PT Interventions for the Cardiac System Flashcards
what is the importance of PT in cardiac interventions?
assess for s/s of decompensation
interventions and advice for symptom management
offer safe and appropriate exercise interventions
communicate concerns to the interdisciplinary team members
what is the concern with stage 4/D HF?
decompensation
what stage of HF do pts have symptoms at rest and are unable to do and physical activity without symptomology?
class 4 C/D HF
t/f: ppl can move back and forth bw stages of HF
true
who is the HF CPG NOT appropriate for?
those in NYHA class 4 HF
those with signs of decompensation
who is the HF CPG NOT indicated for?
ppl w/o participation restriction and are physically active
what settings is the HF CPG most relevant to?
outpatient, home care, and SNFs
why is the HF CPG not very relevant to acute care most times?
bc most pts with HF in acute care are decompensated to some degree
t/f: pts with HF don’t need to have completely clear lung sounds to be appropriate for PT
true
when is the initiation of PT appropriate with HF pts?
when RR<30 and can speak comfortably
when resting HR<120 beats/min
when crackles are below rib 5 posteriorly
CI>2L/min/mg2
CUP <12 mmHg
MAP >60 mmHg
minimal to no weight gain in 24 hours
what are reasons to stop PT with pts with HF?
when RR>40 and unable to speak comfortably
onset of S3 heart sounds
pulmonary crackles above rib 5 posteriorly
HR decreased >10 beats/min
SBP decreased >10 mmHg
MAP increased >10 mmHg
CVP inc or dec >6 mmHg
new or worsening dysrhythmias
in pts with HF, why should we be monitoring for signs of hypotension?
bc of the decreased CO associated with it
what vitals should we be monitoring in pts with HF?
JVD and peripheral edema
RR, PR, and rhythm
S3 heart sounds
RPE
what are the signs of exertional intolerance?
chest pain
abnormal VS response
new onset pulmonary crackles
new onset S 3 heart sound
new onset/change in cardiac rhythm (ECG, auscultation, pulse)
if someone has no participation restriction and is active, is PT indicated?
likely not
if someone has no participation restrictions, are not active, and have no activity limitations, what may be indicated?
education, aerobic training, resistance training, or a combo
if someone has no participation restriction, is not active, has activity limitations but can perform the activity with no endurance limit, what is indicated?
identify a new task
if someone has no participation restriction, is not active, has activity limitations and cannot perform the activity, what is indicated?
PT as appropriate (education, NMES, inspiratory muscles training, etc)
if someone has no participation restriction, is not active, has activity limitations but can perform the activity with endurance limitations and no signs of exersion, what is indicated?
education, aerobic training, resistance training, NMES, HIIT, inspiratory muscles training, or combo
if someone has no participation restriction, is not active, has activity limitations but can perform the activity with endurance limitations and signs of exersion that are not relieved with rest, what is indicated?
ER!
if someone has no participation restriction, is not active, has activity limitations but can perform the activity with endurance limitations and signs of exersion that are relieved with rest, what is indicated?
contact their PCP
if someone has a participation restrictions, activity limitations, and cannot perform the activity, what is indicated?
PT as appropriate (education, NMES, inspiratory muscle training)
if someone has a participation restrictions, but no activity limitations, what is indicated?
education, aerobic resistance, combo
if someone has a participation restrictions, activity limitations, can perform the activity with no endurance limitations, what is indicated?
ID a new task
if someone has participation restrictions, activity limitations, can perform the activity but has endurance limitations with no signs of exersion, what is indicated?
education, aerobic training, resistance training, NMES, HIIT, inspiratory muscles training, combo
if someone has participation restrictions, activity limitations, can perform the activity but has endurance limitations with signs of exersion not relieved with rest, what is indicated?
ER!
if someone has participation restrictions, activity limitations, can perform the activity but has endurance limitations with signs of exersion relieved with rest, what is indicated?
contact their PCP
what do we address first, activity limitations or endurance issues?
activity limitations
what is the definition of physical activity?
any bodily movt produced by skeletal muscles that results in energy expenditure beyond resting expenditure
what is the definition of exercise?
subset of physical activity involving structured, repetitive, and purposeful move to improve overall physical fitness
what are the benefits of physical activity?
physiologic, MSK, and psychosocial benefits
physical activity can also improve what peripheral conditions of HF?
impaired vasoactvity
reduced MSK oxidative capacity
fxnal iron deficiency
decreased bone mineral density
t/f: adherence to exercise is crucial to improve exercise capacity and performance and increase overall daily physical activity in pts with HF
true
why is long term adherence to exercise important for pts with HF?
bc it helps break the negative cycle of inactivity and deconditioning that occurs with chronic conditions
what are some approaches to adherence encouragement?
goal setting
positive feedback
problem solving
learning by doing
role modeling
supportive visits and phone calls
caregiver engagement
PTs _______ advocate for physical activity as an essential component of care for pts with stable HF
SHOULD
t/f: HIIT should start out lower
true
what is the frequency for aerobic HIIT?
