Quiz 1 - 1 Flashcards
Therapeutic ex - 3
systematic performance/execution of planned physical movements, postures, or act inteded to allow the pt to
- remediate/prevent impairement
- enhance function, fitness, and well being
- decrease risk
- optimize overall health
symptom free movement is the ultimate goal
adaptation, recovery/prevention at levels of impairment and activity limitations
Therex simplified - 4
carefully graded physical stresses and forces that are imposed on impaired body systems, specific tissues/ind structures in a controlled, progressive, safely executed manner to decrease physical impairments and increase function
specific to pt’s functional needs and impairments
systematically reassess with outcome measures
progress, modify and/or adapt ex slowly and methodically
Physical inactivity
epidemic - soceital, med, PT issue
> 65 yr
Fastest growing segment and increase chronic conditions and associated diabetes
Evolution and changes of PT - 4
passive -> active rehab
decrease in # of sessions - insurance
increased awareness about health and wellness
recognized benefits of ex
exercise is medication - 3 - 1
decrease pain (chronic pain syndrome)
mental health illness
stroke, cancer, resp, neuro
teach and promote as PT
Evolution and challenges of PT - 2
young healthy adult literature
specific tasks transfer into sports med but what about ADL? unfit pop? chronic condition?
from the pyramid to the rings
Feel better (less pain do more) move better (ADL) perform better in decreasing importance to equal importance - move and perform better has to do with intensity
What is therex - 10
aerobic conditioning/reconditioning
m. performance ex - strength, power, endurance
mobilization - jt ROM, tissue and jt stretching
neurom. control, inhibition, facilitation techniques - proper movement
posture awareness training - core
stabilization - lower back/shoulder/knee
balance, proprioception and agility
relaxation - decrease m. tone to engage other m
breathing ex and ventilatory m/ training
task specific functional training
Whos of therex
type, age, ability levels, - mirror therapy, animal therapy
When and where of therex - 3
phases of healing - all modifications and considerations for optimal healing
prevent - acute rehab - RTA - monitor
environments - hospitals, rehab centres, private - community, clinics, home care, gyms, and training facilities - class based and ind
principles of therex - 6
exercise prescription functional exercise quality and quantity progression and load management strength and conditioning principles compliance
What to consider for exercise prescription? - 2
always taught and communicated
correct ex
How to know if it is the correct ex? 1-3
pt impairment
pt info - subjective (history) and objective (clinical measures) assessment , goals/act/function
injury info - weak m vs nerve damage from diabetes, phase and severity
goals of ex
Dosage parameters of ex prescription - 5
number of reps set and frequency, why intensity - difficulty, resisitance speed - pace resistance? type? normal function? do at home? order of ex?
best dosage of ex prescription - 2
considering pt and injury info and goals of ex
pt ability to perform ex with proper technique without reproducing S&S of injury/condition
pain free with prescribed ex
progress to more typical ex prescription guidelines
right ex should
change targeted feature - increase ROM, walking endurance, able to roll in bed
how to quantify changes - 1-2
outcome measures
HR, ROM, pain, functional improvement, pt satisfaction, strength
standardized - Berg balance scales, LEFs, etc
Functional ex 1-2-1
purposeful training
- purpose that fits pt and condition
- duplicate movement pattern - jt, ROM, flexibility, m. act (type of contraction, power, strength, endurance, and environment (WB vs NWB, equipment of goal/act)
e. g balance - sit to stand - bow squat
quality of exercise - 2
nuerom. function but without quantity consideration could still cause injury
performance
quantity of ex
capacity
without quality would cause injury
progression and load management of therex - 3
proper stress is key to healing tissues - adapted as tissue responds
Specific Adaptation to Imposed Demand
slowly add load and change over time to challange pt and healing tissue
load management - 2
slowly adding weight
unload componenet - change velocity of movement, accel/decel, chagnge direction, planes of movement, ROM, kinetic change integration, strength, pow er, endurance
S&C - 2 - 2
perform better - strength and power relative to ind pt need
avoid 1RM living - regular demands near/> ones max capacity/1RM
- risk of falling, movement, fatigue, reinjury
- physical resilience and functional reserve
ex of ex progressions - 10
increase volune (reps, sets increase resistance/load increase speed increased ROM decrease ROM add leverage change base of support add displacement add multiple systems multidirectional
guides for progression - 2
specific injury site/tissue sufficiently healed/strong enough to endure an increased load
able to perform preceding ex with proper technique/control and without any reproduction of S&S AND there has been improvement in outcome measure matched to impairment
modification/adaptation of an ex - 9
decrease volume - reps and sets decrease resistance/load increase or decrease speed increase or decrease ROM change leverage change base of support change displacement begin with 1 system at 1 time unidirectional
what makes the best ex?
