluble vitamins) |
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Exercise considerations for patients with interstitial lung disease |
Interstital lung disease Pacing and energy conservation – lung function affected by scarring in connective tissue, stiff tissue can't accommodate increased O2 demand, pathology limits their lungs' ability to expand Interstitial lung disease = Pulmonary Fibrosis, or plural effusion and pulmonary edema (but those two are acute, not chronic) People with pulmonary fibrosis are very sad. Dr. Warren saw a guy in Lima who was 52 and being evaluated for a lung transplant. Looked like he was 72. Worked in the mines in Peru. Often insidious. Can be environmental, post-infection (post tuberculin syndrome – little pod people living in the lungs), immune response |
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Exercise considerations for patients with obesity |
Obesity Consider water exercises – useful to decrease load |
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Exercise considerations for patients with neuromuscular disease |
Neuromuscular disease Maintain muscle conditioning without excess muscle fatigue Neuromuscular disease includes spinal cord injury Next spring in neuro clinic, think about their pulmonary function and intervene if appropriate. Listen to their lungs! Ask them to take a deep breath. Assess dyspnea and fatigue – monitor s/s so you don't over fatigue them! |
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Exercise considerations for patients with pulmonary hypertension |
Pulmonary hypertension Be very careful with them! Exceedingly careful! Why? Don't want to risk pulmonary artery rupture Low-intensity exercise with close monitoring No strength training – bad if they hold their breath at all... Pacing and energy conservation particularly important |
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Criteria for stopping a maximal exercise test |
Cardiac, pulmonary, neurologic, or musculoskeletal signs or symptoms With increasing work Drop in SBP ≥ 10 mmHg Failure of HR to increase SBP > 250 mmHg or DBP > 115 mmHg Participant requests to stop |
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Criteria for stopping a submaximal exercise test |
Maximal criteria... Cardiac, pulmonary, neurologic, or musculoskeletal signs or symptoms With increasing work Drop in SBP ≥ 10 mmHg Failure of HR to increase SBP > 250 mmHg or DBP > 115 mmHg Participant requests to stop
PLUS… 70% heart rate reserve (85% HRmax) |
