Exam 1 (cont) Flashcards
10 year EX training in CHF:
- 123 pts
- Trained group: supervised EX training @ 60% VO2 peak , 2x/week, x10 years
- Nontrained group: “did not Ex formally
- Changes in peak VO2 (T vs NT)
- Conclusion, “Moderate supervised ET performed _____ weekly for 10 years maintains _______________________ of more than 60% of maximum VO2…”
- NT pts, peak VO2 _________progressively
twice
functional capacity
decreased
"Aerobic interval training versus moderate continuous training" - HF, Results: VO2 peak increased (\_\_) Decreased LVEDV and LVESV (\_\_\_) Increase LV EF (\_\_\_) BNP decreased (\_\_\_)
(IT & C)
(IT only)
(IT only)
(IT only)
Benefits of EX in HF:
Exercise training may reverse peripheral abnormalities
autonomic function, skeletal muscle blood flow, localized oxidative capacity
Heart failure education:
- frequent bouts w/ rests in-between
- teach daily weighting to check for changes in fluid
- Teach daily checks on activity by instructing in RPE or dyspnea monitoring
- Teach about watching for dyspnea when laying down
- Energy conservation
Perception scales:
- “How hard are you working?”
- “Pain scale” (1+light, barely noticeable ,2+ moderate/bothersome, 3+ server/very uncomfortable, 4+ most severe pain)
- “Breathing Scale” (1+mild noticeable to pt, 2+ mild noticeable to observer, 3+ moderate difficulty , 4+ severe difficulty)
Aerobic EX improves:
- VO2 max
- Dyspnea
- LV function
Resistance Ex improves:
- LV function
- Peak lactate levels
- Muscle strength & muscle endurance
Do you need to include both (aerobic Ex & resistance Ex) types of Ex in patients with HF?
yes, include both
Name 1 Contraindication to EX training:
progressive worsening of exercise tolerance or dyspnea at rest over previous 3-5 days
Name a 2nd Contraindication to EX training:
significant ischemia during low-intensity EX (2 METS)
Name a 3rd Contraindication to EX training:
uncontrolled diabetes
Name a 4th Contraindication to EX training:
Recent embolism
Name a 5th Contraindication to EX training:
thrombophlebitis
Name a 6th Contraindication to EX training:
New-onset atrial fibrillation / atrial flutter
Name some potential outcome tools:
- knowledge of disease /self management of disease
- chair raise
- Gait speed
- 6 MWT
- Balance
- Symptom history
- Anxiety/ depression
- Quality of life - HRQOL
Inspiratory muscle training leads to:
- Pi max –>
- Peak oxygen uptake –>
- 6 MWT –>
- VO2 slope during recovery, ventilatory response to exercise and QOL ________
115%
17%
19%
improved
** List 5 clinical implications for PT regarding HF:
- screen for CV & orthopedic conditions
- identify medication action & side effects
- re-evaluate CV status every session & throughout EX
- Know abnormal responses to EX and observe patient carefully (HR, BP, dyspnea, fatigue, angina)
- Prescribe effectively (aerobic & strength
Cardiac rehab is defined asa supervised program to help pts recover from:
- Myocardial infarction (MI)
- Heart surgery such as bypass, ventricular assist device (VAD), valve repair
- Minimally invasive procedures such as angioplasty, stenting, valve replacement, pacemaker or implantable cardioverter defibrillator (ICD)
- risk factors such as CAD or angina
- HF
“All cardiac rehab programs should contain specific core components that aim to _____________________________________, foster healthy behaviors and compliance with these behaviors, ______________ and promote an active lifestyle for pts w/ cardiovascular disease.”
“All cardiac rehab programs should contain specific core components that aim to OPTIMIZE CARDIOVASCULAR RISK REDUCTION, foster healthy behaviors and compliance with these behaviors, REDUCE DISABILITY and promote an active lifestyle for pts w/ cardiovascular disease.”
What is one goal of cardiac rehab:
Mitigate the adverse physiologic effects of cardiac illness
What is a 2nd goal of cardiac rehab:
mitigate the adverse psychological effects of cardiac illness
What is a 3rd goal of cardiac rehab:
reduce the risk of sudden death or reinfarction
What is a 4th goal of cardiac rehab:
control cardiac symptoms
What is a 5th goal of cardiac rehab:
stabilize or reduce atherosclerosis
What is a 6th goal of cardiac rehab:
improve functional capacity
What is a 7th goal of cardiac rehab:
enhance psycho-social and vocational status
What is a 8th goal of cardiac rehab:
gives the pt a safe, monitored EN for EX
Name 5 general principles/ Goals of Cardiac rehab:
- decrease length of hospital stay to 3-5 days
- early mobilization
- assessment
- prepare for readiness for discharge
home - recommendations for home care
- referral to outpatient cardiac rehab program.
