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533 Cards in this Set

  • Front
  • Back
Annual incidence and lifetime prevalence of low back pain in the US
- annual incidence: 5-10%
- lifetime prevalence 60-90%
General guidelines for the clinical course of low back pain
50% resolve by 1-2 weeks
90% resolve by 6-12 weeks
but 85% recur within 1-2 years
Percentage of patients with low back pain that continue with residual complaints
10%
Back pain with gait ataxia and upper motor neuron changes is a red flag for
Myelopathy
Back pain with bowel, bladder and sexual dysfunction is a red flag for
Cauda equina syndrome
Back pain with night pain and weight loss is a red flag for
Tumor
Back pain with fevers/chills is a red flag for
Infection
Top 2 causes of work absenteeism
- colds
- low back pain
Describe the general expectations for return to work for patients with low back pain based on how many months they're been off work
- 6 months: 50% return
- 12 months: 25% return
- 24 months: 0 return
What is the Joint of Luschka
degenerative changes in the cervical spine that lead to an uncovertebral joint
What do you call the changes in the cervical spine that lead to an uncovertebral joint?
Joint of Luschka
What is unique about the vertebral bodies of C3-C7
They have uncinate processes projective superiorly from the lateral aspect of the vertebral body
Which cervical vertebrae have a bifid spinous process
C2, C3, C4, C5, C6
What is the shape of the spinous process of C3, C4, C5, C6
Bifid
What is the shape of the C7 spinous process
nonbifid
Name 2 important anatomical features of the atlas (c1)
- ring shaped bone with 2 lateral masses
- no vertebral body or spinous process
Name 2 important anatomical features of the axis (C2)
- vertebral body has odontoid process
- bifid spinous process
The posterior border of the dens foramen is the
transverse ligament
2 important anatomical features of the thoracic vertebrae
- facets for the head of the rib
- long spinous process
Define lumbar sacralization
An anomalous fusion of the 5th lumbar vertebrae with the sacrum
What is the incidence of lumbar sacralization?
- 1% complete
- 6% incomplete
What are the 3 joints that form the motion segment in the lumbar spine?
1- disc
2- zygapophyseal joint
3- zygapophyseal joint
What are the foramina like in the sacrum?
There are 4 PAIRS of foramina (anterior and posterior)
How many fused vertebrae are in the sacrum?
5
Define sacral lumbarization
An anomalous partial or complete nonunion of the 1st and 2nd segments of the sacrum
Incidence of sacral lumbarization
4%
5 major components of the zygapophyseal joint
- superior articular process
- inferior articular process
- joint capsule
- articular cartilage
- meniscus
Which vertebral joints do not participate in true zygaophyseal joints?
Atlantoaxial
Atlanooccipital
General orientation of the facets joints as you progress throught the spine
cervical: coronal
thoracic: coronal
lumbar: starts sagital, progresses to coronal by L5/S1
Orientation of cervical z-joints
coronal
Orientation of thoracic z-joints
coronal
Orientation of lumbar z-joints
start sagital, then progresses to coronal by L5/S1
Weight bearing on the facet joint is increased in which position?
extension
Major function of the z-joints
Direct vertebral motion including resisting shearing and rotation forces
The intervertebral disc is made of these 2 parts
- nucleus pulposus
- surrounding annulus fibrosus
Major molecular components of the nucleus pulposus
- water
- proteoglycans
- network of type II collagen
The annulus fibrosus is made of mainly
Type I collagen fibers
General arrangement of collagen fibers in the annulus fibrosus
obliquely running lamellae
Where does the annulus fibrosus attach?
At the vertebral endplates
What forces is the annulus fibrosus good and bad at resisting
- Good: distraction, bending
- Bad: torsion
What makes up the top and bottom of the intervertebral disc?
The vertebral endplate
What is the vertebral endplate?
cartilaginous covering of the vertebral boy apophysis
What is the vascular supply of the intervertebral disc?
Essentially avascular by adulthood
What are the 2 major functions of the intervertebral disc?
- allows for vertebral body motion
- weight bearing
What happens to the nuclear water content of the intervertebral disc with age?
decreases
What happens to the ratio of chondroitin:keratin of the intervertebral disc with age?
decreases
What happens to proteoglycan molecular weight of the intervertebral disc with age?
decreases
What happens to the fibrous tissue of the intervertebral disc with age?
increases
What happens to the cartilage cells of the intervertebral disc with age?
increases
What happens to the amorphous tissue of the intervertebral disc with age?
increases
What general part of the nerve gives contributions to the trunk musculature and the lumbosacral plexus?
the ventral primary rami
In general, the lateral branch of the dorsal primary ramus innervates
- iliocostalis
- skin
In general, the intermediate branch of the dorsal primary ramus innervates
- longissimus
In general, the medial branch of the dorsal primary ramus innervates
- multifidus
- spine rotators
- interspinalis
- intertransversei
- posterior spinal ligaments
- z-joints
What innervates the iliocostalis?
lateral branch of the dorsal primary ramus
What innervates truncal skin?
lateral branch of the dorsal primary ramus
What innervates the longissimus?
intermediate branch of the dorsal primary ramus
What innervates the multifidus?
medial branch of the dorsal primary ramus
What innervates the spinal rotators?
medial branch of the dorsal primary ramus
What innervates the interspinalis?
medial branch of the dorsal primary ramus
What innervates with intertrnsversei
medial branch of the dorsal primary ramus
What innervates with posterior spinal ligaments?
medial branch of the dorsal primary ramus
What innervates the z-joints?
medial branch of the dorsal primary ramus
What does the sinuvertebral nerve innervate?
- posterior longitudinal ligament
- posterior disc
- anterior dura
- vertebral body
- anterior-lateral disc
What innervates the posterior longitudinal ligament?
the sinuvertebral nerve
What innervates the posterior disc?
the sinuvertebral nerve
What innervates the anterior dura?
the sinuvertebral nerve
What innervates the vertebral body?
the sinuvertebral nerve
What innervates the anterior-lateral disc
the sinuvertebral nerve
Define axial cervical pain
pain occurring in all or part of a corridor extending from the inferior occiput inferiorly to the the superior interscapular region, localizing to the midline or just paramidline
Define cervical radicular pain
pain involving the shoulder girdle and distally
Incidence of neck pain
30%
Prevalence of neck pain
9-18%
Percentage of those with traumatic neck pain that becomes chronic
40% (10% severe)
Incidence of cervical radiculopathy
83.2/100,000
Peak age from cervical radiculopathy
50s
Orientation of the cervical z-joints
45 deg sagital inclination
C1-2 allows what % of cervical rotation
about 50%
In cervical spine, lateral flexion is coupled with ____
rotation in the same direction
Cervical spine segments at C2-3 and above move primarily in what directions?
rotation
Cervical spine segments below C2-3 move primarily in what directions?
flexion, extension and lateral bending
The z-joints are generally innervated by the
medial branches of the cervical dorsal rami
The C0-1 joint is also innervated by
C1 ventral ramus
The C1-2 joint in also innervated by
C2 ventral ramus laterally and the sinuvertebral nerves of C1-3 medially
The greatest amount of flexion in the cervical spine occurs at what level?