3-5 days/week
what is the frequency for strengthening HIIT
1-2 nonconsecutive days/week
what is the time for aerobic HIIT?
progressively increase to 30 min/day up to 60 min/day
what is the time for strengthening HIIT?
2 sets of 10-15 reps with a focus on major muscle groups
what type of exercise is included for aerobic HIIT?
treadmill
free walking
stationary cycle
what type of exercise is included for strengthening HIIT?
resistance machines may be best
what is the intensity for aerobic HIIT?
moderate
60-80% HRR
OR
RPE 11-14 on 6-20 scale
what is the intensity for strengthening HIIT?
begin with 40% 1RM UE and 50% 1RM LE
increased to 70% 1RM
why is the UE HIIT guidelines diff from LE?
bc the UE activity will result in increased return to the heart and so we want to be more careful and gradual with UE activity than LE
PTs _____ make appropriate nutrition referrals, perform medication reconciliation, and provide appropriate education on preventative self-care behaviors to reduce risk of hospital readmissions
MUST
what things MUST a PT do according to the action statements of the HF CPG?
make appropriate nutritional referrals, performs medication reconciliation, and provide appropriate education on preventative self-care behaviors
prescribe aerobic exercise training for pts w/stable NYHA class 2-3 HF
what things SHOULD a PT do according to the action statements of the HF CPG?
advocate for physical activity as an essential component of care in pts with stable HF
prescribe HIIT for pts w stable NYHA class 2-3 HFrEF
prescribe resistance training for the UE/LE major muscle groups for pts with stable NYHA class 1-3 HFrEF
prescribe inspiratory muscles training w/a threshold device for pts with stable NYHA class 2-3 HFrEF
prescribe NMES in pts with stable NYHA class 2-3 HFrEF
what things MAY a PT do according to the action statements in the HF CPG?
prescribe combo aerobic and resistance training for pts with stable NYHA class 2-3 HFrEF
prescribe inspiratory muscles training w/aerobic training
what is involved in nutritional education for pts according to the HF CPG?
daily weight measurements to ID an increase of >2-3 lbs in 24 hrs or 5lbs in 3 days
recognition of s/s of exacerbation
action planning (nutritional plan, medication management)
what weight gain in 24 hours would be a red flag for pts with HF?
2-3 lbs
what weight gain in 3 days would be a red flag for pts with HF?
5 lbs
what is the protocol for aerobic training?
20-60 minutes
50-90% peak VO2 or peak work
3-5x/week for at least 8-12 weeks
treadmill or cycle ergometer or dancing
what is VO2max?
max volume of O2 consumed per unit of time (usually per min)
what is the gold standard for measurement of cardiorespiratory fitness?
VO2max
VO2max is related to____ _____
cardiac output (CO)
what measure is considered to be the fxnal capacity of the heart?
VO2max
what is VO2peak?
max O2 consumed during exercise testing when testing is limited by factors other than circulatory dynamics (muscle fatigue or ventilatory capacity)
is VO2max or VO2peak more often used in chronic disease populations?
VO2peak
how do we estimate VO2max from submaximal tests like the 6MWT?
based on the HR workload relationship
use the distance, their age, their weight, their height, their rate pressure product (HR x SBP)
VO2max=…….=……..
mL/kg/min=resting + horizontal + vertical/resistance
PTs must prescribe aerobic training to HF pts in what NYHA class?
2-3
PTs SHOULD prescribe HIIT to HF pts in what NYHA class?
2-3
PTs ______ prescribe HIIT for pts w/stable NYHA class 2-3 HFrEF
SHOULD
what is the protocol for HIIT according to the action statements for the HF CPG?
> 35 min total of 1-5 min high intensity (>90%) alternating with 1-5 min at 40-70% active rest intervals w rest intervals shorter than the work intervals
2-3x/week for at least 8-12 weeks
treadmill or cycle ergometer
working at a % VO2max is ideal, but we can use what other measures?
%HR or RPE
PTs _____ prescribe resistance training for the UE/LE major muscle groups for pts with stable NYHA class 1-3 HFrEF
SHOULD
what is the protocol for resistance training according to the action statements from the HF CPG?
45-60 min/session
60-80% 1 RM, 2-3 sets/muscle group
3x/week for at least 8-12 weeks
t/f: resistance exercise has an effect on skeletal muscle but elicits less strain on the cardiorespiratory system compared to aerobic exercises and may therefore be a suitable alternative for pts with CHF
true
how does resistance training work as an alternative b4 aerobic training if a pt cant tolerate aerobic training?
it lowers the O2 needs of muscles, lowering dyspnea do they can tolerate aerobic training
PTs ____ prescribe combo aerobic and resistance training for pts with stable NYHA class 2-3 HFrEF
MAY
what is the protocol for combo resistance training and aerobic training according to the action statements from the HF CPG?
