Lecture 11: CV Rehab Management Pt. 1 Flashcards
describe activity tolerance of pts with CV dysfunction and APTA recommendations
poor activity tolerance and physical inactivity = increased risk mortality
decreased walking/standing tolerance; inability to perform ADLs
APTA recommends increased physical activity by increase in total activity, number of steps, and total time out of bed
ASCM/AHA/CDC guidelines for activity
150-300 min/week of moderate intensity aerobic exercise
OR
75-150 min/week vigorous exercise throughout week
moderate intensity strength at least 2 days/week
what does research say about activity tolerance for CV pts
variety of literature on when and how much activity
most research is only on exercise with treadmill/cycle
poor definition of parameters
may have to look at similar but not exact diagnoses
ASCM guidelines for older adults
when older adults cannot do >150 of moderate aerobic activity due to chronic conditions, they should be as physically active as their abilities/conditions allow
perform balance training in addition to aerobic and strength
strength training considerations for pts with CV dysfunction
ACSM/AHA recommends 10-15 reps of RPE 11-13/4-6
slower progression of exercise weights and reps
lower 1RM
decreased resistance tolerance with these pts
limited research on resistance training post op CV pts due to beliefs about sternal precautions
known benefits of strength training
decreased insulin resistance
SVR
BP
CABG ACSM guidelines on resistance training
wait 4-8 weeks
start low weight high reps
12 weeks or more until higher weight is added
PCI/stent ACSM guidelines for resistance training
wait 2-5 weeks
gradual increase in weight
valve repair/replacement resistance training guidelines
wait 4-8 weeks
start with low weight and high reps
MI resistance training guidelines
wait 3-4 weeks
start <30-40% 1RM
HF guidelines on resistance training
wait 3-4 weeks post event
start with 8-10 reps of low weight
gradual increase in resistance based on symptom response
focus on weight for pt to perform high reps
guidelines for addressing ROM limits in pts with CV dysfunction
if pt has prolonged sx precautions they may present with decreased ROM that can affect chest wall movement and posture
pain free ROM beneficial post sternotomy, especially unilateral, to prevent adhesions during healing
things to keep in mind when addressing balance impairments with pts with CV dysfunction
take neuropathy or PVD into consideration; how will it affect balance
implications of cognitive impairments in pts with CVD
1/3 pts with CVD present with some type of cognitive impairment
potential causes:
- hypotension
- alterations in CO affecting cerebral hypo perfusion
- micro emboli
- O2 desaturation
- cardiopulmonary bypass “pump head”
implications = ability to follow instructions for rehab/precautions, med compliance, performing ADLs, and qualification for post acute rehab
% of pts with HF with mild cognitive impairments (MOCA scores 17-25)
74%
interventions for CVD pts with cognitive deficits
family involvement
frequent reorientation
healthy sleep/wake cycle
structured schedule
increased mobility and ADLs
things to keep in mind regarding pain with CV pts
intercostals = highly innervated; pain very common with chest sx
post op lines = irritate parietal pleural
LE vein graft site can be very bruised/swollen
sx positioning can cause neck/shoulder pain
post op pain has major effects on respiratory function
higher pain levels = stimulate SNS
what does SNS activation look like in pts with higher pain levels
decreased peripheral autonomic function (i.e. GI tract)
increased stress hormone release
decreased immune function
barriers to CV rehab
baseline functional capacity, disability, or frailty
poor exercise tolerance
decreased knowledge of condition, poor health literacy
poor medical compliance
frequent hospitalization
QOL, depression
lack of resources or access to resources
implications of HTN meds
more HTN meds pt is on, the more you need to be aware of side effects
context is important
anti-HTN meds lower resting BP but might now have the same effectiveness during exercise or isometric activities
pharm implication of thiazides and loop diuretics
higher risk of hypokalemia
mm cramps/fatigue
ST depression
GI slowing
K-sparing diuretics and BB pharm implications
higher risk of hyperkalemia
mm weakness/paralysis, hypotension, bradycardia, ventricular arrhythmias, ST elevations
only intervention for critically elevated K is emergent dialysis
how much of a reduced exercise capacity do pts with HTN have
15-30% reduction in exercise capacity
watch for exaggerated response to exercise even if on anti-HTN meds
APTA rec for monitoring BP
monitor BP in pts >35 with HTN risk factors in any setting
things to look out for during rehab with pts who have HTN
watch for hypotension with position changes, post exercise, long term standing tasks, or in hot/warm environments
avoid valsalva
focus on low weight, high reps for strength
medication implications for patients with Hyperlipidemia (HLD)
statins are most prescribed bc most effective for lowering cholesterol, despite their side effects
type/dose of meds is important
acute MSK symptoms if statin just started should be differentially diagnosed
statin drug interactions
ETOH + statin increases risk of side effects
selected HIV meds, antivirals, anti-rejection transplant meds, vibrates, and grapefruit juice all affect how statins are broken down and metabolized
purpose of wells criteria
gold standard for determining DVT likelihood
what may happen if a pt presents with recently unprovoked or provoked VTE
if pt on prophylactic dose of anticoagulant (half dose) , they increase the dose to full amount if pt develops VTE
catheter based thrombolysis may be indicated and planned
if pt with LE DVT cant be anticoagulated, IVC filter placement may be indicated and planned
APTA VTE action statements related to pharm
9: with recently diagnosed VTE treated pharmacologically, confirm medication class and date/time initiated prior to mobilizing pt
10: when pt recently diagnosed LE DVT reaches therapeutic threshold of anticoagulant, mobilize the pt
INR <2. mobilize or not?