C4-5 and C5-6
The greatest amount of lateral bending in the cervical spine occurs at what level?
C3-4 and C4-5
Which vertebrae have joints of Luschka?
C3-7
Normally the dorsal root ganglia/radicular complex takes up what % of space in the neural foramen?
25%
What besides nerve tissue is in the neural foramen
- adipose tissue
- Hoffman's ligaments
- radicular artery
- numerouss venous conduits (encircle nerve root)
Innervation of the annulus fibrosis
posterolaterally by the sinuvertebral nerve, anteriorly by the vertebral nerve
How do discs contribute to the normal cervical lordosis?
They are thicker anteriorly
The mechanism of somatically referred pain involves ______
convergence
Describe convergenge is referred pain
afferents from spine and distal limb converge on second-order neurons within the spinal cord
Does cervical disc pain tend to be unilateral or bilateral?
30-50% in bilateral
The structures that threaten nerves in the intervertebral foramina
- zygapophyseal joints
- uncovertebral joints
- intervertebral disk
Ddx causes of cervical radiculopathy
- arthritis
- tumor
- trauma
- sarcoidosis
- arteritis
- cerebral palsy
2 general categories of cervical intervertebral disk injury
- internal disruption
- herniation
Subcategories of intervertebral disk herniation
- protrusion
- extrusion
- sequestration
Define cervical strain
musculotendinous injury produced by an overload injury due to excessive forces imposed on the cervical spine.
Define cervical sprain
overstretchning or tearing injuries of spinal ligaments
Do cervical muscles have tendons?
Many just have direct insertions with myfascial tissue
% of patients in a MVC that develop neck pain within 24 hours
30%
Cervical sprain and strain injuries account for what % of neck pain in the US
85%
Describe the movement of the c-spine during MVC acceleration-decceleration injury
90ms: posterior neck muscles activate
100ms: s-shaped curve
200ms: neck maximally extends to 45deg and then starts forward flexion; neck extensors eccentrically contract
What is the boundary like between the anterior longitudinal ligament and the intervertebral disk?
merges imperceptibly
Muscles most commonly involved in gaurding during neck pain
upper trapezius, SCM
When is imaging indicated in soft tissue neck injury?
- neuro or motor abnormalities
- significant pain in the limbs
Progression of ordering imaging in neck pain
- plain radiographs for fracture/bony malalignment; +/- flex/ext to eval for instability
Non-specific loss of cervical lordosis after neck soft tissue injury is thought to be due to
muscle splinting
General 3 step approach to treating soft tissue neck injuries
- controlling pain/inflammation (NSAIDs/acetaminophen)
- mitigate deconditioning
- functional restoration program
Soft cervical collars used as part of treatment for neck soft tissue injuries should be d/c'd at _____
72 hours
4 major s/s in cervical radicular pain
- myotomal weakness
- paresthesias
- sensory disturbances
- stretch reflex changes
What's the difference between cervical radicular pain and cervical radiculopathy?
radiculopathy implies pathological changes at the nerve root
Most commonly involved levels of cervical radiculopathy (most to least)
- C7
- C6
- C8
- C5
Estimated incidence of cervical radiculopathy
83/100,000
Decade when cervical radiculopathy appears most common
50s
#1 and 2 causes for cervical radiculopathy
-1-cervical intervertebral disk herniation
- cervical spondylitic changes
4 major changes considered part of spondylosis
- ligamentous hypertrophy
- hyperostosis
- disk dengeneration
- zygapophyseal joint arthropathy
2 major (general) ways that herniated disk causes radicular pain/radiculopathy
- mechanical compression
- biochemical irritation
Radicular pain referred to the medial scapular edge is usually from what level(s)?
C5-7
Radicular pain referred to the superior trapezius is usually from what level(s)?
C5-6
Radicular pain referred to the precordium is usually from what level(s)?
C5-6
Radicular pain referred to the deltoid/lateral arm is usually from what level(s)?
C5-6
Radicular pain referred to the posteromedial arm is usually from what level(s)?
C7-T1
What is the shoulder abduction relief sign?
Relief of radicular symptoms by elevating tHe ipsilateral humerus.
What is the classic position in patients with new intervertebral disk herniation?
patients clinically tilt toward the side of the disk herniation.
Where do you look for muscle wasting in C5-6 radiculopathy?
suprascapular fossae, infrascapular fossae, deltoid
Where do you look for muscle wasting in C7 radiculopathy?
tricpes
Where do you look for muscle wasting in C8 radiculopathy?
thenar eminence
Where do you look for muscle wasting in T1 radiculopathy?
first dorsal interossei
Is severe muscle weakness consistent with single level radiculopathy?
Not so much; ddx should then include:
- multilevel radiculopathy
- alpha motor neuron disease
- plexopathy
- focal peripheral neuropathy
3 major reasons for a positive L'hermitte's sign
- tumor cervical cord involvement
- spondylosis
- multiple sclerosis
Progression of imaging in cervical radiculopathy
- plain x-rays (add views if trauma, arthritis, etc)
- CT if concerned about bone
* MRI is modality of choice
Imaging gold standard for degenerative cervical spine conditions
CT myelography
Imaging test of choice for disk pathology in patients who cannot undergo MRI
contrast enhanced CT
General electrodiagnostic guidelines for radiculopathy
abnormalities in two or more muscles innervated by the same root but different peripheral nerves, provided that normal findings are observed in muscles innervated by adjacent nerve roots; need one motor and sensory nerve conduction study in affected limb to rule out plexus or peripheral process; look at corresponding muscles in contralateral limb
For screening upper limb radiculopathy 6 upper limb muscles + paraspinals gives ____ sensitivity
94-99%
How can you use EMG/NCS to predict motor recovery in radiculopathy?
If CMAP amplitude is at least 50% of nomral side then functional recovery can be expected with conservative care
4 major goals of rehab for cervical radiculopathy
- resolution of pain
- improve myotomal weakness
- avoid spinal cord complications
- prevent recurrence
Definitive indication for surgery for cervical radiculopathy
progressive neurologic deficit
General precautions in cervical radiculopathy
- no heavy lifting
- avoid extension, axial rotation and ipsilateral flexion
General guidelines for superficial heat and cold in cervical radiculopathy
- heat: 30 min tid
- cold: 15-30 min qid
Should US be used in cervical radiculopathy?
