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57 Cards in this Set

  • Front
  • Back
Acute cardiovascular responses to exercise
HR - bpm
Stroke Volume - mL/beat
Arteriovenous Oxygen Difference - diff in oxygen saturation leaving heart and returning

Cardiac Output - HR x SV = Amount of blood pumped out of the L ventricle
Blood Flow
Blood
Blood pressure
Cardiovascular and respiratory system functions
Exchange gases between blood and atmosphere
Provide O2 to the tissues
Remove CO2 and metabolic waste products
How does HR respond to ex?
Increases:
Linearly and proportionally to work rate
SNS stimulation
From 60-200
Up to HR max
HR max ≈ 220 – age
Aerobic and resistance

Cardiac drift - heart rate increases gradually during sustained sub-max workout
How does SV respond to ex?
Increases:
Up to ~ 50-60% of max work, then plateaus
May see further increases in highly trained people
Max SV 100-200 mL/beat
25% lower in women
Range 50-110 ml/beat
@ rest
Decreased ventricular filling can make it plateau/decrease
SV with exercise
aerobic and resistance
With exercise, increased venous return, more expansion, ventricular fibers stretch and contract harder, so greater ejection fraction (frank Starling mechanism)
Increased SNS stimulation -> increased norepinephrine -> Ca++ -> cross bridging (faster)

Resistance
Holding breath during heavy load may decrease venous return
Arteriovenous Oxygen difference (a-vO2)
Difference in O2 content between arterial and mixed venous blood
Rest = 5 mL O2/100mL blood
Max exercise = 15-16 mL O2/100 mL blood
Difference increases with increasing workload
Increase in O2 extraction in exercising muscles
Cardiac Output
Q (L/min) = HR x SV
Rest = 5 L/min
Max exercise ≈ 20 L/min
Aerobic
Initial increase due to HR and SV
Later increases due to HR
Resistance: workload dependent
Lighter loads
Similar to aerobic, but smaller effect
Heavier loads
Small increases due to increased HR
Blood Flow
Blood flow is a function of pressure in system and peripheral resistance
Rest: skin and skeletal muscle get 20% of Q
Aerobic
Increase in blood flow to skeletal muscles
Body temperature increases increase in blood flow
Max exercise: up to 80% Q to skeletal muscles and skin
Resistance
Increased resistance to blood flow

= pressure/resistance
Blood - during exercise
Decrease total blood volume
lowers cardiac output

Hemoconcentration increases
more RBC’s per liter blood
Blood Pressure during exercise
Aerobic
Systolic BP (SBP): increases linearly with work
Max 200-240 mmHg
Diastolic BP (DBP): no change or slight decrease
Resistance
Increase in SBP and DBP
-Vasoconstriction
-Increase in total peripheral resistance
Summary of acute cardiovascular effects with exercise: Aerobic
Increased:
Cardiac output
Stroke volume
Oxygen uptake
Systolic blood pressure
Blood flow to active muscles and skin
Decreased or no change:
Diastolic blood pressure
Summary of acute cardiovascular effects with exercise: Resistance - heavy loads
Resistance - heavy loads

Increased:
Heart rate
Diastolic blood pressure
Systolic blood pressure
No change:
Oxygen uptake
Cardiac output
Stroke volume
Minute ventilation (VE)
VE = VT x RR
Volume of air breathed in one minute
Rest: 5-7.5 L/min
Maximal: 75-200 L/min
Increases with exercise immediately
Aerobic
Light effort: increase in VT
Moderate to high effort: RR also increases
Respiratory responses to exercise
Resting air is 5-7.5 liters/minute
tidal volume .5 liters/breath
frequency 10-15/minute
Air moved inc linearly with inc activity
20-25 liters air/L oxygen used lower
30-35 liters air/L oxygen used higher