During the initial assessment, PTs need to review chart and note the following:
- past medical history
- signs & symptoms
- employment
- risk factor assessment and plan for intervention or teaching… stress management psychological concerns, weight, diabetes, smoker, drinker, inactivity, etc
- medications
What CAN’T cardiac rehab do?
- reverse atherosclerotic process (education re: meds may influence)
- decrease myocardial ischemia
- HAVE MUCH EFFECT ON EJECTION FRACTION
- reverse effects of lung disease such as chronic obstructive pulmonary disease (COPD).
Therapy begins after initial acute phase when the patient is relatively _____________.
medically stable
A patient s relatively medically stable as evidenced by (1):
- stable angina (no pain for at least 8 hours
A patient s relatively medically stable as evidenced by (2):
- control of dangerous dysrhythmias
A patient s relatively medically stable as evidenced by (3):
- control of myocardial insufficiency
A patient s relatively medically stable as evidenced by (4):
- labs trending toward normal
A patient s relatively medically stable as evidenced by (5):
- compensated HF (when the heart compensates by increasing rate or contraction)
A patient s relatively medically stable as evidenced by (6):
- s/p cardiac surgery
Name one contraindication:
unstable angina
Name a 2nd contraindication:
danagerous arrhthmias
Name a 3rd contraindication:
uncompensated HF (when the heart cannot compensate even on medications)
Name a 4th contraindication:
embolism
Name a 5th contraindication:
metabolic instability
Name a 6th contraindication:
critical labs such as high blood pressure sugars in the 400 range, hyperkalemia (K+ about 5.8)
Name a precaution to activity:
low ejection fraction (EF), e.g 20% or less (normal is 55-75%)
Name a 2nd contraindication:
presence of other medical conditions: diabetes, obesity, renal failure, stroke
Name a 3rd contraindication:
active infection ( w/ increase heat & blood flow, could favor action and & flow of infection)
Name a 4th contraindication:
abnormal labs
Name a 5th contraindication:
high oxygen requirements
Name a 6th contraindication:
shortness of breath @ rest
Name a 7th contraindication:
sternal precautions
Name 6 limitations to activity:
- HR 20 beats max above resting (medical patient
- Resting HR > 120 beats
- Resting HR 13
- Sternal precautions
Explain why activity is important:
It prevents complications of bed rest and secondary chest infection. It increases cardiac and pulmonary function. It prepares for home discharge through self-care. It monitors for abnormal response to activity such as dysrhythmias, abnormal BP, pulse oximetry
What are the primary 5 sternal precautions:
- no lifting more than 10 pounds
- no shoulder flexion greater than 90 degrees
- keep hands in visual field
- no driving
- no pushing or leaning
The traditional sternal precautions are advised to be followed for _________________________________ following _______________ surgery.
6-8 weeks
median sternotomy surgery
What are 5 components of cardiac rehab?
- medical eval
- behavioral modifications
- CV risk factor modification
- prescribed EX
- counseling
How is cardiac rehab multidisciplinary:
- a dietician, RN/educator, psychologist and pharmacist may all work together on risk factor modification
- A PT, RN, MD supervise, and EX phys may all work together on Ex training
What psycho social factors my contribute to cardiac rehab?
- Type A personality
- Poor eating habits
- anxiety about EX
- forced sedentary lifestyle
- impact of family/enablers
- denial which may lead to non-compliance
- grief - loss of one’s independence / health
- depression
What psychosocial considerations should be allotted for?
- Lifestyle changes take work
- Readiness to change
- Old habits hard to break
- the right to choose one’s lifestyle
- impact of fear
Name 5 safety considerations in the clinic:
- selection of appropriate pts
- proper monitoring
- all professional EX personnel must be able to do basic life support (BLS) including defibrillators (AEDs)
- Emergency procedures must be specified
- warm up and cool down are required
Risk of sudden death is _____ in cardiac pts, but still _______ than healthy individuals
low
higher
Vigorous & uncontrolled ex risk of death: cardiac =
healthy =
1 in 384
1 in 3122
Principle role of cardiac rehab it to define Ex mode & intensity that are _________ & ___________.
Safe & effective
VO2 peak =
peak oxygen uptake
VO2 peak is closely related to _________ & __________________________.