No, increase metabolic response/inflammation can aggravate nerve root injury
Soft cervical collar limit flexion and extension by about ____%
26%
The neck should generally be maintained in a _______ position at rest
neutral or slightly flexed (position thin part of soft collar anteriorly)
Typical force needed in cervical traction
25 pounds, at 24 degrees of pull for 25 minutes (this will distract midcervical segments)
Contraindications to cervical traction
- myelopathy
- L'hermitte's sign
- rheumatoid arthritis
- atlantoaxial subluxation
Medications useful in cervical radiculopathy from herniated disk
* NSAIDs
- muscle relaxants for sleep
- TCAs for sleep
- antiepileptics for persistant pain (start qhs and titrate up)
- short acting narcotics for severe pain disrupting sleep
Key components of stabilization program in cervical radiculopathy
- spinal flexibility
- postural reeducation
- conditioning (cervical strengthening)
Key muscles to have strong in cervical radiculopathy
- trapezius
- serratus anterior
- rhomboids
- rotator cuff
When might a fluoroscopically guided diagnostic selective nerve root block be helpful for considering the diagnosis of cervical radiculopathy?
when the exam and EMG/NCS are equivocal in the setting of abnormal MRI
Sensitivity and specificity of diagnostic selective nerve root blocks for cervical radiculopathy
100% sensitive
87+% specific
Natural history of cervical radiculopathy from herniated disk
~60% have a gradual resolution of symptoms
In general, surgical outcomes studies for cervical radiculopathy indicate a good or excelelnt result in ____% of patients
80-96%
In general, how do outcomes from surgery and conservative care for cervical radiculopathy compare?
surgery provides faster pain relief but they are about the same at a year
Estimated prevalence of chronic traumatic cervical zygapophyseal joint-mediated neck pain
~60%
Painful cervical zygapophyseal joints most commonly occur in association with a ________
symptomatic intervertebral disk at the same level
% of patients with chornic zygaophyseal cervical joint pain that also complain of headache
60+%
% of patient with posterior headaches after whiplash injyury who have C2-3 z-joint pain
50%
Traumatic lower cervical pain from z-joints is usually at what level?
C5-6
Atraumatic z-join pain is often from ____
- spondylosis
- improper biomechanics
(usually effects just one joint)
Are there any clear physical exam findings for z-joint pain?
no
What do you often find on exam with painful C1-2 joint?
focal suboccipital pain that occurs/exacerbated with 45 deg cervical flexion and then axial rotation
General guidelines for imaging in z-joint pathology of the cervical spine
Unclear usefulness
- x-ray or CT if fracture/malalignment suspected
- NM scan does not clearly reflect symptomatic findings
% of diagnostic z-joint blocks that are false positives
30%
Define cervical internal disk disruption
intervertebral disk has lost its normal internal architecture but maintains a preserved external contour in the absence of nerve root compression
% of patients with traumatic chronic neck pain with an element of cervical internal disk disruption
60%
- 20% with CIDD
- 20% with CIDD and facet problem
What's better for cervical internal disk disruption, non-operative or operative intervention?
they are about the same in non-litigation cases
11 elements often part of the symptom complex of cervical internal disk disruption
- posterior neck pain
- occipital/suboccipital pain
- upper trap pain
- inter- and periscapular pain
- non-radicular arm pain
- vertigo
- tinnitus
- ocular dysfunction
- dysphagia
- facial pain
- anterior chest wall pain
Typical exacerbating factors for cervical internal disk disruption
- prolonged sitting
- coughing
- sneezing
- lifting
Typical alleviating factors for cervical internal disk disruption
- lying supine
- resting recumbent with head supported
Markers of disk degeneration on MRI
- disk desiccation
- loss of disk height
- annular fissure
- osteophytosis
- reactive end plate changes
- decreased T2 signal
Is MRI helpful in detecting symptomatic cervical disks
no
Preferred imaging for painful cervical disks
functional imaging such as provocative diskography
Treatment of cervical internal disk disruption
- NSAIDs
- Adjunct meds for sleep
- modalities to modulate pain
- cervical traction
- functional restoration program
Guidelines for checking renal function while patients are on NSAIDs (American College of Rheumatology)
If otherwise healthy, check renal function at 6 weeks, if normal check again at 12 months
Where do cervical internal disk disruptions and facet pathology overlap in referred symptoms?
head and face pain
What levels are transforaminal epidural steroid injections typical performed at for cervical internal disk disruptions?
- C7 if pain at the base of the neck
- C5/C6 if pain in upper neck/head
What is the surgical option for pain from cervical degenerative disk disease?
fusion
Most common cervical cord lesion after middle age
cervical spondylitis myelopathy
Typical age of onset of cervical myelopathy
over 50
Is cervical myelopathy more common in men or women?
men
8 causes to consider for cervical myelopathy
- spondylosis
- multiple sclerosis
- motor neuron disease
- vasculitis
- neurosyphilis
- subacute combined degeneration
- syringomyelia
- spinal tumors
% of patients with cervical myelopathy NOT due to simple degeneration
17%
Proportion of patients with cervical myelopathy with bladder/bowel symptoms
about 1/3
What is the typical mechanism for intrinsic hand wasting in cervical myelopathy?
compression of anterior horn cells
% of middle aged patients with cervical myelopathy that have ossification of posterior longitudinal ligament on imaging
27%
What cervical spine central canal diameter in a symptomatic patient supports a diagnosis of myelopathy?
less than 10mm
% of patients under the age of 64 with asymptomatic central cervical spine stenosis
16%
Minimum % reduction in cross-sectional area of the cervical spine canal to cause symptoms
30%
Imaging finding for cervical myelopathy that best predicts surgical outcome
transverse area of the cord
% of patients with cervical myelopathy who have improvement in motor or sensory symptoms with conservative care
30-50%
Indications for surgery in cervical myelopathy
- progressive symptoms
- severe symptoms
- failure of conservative therapy
General approach to anterior vs. posterior decompression for cervical myelopathy
- if 3 or fewer levels -> anterior
- 3 or more levels with lordosis preserved -> laminoplasty
- 3 or more levels with loss of lordosis -> laminectomy and posterior fusion
% of patients with cervical myelopathy who get pain relief with anterior decompression
~90%
Definition of cervicogenic headache
constellation of symptoms that represent the common referral patterns of cervical spinal structures.