20-30 min resistance training added to aerobic training
2-3 sets/major muscle group at 60-80% 1RM
3x/week for at least 8-12 weeks
would a sedentary pt be a good candidate for combo resistance and aerobic training?
NO
PTs ____ prescribe inspiratory muscle training w/a threshold device for pts with stable NYHA class 2-3 HFrEF
SHOULD
PTs SHOULD prescribe resistance training to pts with HF in what NYHA class?
1-3
PTs MAY prescribe combo aerobic and resistance training to pts with HF in what NYHA class?
2-3
PTs SHOULD prescribe inspiratory muscles training to pts with HF in what NYHA class?
2-3
what is the protocol for inspiratory muscles training for pts with HF according to the action statement from the HF CPG?
30 min/day or less if using HIIT
> 30% MIP
5-7 days/week for at least 8-12 weeks
PTs ____ prescribe inspiratory muscle training w aerobic training
MAY
what is the protocol for combo inspiratory muscles training and aerobic training for pts with HF according to the HF CPG?
30 min/day
> 30% MIP
5-7 days/week for at least 8-12 weeks
pts with HF unable to ambulate >____ m in the 6MWT have poorer short term survival
468
how many meters in the 6MWT seems to be important in determining ST and LT survival w HF?
300
PTs ____ prescribe NMES in pts w stable NYHA class 2-3 HFrEF
SHOULD
PTs SHOULD prescribe NMES to pts with HF in what NYHA class?
2-3
what is the protocol for NMES for pts with HF according to the action statement from the HF CPG?
30-60 min/session
biphasic symmetrical pulses at 15-50 Hz
on/off time=2/5 sec
pulse width for larger muscles of LE should be 200-700ms ; for small LE muscles .5-.7ms
20-30% of MVIC, intensity to contract muscles
5-7 days/week for at least 5-10 weeks
what is cardiac rehab?
a program in outpatient that is multidisciplinary to target exercise, education, and lifestyle modification
what is primary prevention in cardiac rehab?
active intervention for risk factors that cause CVD
who are candidates for primary prevention in cardiac rehab?
those at moderate to high risk of CVD and those with a family hx of CVD
primary prevention in cardiac rehab is needed to address what?
high prevalence of modifiable risk factors of CVD
what are the problems with primary prevention in cardiac rehab?
compliance and lack of payment by insurance
what risk factors are affected by primary prevention in cardiac rehab?
lower total chol/HDL ratio
lower LDLs
increased exercise tolerance and aerobic capacity
increased feeling of wellbeing and stress tolerance
decreased BMI
decreased resting BP
increased glucose tolerance and insulin sensitivity
t/f: rehab of pts with documented CVD may have a primary or secondary CVD
true
t/f: rehab of pts with documented CVD helps them achieve optimal physical, psychological, and functional status
true
what are the components of the rehab program of pts with documented CVD?
education in recognition, prevent, and treatment of CVD
decreasing risk factors
dealing with psychological/behavioral factors influencing recovery
structured, progressive physical activity at rehab or home
vocational or return to leisure activities counseling
ADL and fxnal training
what is phase 1 of cardiac rehab for pts with documented CVD?
in the acute hospital when medically stable
what is phase 2 of cardiac rehab for pts with documented CVD?
early outpatient care with intensive monitoring and lifestyle/risk factor modification
what is phase 3 of cardiac rehab for pts with documented CVD?
maintenance program in larger group exercise
independent progression
what is phase 4 of cardiac rehab for pts with documented CVD?
disease prevention program for those at high risk for infarction or who need continued medical supervision
what are the specific goals of inpatient CR (cardiac rehab) in phase 1?
eval of physiologic responses to self care and ambulation activities
provide feedback to clinicians so recommendations can be made
provide safety guidelines for progression of activity
education
what VSs would show that PT is appropriate in CR phase 1?
RR<30 breaths/min
resting HR <120 beats/min
MAP min of 60 mmHg
SpO2>90%
SBP <140 mmHg
what VSs would indicate to stop PT in phase 1 CR?
unable to speak comfortably
RR>40 breaths/min
onset of S3 heart sound
HR drops >10 beats/min
SBP drops >10 mmHg
MAP increases >10 mmHg
SpO2 <90% or a drop of >4%
new/worsening dysrrhythmia
return of pre-MI angina-like pain
how do we calculate MAP?
SBP +2DBP/3
how long is diastole compared to systole?
diastole is twice as long as systole
what does a MAP increased of >10 mmHg indicate?
kidney failure or heart failure
what are day 1 CR phase 1 activities?
sleeping, watching TV, writing/desk work, typing, slow level ground walking
how many METs is appropriate day 1 in phase 1 CR?