Max air 75 to 200 liters/minute air moved by lungs
Breathing increases between 40 and 60 breaths/min
The amount of air moved by lunges can not be used as an indicator of fitness (depends on mass)
Metabolic Response to exercise
Oxygen uptake (VO2)
VO2 = Q x a-vO2
Amount of O2 available and consumed by the body tissue
Rest = 3.5 mLO2/kg/min
Max = 25-80 mLO2/kg/min
Aerobic

Resistance: not much change noted
Metabolic Response to exercise: Oxygen consumption
Oxygen consumption Liters per minute
Walking requires 1 L/min or 10 ml/kg/min
Jogging doubles

Highly trained 4 and 5 L /minute or
80-90 ml/kg/m
Females about 15-20% lower
Sedentary 20 ml/kg/min
Chronic Adaptations to Exercise
-Physiological Adaptations in Muscle: increased strength
Nervous adaptation
Motor unit recruitment
Golgi tendon organs (inhibition/adaptation)
Improved coordination
antagonist (less active?)

Muscular adaptation
Increase size (more actin/myosin)
hypertrophy of individual fibers >
hypertrophy of muscle (connective tissue?)
fiber splitting ????
less evidence for hyperplasia and fiber splitting
Chronic Adaptations to Exercise
Physiological Adaptations in Muscle: Anaerobic Adaptations
ATP-PC
enzymes responsible for ATP re-synthesis

Glycolysis
increase enzymes in 30” group
increase muscle buffering
Chronic Adaptations to Exercise
Physiological Adaptations in Muscle: Aerobic Adaptations
Capillaries surrounding muscles fibers Endurance athletes 50%
Myoglobin Increases significantly
Mitochondrial “reticulum” increases dramatically
Enzymes of oxidation increase
SDH (succinate dehydrogenase) 25%
inc in ability muscles to oxidize Fat as fuel
The ability to store muscle glycogen is inc.
Fat droplets in muscle inc
Chronic Adaptations to Exercise: Cardiovascular system: HR and SV
HR: Decrease resting heart rate.
SV: Increase SV – up to 20%
heart more efficient
Contractility: increase calcium flux and
calcium myosin-ATPase activity (decreases?)
Cardiac Output: by inc SV since resting HR
More pronounced in endurance Athletes-
get volume overload
Chronic Adaptations to Exercise: Cardiovascular system: Cardiac Output
Cardiac output: Strength athletes have normal
internal ventricular dimensions, but
thicker than normal ventricular muscle
that hypertrophies to same extent
as skeletal.
Maximum Q inc = (from) max SV because
max HR changes little
Chronic Adaptations to Exercise: Cardiovascular system: AvO2 diff, Blood things
Arteriovenous oxygen difference:
Increases slightly
Blood Flow:
Increased because of increase Q
Blood Flow to heart less during sub-
max due to heart more efficient
Blood Pressure:
Reduce resting systolic, diastolic, and
mean BP. Diastolic and mean pressure
dec during max work
Chronic Adaptations to Exercise: Physiological Adaptations to the respiratory system
Static lung volume: changes little
Vital capacity: inc some at expense of residual V
Resting air moved by lungs: little difference
Tidal volume: increased during max levels
Frequency Breathing: slight dec sub-max
Inc substantially with max
Pulmonary blood flow: Increased
Lung diffusion: may inc with max
Chronic Adaptations to Exercise: Physiological Adaptations - Oxygen consumption and VO2 max
Oxygen consumption: same during rest
Relative VO2 @ sub max less due to
increase VO2 max
VO2 max: Significant increase. 4-93%
Inc 20-30% seem reasonable
Untrained 32-40 ml/kg/min
Related to both increased
oxygen delivery to muscles or
by increased oxygen extraction
from blood by muscles related increase mitochondria and content of the muscle
Related to enzyme
The systematic and planned performance of bodily movements, postures, or physical activities intended to provide a patient with the means to
Therapeutic Exercise
The systematic and planned performance of bodily movements, postures, or physical activities intended to provide a patient with the means to
Remediate or prevent impairments
Improve, restore, or enhance physical function
Prevent or reduce health-related risk factors, restrictions, disability
Optimize overall health status, fitness, or sense of well-being
Patient vs. Client
PATIENT: With impairments and functional deficits, diagnosed by PT
CLIENT: without diagnosed dysfunction -> promote health and wellness
and to prevent dysfunction
What are the components of physical function
Balance/Postural Equilibrium
Cardiopulmonary/Endurance
Neuromuscular control/Coordination
Mobility/Flexibility
Muscle performance
Stability