Are women or men more commonly affected by cervicogenic headaches?
women
Mean age for cervicogenic headache
43years
How are cervicogenic headaches possible?
convergence
Primary structres thought to be the source of cervicogenic headaches
- C2-3 z-joint
- C2-3 intervertebral disk
- C3-4 intervertebral disk
- C4-5 intervertebral disk
- C5-6 intervertebral disk
Typical history for cervicogenic headaches
trauma
Sequence of injections often tried for cervicogenic headaches
intrarticular injections at:
C2-3
C3-4
C1-2
3 components of "whiplash"
- whiplash event (biomechanics)
- whiplash injury (injured structure)
- whiplash syndrome (symptoms)
Common symptoms with whiplash
- neck pain
- headaches
- shoulder girdle pain
- upper limb paresthesias
- weakness
Less common symptoms with whiplash
- dizziness
- visual changes
- tinnitus
General recovery after whiplash
- most recover in 2-3 months
- after 2 years 80% are symptom free
Function of the anterior longitudinal ligament
- limits hyperextension
- limits anterior translation
Course of the anterior longitudinal ligament
attaches to all vertebral bodies anteriorly
Course of the posterior longitudinal ligament
Posterior rim of the vertebral bodies and disc from occiput (tectorial membrane), C2 to sacrum
Function of the posterior longitudinal ligament
limits hyperflexion
Course of the ligamentum nuchae
continuation of the supraspinaous ligament
Function of the ligamentum nuchae
boundary of the deep muscles in the cervical region
What's the boundary of the deep muscles in the cervical region
ligamentum nuchae
Course of the ligamentum flavum
attaches laminae to laminae
Function of ligamentum flavum
maintains constant disk tension and assists in straightening the spinal column after flexion
Supraspinous ligament runs from
C7-L3
Function of the interspinous ligament and supraspinous ligament
resists spinal separation and flexion (weak)
Course of intertransverse ligament
transverse process to transverse process
Function of intertransverse ligament
resists lateral bending of the trunk
Anterior landmark of C2
transverse process at the angle of the mandible
Anterior landmark of C3
hyoid bone
Anterior landmark for C4/C5
thyroid cartilage
Anterior landmark for C6
- first cricoid ring
- carotid tubercle
Posterior landmark for C2
- first palpable midline spinous process
- 2 fingerbreadths below the occiput
Posterior landmark for C7
vertebral prominens
Posterior landmark for T3
spine of the scapula
Posterior landmark for T8
inferior angle of the scapula
Posterior landmark for T12
lowest rib
Landmark for L4
iliac crests
Landmark for S2
Posterior superior iliac spine
What are the extrinsic back muscles?
Superficial
- trapezius
- latissimus dorsi
Intermediate
- serratus posterior
What are the superficial intrinsic back muscles?
- splenius capitis
- splenius cervices
What are the intermediate intrinsic back muscles?
Erector spinae...
- Iliocostalis: lumborum, thoracis, cetrvices
- Longissiumus: Thoracis, cervicis, capitis
- Spinalsi: thoracis, cervicis, capitis
What are the deep intrinsic back muscles?
* Transversospinal muscles:
- semispinalis: thoracis, cervicis, capitis
- multifidus
- rotators
* interspinalis, intertransversarii
What back muscle are normally active in erect posture?
Mild activity in the erector spinae muscles
What muscles are active (in sequence) as you flex the trunk forward?
- initial: increased erector spinae activity
- mid flexion: increased gluteus maximus activity
- Late flexion: increased hamstring activity
- terminal flexion: electrical silence
50% of the flexion of the cervical spine occurs at the ____ joint
occipitoatlantal
50% of the extension of the entire cervical spine occurs at the ____ joint
occipitoatlantal
50% of the rotation oft eh entire cervical spine occurs at the ____ joint
atlantoaxial
3 phases of the Kirkaldy-Willis function degenerative classification
1) dysfunction
2) instability
3) stability
Enzyme released from herniated nucleus pulposus thought to be involved in starting the inflammatory cascade
phospholipase A2
Inflammatory mediators thought to be involved in pain from herniated nucleus pulposus
- leukotrienes
- prostaglandins
- platelet activating factors
- bradykinins
- cytokines
Typical age for herniated nucleus pulposus
30-40
3 most common spine levels for herniated nucleus pulposus
L4-5
L5-S1
C5-6
Natural clinical course in herniated nucleus pulposus
3/4 will resolve with conservative care in 6-12 months
Central herniated nucleus pulposus is typically made worse by what movement?
forward flexion
posterior-lateral herniated nucleus pulposus is typically made worse by what movement?
forward flexion
lateral herniated nucleus pulposus is typically made worse by what movement?
extension
Reflex abnormality at L2
Cremaster
What is Lasegue's test?
dorsiflexion of the ankle with straight leg raise neural tension test
What is Bowstring test (Cram test)?
with positive straight leg raise, then bend the knee about 20 degrees and apply pressure to the nerve behind the popliteal fossa
Indications for cervical traction
radicular pain
muscle spasm
Contraindications for cervical traction
- ligamentous instability
- radiculopathy of unclear origin
- acute injury
- rhematoid arthritis
- vertebrobasilar arteriosclerotic disease
- spinal infections
Epidural steroid injections can exacerbate these underlying medical conditions
- DM
- CHF
- HTN
Chymopapain injections are used to treat what?
herniated nucleus pulposus
Mechanism of action of chymopapain injection
dissolve subligamentous herniations contained by the posterior longitudinal ligament (poor efficacy)
5 major causes of cauda equina syndrome
- large central disk herniation
- epidural tumors
- hematomas
- abscesses
- trauma
Internal disk disruption is association with
- annular fissures
- nuclear tissue disorganization
Grading of internal disk disruptions
grade 0 = no annular disruption
grade 1 = inner 1/3 annular disruption
grade 2 = inner 2/3 annular disruption
grade 3 = outer 1/3 annular disruption +/- circumferential spreading
Etiology of internal disc disruption
endplate fractures from excessive loads
Internal disc disruption pain is usually worse with what position?
sitting
Best imaging for radial fissures of the disk?