no mobility
risk of clot too high
INR >5. mobilize or not?
proceed with caution vs hold mobility
risk of bleeding too high
if an IVC filter is present in a limb with DVT is it okay to mobilize?
yes
if an acute PE is present with any R heart failure (via echo) is it okay to mobilize?
no
do not mobilize
if an acute PE is present with unstable or increasing O2 requirement is it okay to mobilize?
no
do not mobilize
S&S of post thrombotic syndrome (PTS)
edema or swelling
chronic leg or arm pain
skin changes
heaviness of limb affected by DVT
20-50% LE DVT results in PTS>2 years s/p acute DVT
what does the CPG say about pts who present with S&S of PTS
recommend mechanical compression (i.e. intermittent pneumatic compression and/or graduated compression stockings)
should compression be used with every pt diagnosed with DVT to prevent PTS or recurrent DVT
no, not every pt
should be decided on a case by case basis
crucial to understand risks of compression, especially with pts with CV pathologies
what type of evidence is there for compression with pts with PTS
low certainty
what type of evidence is there for use of compression with pts with venous and lymphatic disorders for the treatment of PTS
high certainty
indications for LE compression
*when in contact of the entire medical picture of each individual pt
chronic venous insufficiency
post sx or interventional treatment of varicose veins
prevention of VTE
prevention and treatment of PTS
chronic lymphedema
superficial thrombophebitis
pregnancy
dysautonomia/POTS
corresponding pressures to strengths of compression
low = <20 mmHg
medium = 20-30 mmHg
high = >30 mmHg
ABSOLUTE contraindications for compression
peripheral arterial disease
any peripheral vascular bypass revascularization
heart failure
severe peripheral neuropathy
local skin or soft tissue condition (skin grafts, cellulitis, infections, etc)
extreme deformity of leg or unusual size/shape preventing correct fit
pt discomfort
edu for pts/caregivers regarding LE compression
purpose for Rx
benefits of regular use
how to apply- no wrinkles
how long to wear - >12 hours; depends
when to take off; immediate removal if SOB, LE numbness, acute pain
daily hygiene- remove at least 2x/day for hygiene and skin inspection
signs of potential problems/when to remove; if unsure, always remove
what to do/who to contact if problems occur
what happens with PAD
results in inability to balance supply with increasing demand of exercising mm
ischemia develops and produces lactic acid
difference in S&S of lactic acid in mm vs in circulation
lactic acid in mm = claudication pain
lactic acid in circulation = respirator stimulated = SOB
intermittent vs resting claudication
resting = higher risk for limb ischemia/loss
intermittent = more predictable
claudication pain scale
0 = no pain = resting or early exercise effort
1 = mild = 1st feeling of any pain in legs
2 = moderate = pain level at which exercise training should cease
3 = intense = near max pain
4 = unbearable = most severe pain ever experienced
PAD rehab management tips/implications
exercise to tolerable level of pain bit not over for best benefits
interval training
- start with equal intervals 1-5 min of exercise to rest
- slowly progress exercise intervals and decrease rest intervals
walking is most functional/convenient
non-impact exercise allows for longer duration and higher intensity
colder temps require longer warm up periods
emphasize good footwear/hygiene