1-2 METs
what are day 2-5 CR phase 1 activities?
up to average walking speed on even ground
stationary cycling at very light effort
how many METs is appropriate day 2-5 in phase 1 CR?
2-4 METs
how many METs is very light intensity?
<3 METs
what activities are included in very light intensity?
anything up to light walking
how many METs is moderate intensity?
3-6 METs
what activities are included in moderate intensity?
anything up to light biking
how many METs is vigorous activity?
> 6 METs
what activities are included in vigorous activity?
anything up to jumping rope
what is the frequency for phase 1 CR?
2-3x/day working up to 5-6x/day by the end of week 1
what is the intensity for phase 1 CR?
HR increase of 20-30 bpm
Borg rating bw 11-13 (light to somewhat hard)
how long should interventions in phase 1 CR be?
3-5 minutes working up to 30 minutes by week 4
what types of activities are included in phase 1 CR?
ADLs, fxnal activity, walking, stair assessment
who may be a candidate for phase 2 CR?
MI (w/in 12 months)
HF
angioplasty
heart transplant
stable angina
CABG
valve replacement
comorbid conditions
poor ejection fraction
cardiomyopathy
serious arrhythmias
where is the biggest growth in home-based CR in phase 2?
tele-based CR
who would be a good candidate for home-based CR phase 2?
pts diagnosed with chronic HF that were recently dc from the hospital
what is involved in secondary prevention in CR?
interdisciplinary approach
smoking cessation, nutrition, exercise, psych, HTN management, DM management, bone density
what are the components of the initial assessment in rehab/secondary prevention CR in outpatient settings?
thorough medical and psych hx
pt/fam interview
physical exam
exercise test, 6MWT, or shuttle walk
blood chem panel
physical activity status
QOL questionnaire
what factors determine the frequency of monitoring and the degree of supervision during rehab/secondary prevention CR in outpatient settings?
prior clinical course
exercise test results
degree of ventricular impairment
initial assessment
risk stratification
ideally, when does the rehab/secondary prevention CR program begin?
as soon as it’s safe after hospital d/c
what types of interventions are included in the rehab/secondary prevention CR program?
ther ex, pt ed, coordination/communication
aerobic exercise, resistance training, flexibility, circuit training
what is the intensity of rehab/secondary prevention CR?
70-85% max HR
50-85% VO2max
t/f: the rehab/secondary prevention CR program exercises muscles frequently used by the pt
true
what is circuit training?
series of activity one after another keeping the HR high
how can we progress the CR program?
increase duration of exercise
increase intensity of exercise
change the mode of exercise
what are the post op precautions for a new pacemaker/ICD?
no shoulder mov’t >90 deg
no lifting >10-15 lbs
how long will precautions be in place after pacemaker/ICD placement?
up to 4 weeks
what precautions are followed after a median sternotomy?
sternal precautions
what is the risk following a median sternotomy?
wound infection
sternal dehisence
what risk factors increase chances of infection or dehiscence post median sternotomy?
obesity (BMI>30)
DM requiring meds for BG control (HIGHEST RISK FACTOR)
HF
previous sternotomy
respiratory failure
what are the sternal precautions?
no UE use above shoulder level
no UE behind the back
no lifting >5-10 lbs
no excessive pushing/pulling
no UE use with functional movt
what are the limitations of sternal precautions?
there are no universally accepted set of precautions
it is based on anecdotal evidence and expert opinions
it is applied to all pts w/o consideration for individual differences
it may impede on fxnal recovery bc it is too restrictive
it is not supported by current evidence
what is a new alternative to sternal precautions that are sometimes used?
keep your move in the tube
what does “keep your move in the tube” do?
it reduces the force on the sternum by keeping the UEs closer to the midline during weighted movt and arm WB activities
what are some considerations for CTs following surgery?
pain
complications
respiratory effects
what are the consequences of CT pain following surgery?
can limit deep breaths
do younger or older pts tend to have more pain with chest tubes?
younger
why may younger pts have more pain with CTs?
they have more muscle
they have more perceptible nerve endings
they have more vasculature
what is a common complication from CTs (chest tubes) seen in days 3-5 post-op?
A fib
what are the respiratory effects of chest tubes post-op?
pain with inspiration and coughing
volume overload–>pulmonary edema–>dyspnea
atelectasis (not taking deep breaths)
what are relative contraindications to continuing exercise?
HR increase of >50 bpm w/low level activity
HTN SBP >210 mmHg or DBP >110 mmHg
decrease in SBP >10mmHg w/low level activity
angina, excessive fatigue, dyspnea, mental confusion, dizziness, severe LE cluadication pain
palor, cold sweats, ataxia
changes in heart sounds
changes in EKG
decrease in SBP, excessive HTN, or low heart response w/ excessive activity