postdiscogram CT
Most common levels of spinal stenosis
L3 and L4
Normal spinal canal size
17mm
The spinal cord is typically ____ in diameter
10mm
3 sub-areas of lateral spinal stenosis
- lateral recess
- mid zone
- intervertebral foramen
Stenosis at the lateral recess is typically caused by
hypertrophic facet joints
Stenosis at the pars region (midzone) is typically caused by
osteophytes under the pars
Stenosis at the intervertebral foramen is typically caused by
hypertrophic facet joints
The root level affected by lateral recess stenosis is
the same level as the vertebrae
The root level affected by midzone stenosis is
the same level as the vertebrae
The root level affected by intervertebral foramen is
one level up from the vertebrae
Pain in neurogenic claudication is typically described as
numbness, aches
Pain in vascular claudication is typically described as
cramping, tightness
Location of pain in neurogenic claudication is typically described as
thigh and calf
Location of pain in vascular claudication is typically described as
calf
Neurogenic claudication is often exacerbated by
standing
walking
lying flat
Vascular claudication is often exacerbated by
walking/cycling
In neurogenic claudication the bicyle test is
painless
In vascular claudication the bicyle test is
painful
In neurogenic claudication walking downhill is
painful
In vascular claudication walking downhill is
painless
In neurogenic claudication walking uphill is
painless
In vascular claudication walking uphill is
painful
Neurogenic claudication is alleviated by
- flexed position
- bending
- sitting
Vascular claudication is alleviated by
- standing
- resting
- lying flat
Associated factors in neurogenic claudication
- back pain
- decreased spine motion
- atrophy
- weakness
- normal pulses
Associated factors in vascular claudication
- rare back pain
- normal spine motion
- rare atrophy/weakness
- abnl pulses
- shiny skin
- loss of hair
Average length of stay on acute care post-MI and post cardiac surgery
post-MI: 3-5 days
post surgery: 5-7 days
Leading cause of morbidity and mortality in the USA in both men and women
cardiovascular disease
% of people between the ages of 55-64 with cardiovascular disease
- men 51%
- women 48%
% of people over the age of 75 with cardiovascular disease
- men 71%
- women 79%
% mortality 1 year and 8 years after MI
- 1 year men: 25%
- 1 year women: 38%
- 8 years: 50%
Globally, heart disease contributes to what % of deaths each year
33%
% of adults in the US that participate in regular physical activity
40%
Risk factors for generally being less physically active
- single women
- elderly
- less educated
- less affluent
- African American
- Hispanic
American College of Sports Medicine general recommendations for exercise
30 min of moderate activity on most days of the week (aprox 600-1200 kcal)
How does exercise best relate to modifying cardiovascular risk factors
Total energy expenditure is more important that intensity or duration of activity
Risk of cardiac event from exercise in patient with CV disease
1/400,000-1/800,000 hours of exercise; lower in regular exercisers

(that's once in 545 years of exercising for 30 min every day)
SBP or DBP parameters for normal BP
SBP <120
DBP <80
SBP or DBP parameters for prehypertension
SBP 120-139
DBP 80-89
SBP or DBP parameters for stage 1 hypertension
SBP 140-159
DBP 90-99
SBP or DBP parameters for stage 2 hypertension
SBP >160
DBP >100
Most significant risk for death worldwide
HTN
Risk for MI and death from HTN increases above what BP level?
115/75
A 5mmHg decrease in blood pressure provides what % reduction in mortality from CAD?
9%
Expected effects of lifestyle modification on BP
lower SBP about 4mmHg
How long of a trial of lifestyle modification do you get for HTN before you're started on medications?
- 12 months for stage 1 HTN with no other CAD risk factors
- 6 months for stage 1 HTN with other risk factors
- Done with meds for stage 2 HTN
Number of people in the USA who start smoking every day
4,000
% of men and women in the US who smoke
- men 25%
- women 20%
Leading cause of preventable illness and death in the US
cigarette smoking
Someone who quits smoking can expect what reduction in CAD risk after 1 year
50%
% of people who quit smoking after CABG who relapse within 1 year
70%
What is the best program for smoking cessation (and its success rate)
20% success with:
behavioral support, nicotine replacement, and sustained release bupoprion
General categories now used for classification of dyslipidemia
- optimal
- near optimal
- borderline high
- high
- very high
(but not all used for each subset of lipds)
Classification of total cholestrol in dyslipidemia
- Optimal <200
- Borderline high 200-239
- High >240
Classification of LDL in dyslipidemia
- Optimal <100
- Near optimal 100-129
- Borderline high 130-159
- High 160-189
- Very high >190
Classification of triglycerides in dyslipidemia
- Optimal <150
- Borderline high 150-199
- High 200-299
- Very high >500
Classification of HDL in dyslipidemia
- optimal >60
- higher risk <40
What % of dyslipidemia can be explained by modifiable factors like weight, activity, smoking and DM?
50% (genetics play the other large role)
Benefits of exercise in dyslipidemia continue how long?
as long as exercise is continued
Definition by BMI of overweight and obese
>25 = overweight
>30 = obese
% of American adults that are overweight
60%
% of American adult that are obese
- Causasians 30%
- AA men 30%
- AA women 50%
Changes in weight that appear to be significant for changing cardiovascular disease risk
- gain of 10 pounds
- loss of 10%
General dietary guidelines of lipid management
Total fat 30% of cal
Carbs 50% of cal
Protein 15% of cal
Cholesterol <200mg/day
Fiber 20-30 grams/day
Fasting glucose that = diabetes
>125
What's a normal fasting glucose?
less than 110
Impaired fasting glucose is
110-125
Prevalance of DM in USA
7% adn increasing
What characterizes the metabolic syndrome
1. abdominal obestiy
2. triglycerides >150
3. HDL <40 in men or <50 in women
4. HTN >130/85
5. Fasting glucose >110
6. proinflammatory state
7. prothrombotic state

(3+ of #1-5 must be present)
% of people with metabolic syndrome
- 45% of people 60yo+
- 30% of all people who are overweight/obese
4 emerging risk factors for CAD
- lipoprotein a
- homocysteine
- prothrombotic states
- high-sensitivity CRP
3 substrates used in metabolic pathways
carbohydrates, fats, proteins
Carbohydrates are stored as
glycogen in liver and muscle
Fat is stored as
triglycerides in adipose tissue
Protein is stored as
muscle
Carbohydrates for metabolism circulate as
glucose
Fat for metabolism circulates as
fatty acids, glycerol
Protein for metabolism circulates as
amino acids
In exercise, carbohydrates are converted to
- pyruvate
- acetyl coenzyme A
In exercise, fat is converted to
- acetyl coenzyme A
- glucose
In exercise, protein is converted to
- pyruvate
- acetyle coenzyme A
Metabolic pathway for carbohydrates in exercise
citric acid cycle in mitochondria
Metabolic pathway for fats in exercise
beta-oxidation, citric acid cycle
Metabolic pathway for proteins in exercise
deamination
Stored ATP in muscle is suffecient for what duration of intense muscle activity?