Systems of the body that control each of these elements of physical function
React, adapt, and develop in response to forces placed on the tissues that make
Up the body systems
Therapeutic exercise interventions involve the application of
carefully graded physical stresses and forces that are imposed on impaired body systems, specific tissues, or individual structures in a controlled, progressive, safely executed manner to reduce physical impairments and improve function.
What are some aspects of safety?
Patients health history/current health status
Environment
Accuracy with which patient performs exercises
Therapist proper body mechanics
What are past and present models of functioning and disability?
past – focuses on a spectrum of disablement
Nagi model (injury limits function, ability)
ICIDH (... Impaired disability and handicap)
NCMRR
Present
ICF companion (ICD) International Classification of Functioning, Disability and Health
What is the benefit of the ICF model (as opposed to others)
Arrows are bi-directional, shows that PT can have impact on activities and participation
Addresses entire person, not focused on labeling with specific disease, but its effects and how to influence them
(The classification system provides a process for developing Impairment/function-based diagnoses that guide the treatment Of individuals with health conditions)
activity is at the center of the ICF framework (see visual representation)
What are components of the ICF
Impairment in Body Function
Impairment in Body Structure
Activity limitation
Participation restriction
Contextual Factors
Environmental
Personal

Body functions and structures
Activities and Participation
Functioning and Disability
Components of Functioning and Disability Models and Applications in Physical Therapy
-some history
Back-in-the-day: focus on Elimination and Remediation of Disability
Then more Promotion of well-being
Preventing or reducing risk factors
1990s - clinical decision making and standardized terminology
Became the practice act - 2001 Guide to PT (document of consensus for best practice)
ICF - Health Conditions
(Pathological/Pathophysiological Conditions)
Health Conditions
(Pathological/Pathophysiological Conditions)
Acute or chronic diseases, disorders, or injuries
Active pathology that disrupt body’s homeostasis
Model - Impairments/ body function and body structure
Consequences of pathological conditions and encompass the signs and symptoms
That reflect abnormalities at the body system, organ, and tissue level

Body function and body structure
Primary and secondary - primary is direct effect, secondary is consequence

Musculoskeletal
Neuromuscular
Cardiovascular/P
Integumentary
Common musculoskeletal physical impairments
Pain
Weakness
Decreased endurance
Limited ROM due to
Restricted jt capsule
Restricted periarticular tissue
Decreased muscle length
Jt hyper mobility
Faulty posture
Muscle strength imbalance
Common cardiovascular physical impairments
Decreased aerobic capacity
Impaired circulation
Pain with sustained physical activity
(intermittent claudication)
Common Neuromuscular Physical Impairments
Pain
Impaired balance
Incoordination
Delayed motor development
Abnormal tone
Ineffective, inefficient functional movement strategies
Common integumentary physical impairments
Skin hypomobility
Patient management and clinical decision-making: An interactive relationship
Clinical Decision-making
Clinical Prediction Rules (CPR’s)
Evidence-Based practice
Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of an individual patient
Identify problem
Search literature
Analyze evidence
Integrate with expertise
Incorporate into patient management
Assess outcomes
Clinical Prediction Rules
Classic Example
Predictive factors help establish diagnosis
Improve accuracy of diagnosis
Identify subgroup of patients most likely to benefit from a particular approach
Classic Example: A clinical prediction rule to identify patients with low back pain
most likely to benefit from spinal manipulation: a validation study