the one you taught the pt and theyre doing
how to engage your pts - 4
educate - why how it relates to them, injuries and goals
involve them in process - engage, empower and give responsibility
pt buy in
engaged, excited, empower
when prescribing ex always start with
small numbers for safety and figure out what pt can tolerate then work with her functional level
Menopause and osteoporosis
lose bone density
first fracture leads to more
history of bed rest - 3
rare up to 19th century - sin to die with boots off
misinterpretation of Dr John Hilton - overemphasize on bedrest
stayed like that till 1940s - WWII soldiers need to be ready ASAP, space research said bed rest was bad
complications of bedrest - 7
CV and resp deconditioning
skeletal m.atrophy and weakness
disuse osteoporosis/loss of bone mineral density
jt contractures
pressure ulcers (could be prevented by good health care)
psych effects
others - systemic inflammation, microvascular dysfunction, changes to metabolism/insulin resistance, thromboembolic cdisease, ateletasis, increase risk of incontinence
7 common causes of bed rest
multiple trauma/ortho surgery
SCI
stroke
prolonged hospitalization - organ failure, resp failure, systemic shock, cardiac failure, infection etc
failure to thrive - long term care
fetal and maternal complications - preeclampsia
medically unstable conditions - brain bleed
Bed rest and CV changes 1- 6
depends on bed rest duration
- decreased VO2max
- decreased plasma volume
- decrease RBC mass
- blunted vasodilation and function
- cardiac atrophy
- decreased peripheral o2 diffusing capacity
VO2 max
max o2 uptake - body’s capacity to use o2 - max amt of O2 consumed/min when ind reaches max effort
7 potential benefits of bedrest
conserve metabolic resources for healing/recovery
decrease o2 consumption by m.divert to injured tissues/organs
decrease requirements for ventilation
increased blood flow to CNS
decrease harmful falls
decrease stress to heart - prevent ischemia and dysthythmias
avoid pain and additional injury
low CR fitness and bedrest
independent predictor of increased risk of CV event
increased risk of all cause mortality
Postural Hypotension - 2
LBP from sitting/lying to standing
- blood and lymphatic rush to LE
- unless quickly corrected will be potential for drop of blood flow to the brain - dizziness and fainting
Why does bedrest lead to postural hypotension - 1-4
when does it happen?
when do we know?
how long does it take to recover
normal mechanisms to counteract effects are restricted/diminished
- lower blood volume - greater pressure drop
- blunted baroreceptor response - less blood, less stretch
- decreased venous return and stroke volume
- cardiac deconditioning - less effective pump
- as early as 20 hrs of bed rest
- apparent when pt just starts to move - (often without pt and they fall out of bed so always check at sitting)
- slow recovery - several weeks in young healthy adult
Downward respiratory cascade - 5
decrease m. strength and endurance
decrease movement of diaphragmatic, intercostals, abs
pooling of mucous and impaired ciliary function in affected airways
impaired cough - mucous plugging and atelectasis
development of pneumonia - terrible in frail elderly
m. atrophy and weakness and bedrest - 4
-recovery
m. mass decrease
WB LE
why loss of m. mass
survivor of critical illness suffer for wks - months after
- affect functional tolerances like walking - strength affects function
m. mass decrease by 1.5-2%/day or 10-20%/wk during first 3-5 wks depending on lvl of BE, moving in bed and bed ex decrease these effects
LE and torso worse - knee extensors 15-22% after 2 wks, 53% after 28 days
loss of mass bc loss of size of m. fibres
bed rest and increased risk of clot formation
increased blood viscosity due to loss of plasma
virchows triad
virchows triad 1 - 3
theses factors cause clots to form
venous statis & pooling at heart/ skeletal m less efficient
hypercoagulability - clotting factors not cleared, loss of plasma
blood vessels damage - supine posiiton, poor flow
deep vein thrombosis could lead to 4
emboli
pulmonary embolus
stroke
myocardial infaction
Easy ex to prevent clot formation
ankle pumps, quad contractions
bed rest and changes to bone/disuse osteoporosis - 3
caused by loss of bone density due to increased reabsorption caused by lack of WB, gracity and m.act on bone mass
LE bones largest decrease
recovery much slower at occurance rate
joint contractures and bed rest
2jt m.