10 seconds
Is production of pyruvate aerobic or anaerobic?
anaerobic
Is use of stored ATP and phosphcreatine in muscle consider aerobic or anaerobic?
anaerobic
Effects of lactic acid production during anaerobic exercise
- imapired cellular metabolism
- muscle soreness
- fatigue
- respiratory stimulation
- forced decrement of exercise
2 main ways of degrading lactic acid
- Cori cycle (liver)
- buffering systems
How can you identify the transition from aerobic to anaerobic exercise?
- when rate VO2 exceed oxygen consumption
- spike in CO2 production
What is the anaerobic threshold?
when the rate VO2 exceeds oxygen consumption
When is the anaerobic threshold important in cardiac rehab?
Patients with heart disease don't feel well above the threshold and program should be designed to keep them below the threshold
At rest, what is the average rate of oxygen consuptiom of a 70kg man?
3.5cc of O2/min/kg
Define 1 MET
the unit of oxygen consuption at rest (basal metabolic rate)
What is aerobic capacity?
maximum rate of O2 consumption
List MET equivalents for different level of exercise intensity
Light = 1-3 METS
Light to mod = 3-4 METS
Mod = 4-5 METS
Heavy = 5=7 METS
Very Heavy = >7 METS
Example of self-care activity that's 1-3 METS
- sponge bathing
- shaving
- dressing/undressing
Example of self-care activity that's 3-4 METS
- showering
- climbing stairs
- driving
Having sex is how many METS?
4-5
Example of household activity that's 1-3 METS
- light meal prep
- setting the table
- dusting
Example of household activity that's 3-4 METS
- light gardening
- ironing
- vacuuming
- grocery shopping
Example of household activity that's 4-5 METS
- heavy gardening
- cleaning floors
- moving furniture
- raking
- washing car
Example of household activity that's 5-7 METS
- splitting wood
- shoveling snow
- climbing ladder
Example of household activity that's >7 METS
- moving heavy furniture
- pushing or pulling hard
Example of recreational activity that's 1-3 METS
- walking 2mph
- writing
- reading
- playing piano
Example of recreational activity that's 3-4 METS
- walking 3mph
- slow bicycling
- golfing with cart
Example of recreational activity that's 4-5 METS
- walking 3.5mph
- doubles tennis
- slow dancing
- easy swimming
- bicyling 8 mph
Example of recreational activity that's 5-7 METS
- walking 4-5 mph
- tennis
- mod cross country skiing
- gymnastics
Example of recreational activity that's >7 METS
- Jogging at 5 mph
- soccer
- basketball
- horseback riding
Example of job activity that's 1-3 METS
- typing
- light machine work
- lifting <10 pounds
- sewing
Example of job activity that's 3-4 METS
- light carpentry
- assembly line
- lifting 20 pounds
- bricklaying
Example of jobactivity that's 4-5 METS
- light shoveling
- mixing cement
- light farming
- lifting 50 pounds
Example of job activity that's 5-7 METS
- heavy farming
- heavy industry
- lifting 50-100 pounds
Example of job activity that's >7 METS
- Heavy construction
- lifting 100 pounds
Effecient oxygen transportion during activity is dependent on what 3 major systems?
lungs, CV, muscle
What is the Fick equation
(oxygen consumption) = (cardiac output) x (AV O2 difference)
Describe the mechanisms for increased cardiac output as activity intensity increases
- initally from increased stroke volume
- then becomes dependent on HR as diastolic filling time become more limited
What is the general relationship between exercise intensity and cardiac output
linear
What is the general relationship between exercise intensity and HR
linear
Maximal HR estimation in a healthy person
220-age
Is aerobic training muscle group specific?
Yes; a treadmill conditioning program will NOT increase conditioning for bicycling in the same way
Signifcant adaptions are noted with aerobic training withing what time frame?
- 6-10 weeks grossly
- 10 days at biochemical level
Benefits of aerobic conditioning are lost ____ weeks after stopping training
2-3 weeks
Why is an exaggerated HR response common after MI?
- decreased vagal tone
- increase sympathetic tone from circulating catecholamines
True or false: Av O2 difference rapidly declines with bed rest
true
What does AV O2 difference represent?
the body's ability to extract O2 for metabolic use
General muscle changes seen with CHF
- altered cellular structure
- depletion of phosphocreatine
- depletion of oxidative capacity
- muscle fiber atrophy
- increased vasoconstriction
- impaired arterial dilatation
Why is there resting tachycardia after heart transplant?
loss of vagal tone to the sinoartrial node
Why is rate of HR increase and cardiac output response to exercise blunted after cardiac transplant?
heart is dependent on circulating catecholeamines to increase these parameters
Peak HR and rate of oxygen consumption in a patient s/p heart tranplant compared to controls
- HR 25% lower
- rate V02 33% of predicted
Aerobic training influences what determinant of the Fick equation?
all of them
Why is heart rate at rest and submaximal work intensities decreased after aerobic training?
increased vagal tone
Adaptations allowing increased AV O2 difference following aerobic training
- increased Hb O2 sat
- increased RBC [Hb]
- Increased artery size to muscle
- increased capillary density
- increased size of type 1 muscle fibers
- increased muscle fiber myoglobin concentration
- increased mitochondrial size and concentration
- increased aerobic enzymes concentration
- enhanced minute ventilation
Major determinant of myocardial blood flow
diameter of the coronary arteries
How is cardiac ischemia noted on EKG, echo and nuclear perfusion
- EKG: ST depression
- echo: wall motion abnormalities
- perfusion: reversible perfusion deficits
What causes more myocardial oxygen consumption, exercise with the upper limbs or lower limbs?
upper limbs
What causes more myocardial oxygen consumption, exercise with upright or supine?
upright
How does myocardial oxygen consumption at rest change after aerobic conditioning and why does this matter for cardiac rehab?
O2 consumption lower at rest and submax exercise. Important because patient able to do more activity before they become ischemic
Which has more myocardial oxygen demand, exercise with or without a significant isometric component?
more demand with isometric component
Future exercise should be performed at a HR of _____ below the ischemic point in patients with CAD
10 bpm
Does exercise training influence the ischemic threshold in CAD?
no
typical ischemic cardiac pain is mediated by the ______ nervous system
autonomic
Sputum in cough associated with heart disease usually has what characteristics
clear or pink; frothy
What variant of Parkinson's disease often has orthostatic hypotension?
Shy-Drager
Common medication for heart disease that causes fatigue
b-blockers
Patients with significant vascular disease may have very different BP readings between arms because of
subclavian stenosis
What BP is a contraindication to exercise?