CO &
functional capacity of the heart
VO2 peak increases most effectively w/ EX of ________ muscle groups in a ______________ pattern such as _____________________________
large
rhythmic
walking or bicycling
HRR and VO2R have ____________ relationship
linear
Maximal HR empirically =
208 - (.7 x age)
Use of betablockers precludes use of the measure:
HRR
HRR (heart rate reserve) =
max HR minus resting HR
Target is 50% HRR at cardiac phase __; 60-80% of HRR by phase ______.
II
IV
Light activity =
example:
Moderate activity =
example:
3-6 METS
walking at a brisk pace, sweeping, mowing, bicycling
Vigorous activity =
example:
> 6 METS
hiking uphill, shoveling snow, skiing
Its important to monitor each position change for ____, _____, _____, and _____..
HR, BP, EKG, and SaO2
Cardiac rehab give a pt a safe, _________________ for EX
monitored EN
During monitored recovery in cardiac rehab it is important to ___________________________.
auscultate heart and lung sounds
Measure the pt’s vitals: blood pressure, HR, EKG, O2 saturation (low ___ stresses the heart)
O2
Checking patient’s subjective symptoms :
fatigue, exertion (Borg scale) etc
Monitor the speed by which the _____ returns to resting levels
HR
What affects HR & BP:
Age, fitness level, medications (B-Blockers such as atenolol, metoprolol), hydration (increase), infection (increase), anxiety, change in position, medical conditions e.g. DM, renal function, temperature, exercise intensity.
What are some expected outcome:
(Ed)-increased participation in PA -Increased aerobic fitness and work capacity - improved circulation - independent carryover - fewer symptoms - improved QOL - improved confidence - improved function (Ed)- weight control (Ed)- decreased mortality
Outcomes: develop, include pts own goals, ______, adjust
analyze
Phase I of cardiac rehab:
inpatient
Phase II of cardiac rehab:
outpatient ECG monitored
Phase III of cardiac rehab:
outpatient –> no monitoring
Phase IV of cardiac rehab:
community -based
Phase I =
cardiac unit, surgical ICU, medical ICU, telemetry unit, transplant unit
In phase I, pt may begin if:
- MD approval/ order
- No chest discomfort (8 hours)
- No new signs of decompensated
- No abnormal EKG changes such as ST segment depression
Goals of phase I rehab:
- Normal cardiovascular response to changes in position and ADLs
- Reach 3-4 MET activity level by discharge
Activity progression in phase I rehab =
slow progression of activity intensity (increase by 1 MET/day)
In phase I of rehab, start w/ bouts of ________________ of activity
3.5 minutes
Phase I, in-patient acute phase rehab:
- AAROM for ______ prevention.
- Change position e.g. dangling, watching for ___ changes; stop if systolic BP drop is >_______.
- Avoid __________. Avoid valsalva maneuver (eg. during ________________).
- Keep activities at ______ to start.
- Avoid head ______ position.
- DVT
-BP , >20mmHg
-isometrics (raises in blood pressure) / blood flow stops w/ release, flows back quickly to heart
during bowel movement
2 MET
down
Phase II education:
- risk factor modification
- stress management
- dietary modifications
- smoking cessation
- safe sexual activity
- cardiac medications
- what to do in case of symptoms
True or false: Education plays a huge part in every phase of cardiac rehab program
True
In phase II supervised outpatient program ______ weeks.
6-8 weeks
In phase II exercise test performed prior to rehab:
tested on dosage of medication they will be on during exercise
In phase II EKG monitoring:
every session
In phase II goals = increase EX capacity to _______.
5 mets
In phase II patient education on HR, _________, symptoms and ____________.
HR, exercise, symptoms and pacing skills
In phase II self monitoring during:
an exercise period
In phase II identify the intensity of:
workload
In phase II ability to work at the appropriate heart rate and RPE when exercising away from:
all of the monitoring equipment of outpaient facility.
In phase II exercise test required ____________ EX
before
In phase II 50% _____, __/week, ____ minute sessions including warm-up and cool-down
HRR, 3x/week, 60
In phase II there is an opportunity to reassure the pt that they can still have a ________________.
high quality of life
In phase II it is possible to relief ___________________ and build confidence to ____________________________.
of fear and anxiety
increase functional activities
In phase II outpatient: ____________________.