fibres and tissues maintained in shortened positions
tissues adapt to length because of contraction of collagen and decrease in m. fiber sarcomeres, tendon, capsule, ligament
skin ulcers - 3
unrelieved pressure
also affect by impaired microcirculation, malnutrition, shear force at pointsof contract and humidity
head up position can increase pressure at sacrum
bed rest and psychological impacts - 3
depression and delirium
loss of control and motivation, feeling of helplessness, stimilation, independent ADLs, loss of hobbies/jobs
changes in affect (anxiety, depression, temp confusion, delirium), cognition - impaired concentration and judgement, perception - disoriented, hallucination, B-psychotic B, apathy, irritability, self-isolation and decreased motivation
What do we need to investigate about bed rest effects?
sexes? age?
How to minimize bedrest effects? - 9
early mobilization - in bed
deep breathing and coughing
AROM and PROM and strengthening ex
frequent changes in position
maintain functional positions of head trunk arms hands feet
adequate hydration and nutrition - ask if they need a drink?
prevent pressure sores
proper skin care - check pressure pts
maintain continence - if they need anything?
recovery from critical care - 2
past ICU - liberal sedation and immobilization - less is more and could cause other problems
focus of rehab begin in ICU - cont to home recovery
intervention to present disuse osteoporosis - 2
WB - walking/standing, standing frame/tilt table, standing in parallel bars, UE WB - press up in bed
General strengthening - strength endurance coordination, force of m. helps decrease bone resorption (m. contraction)
exclusions to early mobilization - 5
alert and sedation minimized
resp instability
hemodynamically unstable - no hypotensive and/or need vasoactive drugs
brain injury - stroke/trauma, severe delirium, terminal diagnosis, spine/limb injury, CPR on admission, pre existing severe physical disabilities
multidisciplinary team approach - promote in nursing, family
reduce contractures - 4
ROM A&P - 1/3 pt get contractures and 1/4 get functional affected,
load - maintain lig, t, cartilage, bony attachment and m.integrity
active enhance vascular benefits of ROM (m.pumps) -> keep moving
splinting and casting - surgical interventions
interventions to decrease CV complications - 3
ambulation - asap
therex - bed, sitting dangling legs, standing
LE reaching overhead, UE, trunk
interventions to decrease resp complications - 4
ambulation
deep breathing and coughing
mucosulary clearance techniques
*train contralat side - 16-18% diff - central connection?
To decrease skin ulcers - 2
frequent change of position - spec mattress, sheep’s skin, foams, boots
increase act increase bloodflow increase m.bulk and strength - self alter positioning in bed and limit time in bed
early mobe in ICU - 3
better outcomes - stronger and more capable pts when discharged
harms of BR> potential harms of rehab
increased rehab funding decrease 20% of stays
Why pre screen - 4
- Assess safety
○ Identify if they are safe to exercise (risk of CV event of MSK injury)- Mini risk
○ ID what you should monitor during EX
○ ID who should participate in a medically supervised program
- Mini risk
- Choose an appropriate test/assessment
○ Their response to exercise normal/abnormal? - Provide effective EX program
○Modifications/precautions
§ Knee replacements don’t kneel on knees
§ Hips - reduced ROM so a recumbent bike
Why are we the first to hear symptoms - 3
- May not have thought to tell them
- May not have time to tell their doc
- May have changed between now and then
method of screening - 2
Watch them move - posture, gait, walking aid, short of breath
Questionnaires - before appt, chart review
what will affect how questions are answered on questionairre?
knowledge of health and condition
4 wrong ways that pts say no
® Pt may think that they are on meds so conditions are under control - I don’t have it - check no
- Pt don’t agree with their Dx - refuse to take meds and if they don’t take it they don’t have it - check no
- Surgeon says they are fixed - they check no for heart conditions
- If readings are good - no idea what reading is - ask for concrete numbers - what is your blood sugar/what is your normal resting blood pressure
7 questions to ask when taking history
○ How are you feeling 2x - first one isnt always the truth
○ Do you have anything that bothers you with EX
○ Are you on any meds and have you taken your meds
○ Have you eaten today
○ Anything new or diff today
○ If they have symptoms
○ What is normal for you right now/since your surgery?