200/110
Common reason for asymmetrical LE edema after CABG
Side with vein harvested for graft will have more edema
Why is cardiovascular disease in patients with DM often not amenable to intervention
often have diffuse artherosclerosis instead of focal plaques
3 common endpoints for submaximal exercise stress testing
- HR 120
- 70% of predicted max HR
- 5 METS
What guidelines should you give patients about caffeine and medications prior to an exercise stress test
- no caffeine for 3 hours prior
- take meds as scheduled
Normal BP changes during exercise stress testing
- SBP increased by 10-30mmHg with peak >140
- DBP stable or decreases
When is exercise stress testing normally terminated?
when 85% of age and gender predicted max HR is reached
Markers of exercise capacity
- exercise duration
- MET level
- max HR
- HRxSBP (direct product)
Why are METs useful to calculate in exercise training?
they allow for comparisions across activities
Arm exercises produces a(n) _______ HR and SBP response compared with similar workload performed by the legs
exaggreated
Compared peak HR with arm vs. leg exercise
Peak HR with arm exercise is 70% of with leg
What's typical force progression of exercise during phase II cardiac rehab?
start at 25W and increase in 25W increments every 2 min
Compare recumbant bicycle ergometry vs. treadmill for cardiac rehab
- less likely to reach VO2 max with bike
- less likely to reach peak predicted target HR on bike
- likely to have early fatigue of quads on bike
- lower anaerobic threshold on bike
Starting point for most common exercise stress test protocol
BRUCE
- start at 1.7mph on 10% grade
- increases at 3 min intervals
Associated prognostic outcome of post-MI exercise -induced angina during exercise stress testing
stable angina within 1 year
Associated prognostic outcome of achieving <85% of age-predicted max HR during exercise stress testing
increased 2-year mortality
Associated prognostic outcome of delayed HR recovery during exercise stress testing
Increased 6-year mortality
Associated prognostic outcome of delayed fall in SBP during exercise stress testing
Increased mortality
Associated prognostic outcome of post-MI inadequate increase of SBP during exercise stress testing
LV dysfunction
Associated prognostic outcome of post-MI rate-pressure product <21,700 during exercise stress testing
increased 6 month mortality
Associated prognostic outcome of 2mm ischemic ST segment depression during exercise stress testing
increased MI with 1% annual increased mortality and multivessel disease on angiography
Associated prognostic outcome of early 1mm ST segment depression during exercise stress testing
increased MI; 5% annual mortality
Associated prognostic outcome of being unable to tolerate exercise stress test
highest adverse cardiac event rate
Associated prognostic outcome of acheiving <5 METS during exercise stress testing
increased mortality
METS =
metabolic equivalents
_____ are especially prone to false positive studies with exercise stress test
Women
Normal exercise response for ejection fraction
increase in EF by at least 5%
The strongest determinant of cardiac events is
coronary plaque burden
How is electron beam computed tomography used in evaluating cardiovascular disease?
creating a coronary artery calcification score correlates well with cardiac events and can be followed over time
Early mobilization at what MET level helps prevent loss of cardiovascular reflexes associated with prolonged bed rest?
2-3 METS
Risk of cardiac events during exercise training is highest in what groups
- poor LV function
- ventricular arrhythmias
- non-ST elevation MI
- non-compliance with exercise rx
- poor compliance with HR restrictions
How is risk assigned prior to starting phase II cardiac rehab
assigned to group:
- no risk
- low risk
- moderate risk
- high risk

Based on ischemia, arrhythmia and pump failure
When is hypoglycemia after exercise most commonly seen in insulin dependent DM?
several hours after exercise
What should you tell a patient with DM with blood glucose >350 about exercise?
postpone exercise as glucose utilization is compromised
Hold exercise when INR above ___ to avoid hemarthrosis and muscle hematoma
5.0
How is phase II cardiac rehab training HR usually calculated?
Karvonen:

training HR = RHR + [(PHR - RHR) xI]

where
RHR = resting HR from EST
PHR = peak HR from EST
I = coefficient based on risk stratification
What is the I in the Karvonen equation for training HR for cardiac rehab based on risk stratification?
- low: 70-85%
- moderate 55-70%
- high 40-55%
Goal HR during cardiac rehab for patients on b-blockers with a blunted HR response
10-20 beat above resting
How do you determine exertional guidelines for cardiac rehab after cardiac transplantation?
50-60% of rate VO2 max
Recommendations for lifelong exercise stress testing after cardiac rehab
yearly to update risk stratification and training HR
Why is a cool down helpful during cardiac rehab
minimize post-exercise hypotension that may result in ischemia
General frequency and duration of outpatient phase II cardiac rehab
three times per week for 12 weeks
To reduce exercise induced angina, when should long-acting nitrates be taken
about 3 hours prior o exercise
Does cardiac rehab for severe angina increase return to work rates?
yes
When is exercise training generally instituted after MI
2-6 weeks depending on the size and risk
Difference in survival rates following MI for those who participate in cardiac rehab vs. those who don't
3 year survival
- with CR: 95% survive
- without: 64%
When can upper body exercise be started after CABG?
at 6 weeks post-operative sternal knitting should be complete
% of patients that have arrhythmias during inpatient cardiac rehab
1/3
Risk factors for arrhythmias during inpatient cardiac rehab
- HTN
- DM
- hyperlipidemia
- older age
- discontinuation of amiodarone
- autonomic dysfunction
When do patients seen improvement in exercise tolerance during cardiac rehab for CHF?
most improvement at 3 weeks but continues for 6 months
% of patients with CHF that have conduction abnormalities
40%
Exertional guidelines after cardiac transplant
Start with Borg scale of 11-13 and then increase to 13-15 as tolerated
Exercise guidelines after LVAD placement
- ambulation at 7-10 days
- treadmill trainig at 3 weeks
- ADLS up to 5 METS at 6 weeks
Is supine or upright exercise more likely to induce ventricular arrhythmias?
supine
Very general recommendations for exercise type in patients with ICDs
upright - less likely to induce arrhythmia
% of patients that experience some cognitive impairment after CABG
80%
cognitive dysfunction in CHF increased mortality ___ times
5
List 5 atherosclerotic diseases
- CAD
- PVD
- CVD
- renal artery stenosis
- abdominal aortic aneurysm
Which rehab patients also need cardiac precautions due to increased associated cardiovascular risk
- thrombotic strokes
- PVD
- dysvascular amputation
The majority of cardiac rehab patients return to work in __ months
6 months
~80% if sedentary work
~60% if heavy work
Avoid sexual intercourse after MI for __ weeks
2
Achieving __ METS on exercise stress test indicates low risk for a cardiac event during sex
6 (assuming familiar partner and place)
Most common lung diesease in the USA
COPD
Biggest contributing factor to COPD
Smoking
90% of new smokers are...
teenagers and young adults
Most common childhood chronic disease
asthma
3 major causes of COPD
- asthma
- chronic bronchitis
- emphysema
COPD is the ___ (rank) leading cause of death worldwide.