Patients were most likely to benefit from spinal manipulation if they met
4 of 5 of the following criteria:
Symptom duration of less than 16 days
No symptoms distal to the knee
Score of less than 19 on fear –avoidance measure
At least one hypomobile segment
At least one hip with more than 35* of IR
A Patient Management Model
Examination
History
Systems Review table 1.3
Specific tests and measures

Evaluation of data collected

Diagnosis box 1.12
Diagnostic process
Diagnostic category

Prognosis and Plan of Care
Setting goals and outcomes in plan of care

Intervention
Coordination, communication, and documentation
Procedural interventions
Strategies for Effective Exercise and Task-specific Instruction
Preparation for Exercise Instruction

Concepts of Motor Learning: A foundation for Exercise and Task-specific Instruction

Adherence to Exercise
Preparation for Exercise Instruction
Does the patient believe exercises will lessen symptoms
Is the patient concerned ex will be uncomfortable
Is patient accustomed to engaging in regular exercise
Motor learning
Motor Learning – a complex set of internal processes that involves the acquisition and relatively permanent retention of a skilled movement or task through practice
Motor performance v. motor learning?
Acquisition v. retention
Aspects showing that motor learning has occurred
Understand the task or goal
Able to activate the motor system
Be able to retrieve motor memories over time
Be able to perform a slight variation of the task in a new context
Types of Motor Tasks
Types of motor tasks
Discrete-recognizable beginning and end.
Serial task- discrete movements combined with particular sequence “eat with a fork”
Continuous task-repetitive uninterrupted movements “walking, cycling”
Closed vs. Open Environment
Closed environment: objects around patient and surface on which task is performed do not move
EX: sitting with support and working at a desk; eating at home
Permits greater focus and self-pacing; predictable

Open environment: objects or other people are in motion; or, support surface is unstable while performing task
EX: ascending/descending stairs in public or crowded area
Unpredictable, match pace to environmental demands; loss of control
Inter-trial variability in the environment: absent or present
Inter-trial variability in the environment: absent or present
In a constant, unchanging environment, there is little opportunity for variability (absent)
Environment is predictable
Attention to task is minimal if skill is well-learned
If the environment changes from one trial to the next, variability increases (present)
Body stable or body transport
Body stable or body transport
Analysis of the task from the person perspective
Must the body be stable/stationary or moving?
Stable = simple task
Donning shoes/socks while seated on a firm surface
Body movement from one place to another = complex
EX: walking, transfer from wheelchair to another surface
Manipulation of objects: absent or present
Manipulation of objects: absent or present
Does the task involve UE manipulation of objects?
Stages of motor learning
cognitive
associative
Autonomous
Cognitive Stage of motor learning
Cognitive stage – What do I need to do? What are the demands of the task? How do I do it?
Learning
Thinking about components of a skill, feel of the skill
Attentional demands are high
High rate of error
Associative Stage of Motor Learning
Associative stage – I understand what I need to do
Refining
Consistency and efficiency evolving
Modify and vary performance
May perform under varied environmental demands
Decreased error rate; self-correcting; problem-solving; less need for feedback
Autonomous Stage of Motor Learning
Autonomous stage - I’ve got this down!
Skill performed automatically
No attention required to perform the task
May multi-task or execute with varied task and environmental demands
Variable that Influence Motor Learning-Considerations for Exercise Instruction and Functional Training
Pre-practice
Understand the purpose
Practice
Part vs whole
Block, random, random/blocked
Feedback
Intrinsic feedback – NOT from therapist
Augmented feedback-verbal or tactile
Knowledge of performance vs know of results
Feedback schedule-timing and frequency
Factors That Influence Adherence to an Exercise Program
Patient-related factors
Factors related to the health condition or impairments
Program-related variables
Strategies to Foster Adherence