- Evaluation
- -> Symptom _____ exercise test
- —> HR, rhythm, ST segment changes, hemodnamics, signs, symptoms, RPE, exercise capacity
- -> Level of ___________ assessment
- Interventions
- -> Individual exercise program (_______ & ______)
- Goals:
- -> Increase aerobic capacity, _______, ________
- -> Reduced symptoms, improved risk factor profile improved _______.
In phase II outpatient: SUPERVISED.
- Evaluation
- -> Symptom -LIMITED exercise test
- —> HR, rhythm, ST segment changes, hemodnamics, signs, symptoms, RPE, exercise capacity
- -> Level of SUPERVISION assessment
- Interventions
- -> Individual exercise program (AEROBIC & RESISTANCE)
- Goals:
- -> Increase aerobic capacity, STRENGTH, FLEXIBILITY
- -> Reduced symptoms, improved risk factor profile improved QOL.
-Repetitions
-Intensity
-Sets
-Frequency
-Use % of 1 RM as for any training program and increase as tolearted. Monitor DBP, SBP, HR, MAP, RPE (submax 1 RM test)
-Choose intensity based on low or high risk. Start at 40% of 1 RM of high risk pt
… ARE ALL what?
Resistance Program Variables
In phase III outpatient:
-Functional capacity goals > _________.
-Training effects ________.
-No _________ symptoms
- EKG monitoring happens occasionally or when increasing _________________.
- Patients learn _____________ of HR and symptoms
Note: few insurance companies reimburse for phase III and beyond
In phase III outpatient:
-Functional capacity goals > 8 METS.
-Training effects EXPECTED.
-No CARDIAC symptoms
- EKG monitoring happens occasionally or when increasing ACTIVITY PARAMETERS.
- Patients learn SELF-MONITORING of HR and symptoms
Note: few insurance companies reimburse for phase III and beyond
In phase IV:
- Unsupervised program
- Community based
Light housework, dining out, shopping, stair climbing, putting a golf ball are expected outcomes for what time frame?
1 month after surgery
bicycling, gardening, dancing, and chipping a golf ball are expected outcomes for what time frame?
1-3 months after
Effects of exercise training:
- lower BP
- HDL +5-15%, helps remove LDL from blood
- helps control body weight along with appropriate diet
- reduction in symptoms of depression (as effective as antidepressant medication in mild to moderate cases)
AACVPR states pts may begin:
- minimum of 5 weeks post MI, including 3 weeks of participation in cardiac rehab
- minimum 8 weeks post CABG, including 3 weeks of participation in cardiac rehab
- resistance training at > 50% of 1 RM
- threshold, light weights (1-3) may be initiated sooner if indicated
Return to work protocol:
- work rates 49-93% after MI
- 20% do not return to work after revascularization surgery
What are factors that influence return to work?
- demographic & socioeconomic factors only 50%
- physical / emotional functioning 29%
- medical factors 20%
- PTS PERCEPTION OF OWN ACTIVITY STATUS VERY PREDICTIVE OF RETURN TO WORK
15% of qualified pts who have had a MI or CABG ______________.
participate :(
___ of pt s/p MI parcitipate in cardiac rehab
1/3
Barriers between pts and attending include:
- lack of physician referral
- logistics
- poor pt motivation
- financial
reimburstment:
- cardiac rehab is rarely a revenue generator for hospitals
- it serves as a community service
- it keeps hospitals on the forefront of necessary services
-Lack of attention to individual needs - limited feedback
- inconvenient location or schedule
- inadequate leadership
- sedentary occupation or leisure time
- lack of insurance coverage
- lack of specialty programs
-lack of knowledge of the benefit in the general population
…. are all:
factors contributing to decreased adherence
Fewer participants who are women, older, less education, non-white, lower socioeconomic status, those w/ co-morbidities and those living in remote locations:
attend cardiac rehab
A 2011 Mayo Clinic study of 2,400 pts showed 46% reduction in mortality of pts following angioplasty who then participated in a:
cardiac program
Early mobilization: the Goldilocks approach t to activity:
not too much, not too little, “just right”
- weight risk versus benefit
- what is the risk of exercising versus the risk of NOT exercising?
If the pt mobilizes after critical illness there is a chance of :
a bad outcome
IF A PATIENT DOES NOT MOBILIZE AFTER CRITICAL ILLNESS, THEN:
THEY ARE SURE TO HAVE A BAD OUTCOME!!!
Muscle is used as a reservoir for protein:
A malnourished pt breaks down protein
Atrophy occurs in the ubiquitin-proteasome pathway which is activated to:
breakdown contractile proteins
It is thought that the critically ill pt has a systemic inflammation that results in weakness beyond:
normal atrophy