5th
Restrictive pulmonary disease is most often caused by
neuromuscular and orthopedic disorders
Incidence of Duchenne muscular dystrophy in the USA
21/100,000 births
6 major modalities used in pulmonary rehabilitation
- general medical management
- oxygen therapy
- chest PT
- exercise training
- nutritional support
- psychosocial support
How does theophylline help in COPD?
- improve respiratory muscle endurance
- central ventillatory stimulation
When is oxygen therapy indicated in COPD?
- arterial O2 sat <88%
- arterial O2 sat <89% with evidence of pulm HTN, CHF or polycythemia
When is it safe to mount portable O2 on a electric wheelchair?
motor and batteries are sealed and covered by a rigid housing
Main ways that breathing retraining works in COPD
- maintain positive airway pressure during exhalation
- reduce over-inflation
List some to the techniques taught for breathing to people with COPD
- general relaxation
- pursed lips
- head down/bent forward
- slow deep breathing
- localized expansion/segmental breathing
Is diaphragmatic breathing helping in COPD?
No - it increased the work of breathing compared to the typical baseline breathing pattern in COPD
Why should coughing be controlled in COPD?
coughing can trigger dynamic airway collapse, bronchospasm or syncope
What is autogenic drainage?
Technique of pulmonary secretion clearance that combines variable tidal breathing (at 3 distinct volumes), controlled expiratory airflow and huff coughing
Mechanical in-exsufflation is contraindicated in
- bullous emphysema
- history of PTX
- history of pneumomediastinum
In obstructive pulmonary disease, vital capacity is increased or decreased?
same or decreased
In obstructive pulmonary disease, FEV is increased or decreased?
decreased
In obstructive pulmonary disease, midmaximal flow is increased or decreased?
decreased
In obstructive pulmonary disease, maximal voluntary ventilation is increased or decreased?
decreased
In obstructive pulmonary disease, residual volume is increased or decreased?
increased
In obstructive pulmonary disease, functional residual capacity is increased or decreased?
increased
In obstructive pulmonary disease, total lung capacity is increased or decreased?
increased
In restrictive pulmonary disease, vital capacity is increased or decreased?
decreased
In restrictive pulmonary disease, FEV is increased or decreased?
same or decreased
In restrictive pulmonary disease, midmaximal flow is increased or decreased?
same or decreased
In restrictive pulmonary disease, maximal voluntary ventilation is increased or decreased?
same or decreased
In restrictive pulmonary disease, residual volumeis increased or decreased?
decreased
In restrictive pulmonary disease, functional residual capacity is increased or decreased?
decreased
In restrictive pulmonary disease, total lung capacity is is increased or decreased?
decreased
What are the 7 general indications for cardiopulmonary exercise testing per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
- eval of exercise tolerance
- unexplained dyspnea
- eval of CV disease
- eval of respiratory disease
- preop evaluation
- to creat exercise rx for pulmonary rehab
- eval impairment or disability
What are the indications for cardiopulmonary exercise testing for respiratory disease (which diseases?) per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
- COPD
- interstitial lung disease
- chronic pulmonary vascular disease
- cystic fibrosis
- exercise induced bronchospasm
What are the indications for cardiopulmonary exercise testing for preop eval (which surgeries) per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
- lung cancer resection
- lung volume reduction surgery
- lung transplant
- other preop
How long does exercise training take for muscles to develop increased ability to perform aerobic exercise?
30min a day for 3-5 days per week for 4-8 weeks
Describe the classification scheme for COPD severity
Stage 0: normal lung function
Stage 1 (mild): FEV1 at least 80% of predicted
Stage 2 (moderate): FEV1 50-79% of predicted
Stage 3 (severe) FEV1 30-49% of predicted
Stage 4 (very severe): FEV1 less than 30% of predicted or presence of respiratory failure or clinical right sided heart failure

(only valid if FEV1:FVC less than 70%)
What improvements can be expected from inspiratory muscle training in a patient with moderate COPD?
- increased max inspiratory mouth pressure
- increased strength of the diaphragm
What improvements can be expected from general pulmonary rehabilitation in a patient with moderate COPD?
- increased max workload
- improved ADL scores
- improved anxiety and depression scores
- increased 6 and 12 minute walking distance
What improvements can be expected from pulmonary rehabilitation with cycle ergometry at 70W in a patient with moderate COPD?
minute volume decreased of 2.5L/min per blood lactate decreased of 1mEq/L
General effects of aerobic exercise in patients with asthma
improves overall fitness and health
Inheritance of cystic fibrosis
autosomal recessive
When is Dornase alfa (Pulmozyme) prescribed to patients with cystic fibrosis and what does it do?
- rx when older than 5years and FVC greater that 40%
- digests extracellular DNA
Pulmonary picture of chronic lung disease in cystic fibrosis
combined severe obstructive-restrictive disease
What's the technical name for "The Vest" for cystic fibrosis chest PT
high-frequency chest wall oscillation
What is the median expected survival age for patients with cystic fibrosis born in the 1990s?
over 40 years
3 major factors that have extended the life span of individuals with cystic fibrosis
- airway clearance
- nutritional support
- antibiotic therapy
Proportion of adults with cystic fibrosis that have multiple-resistance gram negative organisms
1/3
Why shouldn't patients with cystic fibrosis exercise within close proximity of each other?
- possibility of transmitting Burkhoderia cepacia
Survival in cystic fibrosis is correlated with _____ ____ ____
maximal oxygen uptake
6 components of the chest wall
- rib cage
- spine
- diaphragm
- abdomen
- shoulder girdle
- neck
In pulmonary rehab useful in patients with Parkinsons?
yes
Define paradoxical vocal cord dysfunction
vocal cords adduct during inspiration
The diagnosis of paradoxical vocal cord dysfunction is based on
patient history and laryngoscopy
Treatment of acute exacerbations of paradoxical vocal cord dysfunction
Heliox (79:30)
What is the total daily expenditure in patients with COPD compared to normals?
the same, regardless of weight
Major cause of malnutrition in patients with COPD
insufficient food intake
The energy cost of the exercise associated with a pulmonary rehabilitation program is estimated at __ kcal/day
191
3 major indications for phrenic nerve pacing
- congenital central hypoventilation syndrome
- acquired central hypoventilation syndrome
- high SCI
Congenital central hypoventilation syndrome is also known as
Ondine's curse
When is lung volume reduction surgery generally used?
patients with advanced emphysema
What is usually removed in lung volume reduction surgery
one or both apices
Children with SCI over the age of ____ can usually learn glosspharyngeal breathing
over the age of 3 years