Risk strat for CV - age
men >/_ 45 yr, F >/_ 55 yrs
Risk strat for CV family history
® Myocardial infarction, coronary revascularization, sudden death
1st degree relative, m <55 yr, f<65 yr
Risk strat for CV cig smoking
® Current, quit within 6 mo or exposed to environmental smoke
Risk strat for CV physical inactivity
<30 mins, 3x/wk for at least 3mo
Risk strat for CV obesity
® BMI >/_ 30 or waist girth >/_ 102cm(40in) men, 88cm/(35in) F
Risk strat for CV hypertension
® >/_ 140 systolic, 90 diastolic, or on med
Risk strat for CV dyslipidemia
® LDL >/3.37mmol, HDL <1.04mmol, on med, total serum cholesterol >/ 5.18
Risk strat for CV diabetes
® Fasting plasma glucose >/_ 7, HbA1C>/_6.5%, or on med
Risk strat for CV - neg risk ffactor
HDL cholesterol >/_ 1.55
Chronic conditions for canadians
44% of Canadians over 20 has 1 of 10 most common chronic condition
CC lead to other ones and make them worse
1 in 3 canadians will have 2 or more by 45 yr
1 in 2 by age of 60
1 in 4 Canadian will be over 60 in 2030
risk of sudden cardiac death
Before 35 its usually congenital heart disease and after 35 its usually coronoary artery or acquired heart diseases - most dangerous time is the first 3m from going sedentary to active
- More intense - more dangerous
what does active mean?
30 mins 3x/wk for at least 3mo makes you less susceptible
longer duration and high intensity act - 3
more energy
- Heart - increased myocardial contractibility, stroke volume, cardiac output (CO=SV*HR), HR, Systolic BP (each heart beat), Diastolic BP (in bw each heart beat) - wont change or decrease , Mean arterial pressure, increase in ventilation
- Hormones to vasodilate
sedentary vs exercised trained CV systems
CV increases much more pronounced and quickly lower intensities
how to monitor pt symptoms
HR monitor, BP cuff, talk to them
lactate threshold
§ Intensity of exercise at which lactate begins to accumulate in the blood faster than it can be removed
ventilatory threshold - 2
§ Intensity of exercise at which ventilation starts to increase at a faster rate than VO2
§ Byproduct Hydrogen ion - metabolic acidosis - drops in pH
○ Regulate pH - bicarbonate buffering
§ CO2 and H2O
Chemreceptors to pick up change and trigger respiration/inhalation
Out goes more CO2 but metabolism is not kept up so same O2 – Talk to patient
acute CV response to RT
Depends on load and type of m. contraction - bigger during concentric
- Increased intra thoracic pressure - Increased mean arterial pressure - marked increase in SBP - Increased systemic vascular resistance - Increased HR - Increased myocardial contractibility - Increased cardiac output
Valsalva maneuver and RT - 4
- Mod forceful exhalation against a closed airway - breathe holding
- Unavoidable
○ Loads >80% 1RM
○ Lighter loads to failure - Increased intra thoracic pressure - helps to stabilize spine
- Exaggerated BP response
Practical application of valsalva maneuver and RT - 5
○ Brief is safe in apparently healthy ind (<3secs) ○ Avoid in those with or at risk of § Cerebrovascular disease - TIA/stroke § CVD - heart/ischemic heart disease § Hernias, aneurysms ○ Start with loads <80% ○ Avoid reps to failure ○ Breathe out on exertion, in on relaxation
Symptoms of CVD - 10
Angina dyspnea unusual fatigue dizziness or syncope orthopnea or proximal nocturnal dyspnea ankle edema palpitations or tachycardia intermittent claudication known heart murmur
angina - 2
discomfort in chest
○ May result from myocardial ischemia - mismatch bw supply and demand of blood supply in the heart which results in o2 deficit
angina presentation - 3
□ pressure in chest - radiate to both arms - 25%
□ Pain from Belly button to nose front or back could be related
□ Jaws/back
angina character - 5
□ Constricting □ Squeezing □ Burning □ Heaviness Heavy feeling
angina location
Substernal, across mid thorax, ant; one or both arms, shoulders, neck, cheeks, teeth, interscapular region(women)
angina provoking factors - 5
□ Ex/act- vigorous □ Excitement □ Other forms of stress □ Cold weather - constrict arteries □ Occurs after meals
angina reversible?
yes - remove stimulus and it goes away
angina med
nexosprain - potent vasodilator
angina after math - 2
always worried - localized pain not it
characters not for angina - 5
□ Dull ache □ Knifelike □ Sharp □ Stabbing □ Jabs - aggravated by respiration/twisting or bending - push on it and it hurts more or less
not location for angina - 2
□ One sided sub mammary
□ One side of chest/thorax
not provoking factors for angina -2
After completion of exercise, provoked by specific position
second angina
often mimic first presentation
