Quiz 1 - 2 Flashcards
dyspnea - 5
Shortness breath at rest, with mild exertion or usual activities - anything that makes the heart work harder - cold weather, inclines, large meal
○ Abnormally uncomfortable awareness of breathing
○ Strenuous exertion in healthy trained
○ Mod exertion in healthy untrained
○ Abnormal
§ Occurs at a level of exertion not expected to evoke symptom
□ May indicate heart failure or pulmonary disease
Unusual fatigue - 4
gradual decline in energy levels - not aging
○ May be benign and caused by deconditioning
○ May signal of change in CV or metabolic disease
○ May be accompanied by dyspnea
dizziness or syncope
Loss of consciousness, tunnel vision confusion, slurred speech impaired motor function
KEY QUESTIOns for usual fatigue - 2
Key questions
§ How many flights of stairs can you do
□ Unable to do >1-2 w/o stopping
How many blocks can you walk with out stopping
Unable to do >2-3 blocks w/o breaks
2 causes for dizziness/syncope
during exercise
§ Blunted or reduced CO
§ Reduced perfusion to brain
During exercise may be due to cardiac disorders
2 factors to consider for dizziness or syncope
§ Meds - HR, BP, diuretics/water pills - dehydrated
§ Hydration/fluid restrictions
dizziness in healthy
After ex cessation may be due to reduced venous return to heart
Orthopnea or proximal nocturnal dyspnea - 2
short of breath - cant sleep - tired - ejection fraction - 60% is normal
○ Both indication of heart failure - left ventricular dysfunction - built up fluid in lungs
Orthopnea - 2
§ Dyspnea occurring at rest in recumbent position
§ Relieved by sitting upright or standing
Paroxysmal nocturnal dyspnea - 2
§ Dyspnea beginning 2-5 hrs after sleep
Relieved by sitting upright or getting out of bed
ankle edema
- larger or puffy limbs, shoes don’t fit as well, indentations from socks, accompanied by shortness or breath/fatigue - new symptom to emerge, not new go to GP
bilateral ankle edema - 2
§ Most evident at night
§ Indication of heart failure or chronic venous insufficiency
unilateral ankle edema
Indication of venous thrombosis or lymphatic blockage of limb
generalized ankle edema
Kidney disease, heart failure or liver disease
factors to consider - ankle edema
Sudden change in weight >2kg in 1-3 days
palpitations
remember to
could be induced by
sit for a few mins before you measure their HR
Unpleasant awareness of forceful or rapid heart beat
various disorders of cardiac rhythm, anxiety or high CO states - anemia/fever
Normal RHR
60-100
Tachycardia
fast HR >100
Bradycardia
slow HR < 60 - when accompanied by other symptoms - dizziness confusion , change in consciounsness
Intermittent claudication - 1- 6
blockage of artery ○ Pain in LE brough on with exercise ○ Disappear within 1-2 min of rest ○ Doesn’t occur with sitting/standing ○ Reproducible day to day ○ Described as cramping Aggravated by stairs and hills
known heart - murmur - 2
questions to ask
○ Indication of valvular disease or CVD
Most commonly related to exertion related sudden cardiac death
specialist? Additional workup?
2 possible conditions - known heart murmur
§ Aortic stenosis - aortic anerysyms
Hypertrophic cardio myopathy - lethal arrythmias - may not have preceding symptoms - restrictions/parameters of GP first
7 absolute contraindications to aerobic exercise testing
- Acute myocardial infarction within <3-5days
- Ongoing unstable angina
- Uncontrolled arrhythmia with hemodynamic compromise - symptoms
- Symptomatic severe aortic stenosis - symptoms
- Decompensated heart failure - symptoms
- Active or acute infection - endocarditis, myocarditis, pericarditis
- Acute pulmonary embolism, pulmonary infarction, deep vein thrombosis, physical disability that precludes safe and adequate testing
what to do with absolute contraindications
symptoms in front of you - ER, follow up with GP otherwise
7 relative contraindication to aerobic ex
- Known obstructive left main coronary artery stenosis
- Mod to severe aortic stenosis with uncertain relationship to symptoms
- Tachyarrhythmias with uncontrolled ventricular rates HR>120
- Acquired advanced heart block or complete heart block HR<60
- Recent stroke or transient ischemia attack
- Resting hypertenstion with systolic >180 or diastolic >110
Uncorrelated/treated med conditions - anemia, hyperthyroidism
what does a relative contraindication to aerobic ex mean
still may be able to work, parameters from specialist/GP
diabetes
if managed?
- Gp of metabolic disorders characterized by a decrease in the production, release and/or effectiveness, and action of insulin (break down glucose)
not a huge issue by itself - can lead to others or make others worse
9 symptoms for diabetes
○ Increased thirst ○ Dry mouth ○ Frequent urination ○ Weak tired feeling ○ Blurred vision ○ Numbness or tingling in hands or feet ○ Slow healing sores or cuts ○ Dry and itchy skin ○ Frequent yeast infections or urinary tract infections
goal for resting blood glucose
- 4-8mmol - want your sugar a little higher before you start bc exercise burns glucose so you need a buffer - juice box?
BG for post exercise hypoglecemia in insulin dependent
<5.5
Risk of vascular damage is exercising with BG
> 16.5
Neropathy central and peripheral for diabetes - 3
impair ability to feel pain/discomfort
○ Interesting if they are symptomatic
Feet blisters - don’t feel them
foot care for diabetes
foot ulcers
cotton socks - change frequently
14 signs of hypoglycemia - 1
Feeling weak Shakiness/trembling Dizziness Sweating Hunger Irritability or mood Anxiety or nervousness Headache Tiredness Clumsiness m.weakness Difficulty speaking Blurry or double vision Confusion ask what they feel like when they are low - some heart meds can mask these symptoms, diabetic pt not feeling well - check your blood sugar
BG green zone for exercise
5.5-16.5
BG Yellow zone for exercise
<5.5 (ingest carbs) or >16.5 (hydrate)
when adjusting BG for exercise
retest sugar before ex
if the BG is 8 before ex
limit intensity
if BG is 20 or above before ex
forget it for the day
what do you ask your pt if BG was abnormal?
meds? eaten? diff PA?
BG management with exercise - 2 things you need
- Need ability to monitor BG before during and after exercise - esp change in meds, eaten, diff PA - bring it with you! For as soon as symptoms happen
- Readily available fast acting source of carbs - juice, hard candy, fruit - hold you over till you can eat something substantial
when to give carb
- BG <5.5 pre/post ex give carb
- 15-20g will raise BG 1.7-4.4 depending on body weight
- Carb given wait 15-20m before rechecking
To reduce risk of hypoglycemia - 3
avoid ex longer or higher intensity, also consider type of med - oral meds quite rare for hypoglycemia - you want to know which one they are on
- During peak insulin action - fast vs long acting - Late at night - BG will cont to drop into night
3 safety precautions for BG management
- Don’t exercise alone
- Wear/carry med ID
Phone to call
- Wear/carry med ID
incidence of sudden cardiac death
- > 35 yr 1/15000 -1/50000
<35 1/100,000
placement on BP cuff - 4
- Line up line with brachial art
- Right size cuff - cover 80% of arm
- Bottom about 2 inches above fold of elbow
Ensure it’s tight and doesn’t slip
What to pump the BP cuff to?
20-30mmHg above 1st korotkoff sound/normal resting BP
BP source of error - 13
- Inaccurate sphygmomanometer
- Improper cuff size
- Rate of inflation or deflation of cuff pressure
- Faulty equipment
- Auditory acuity of technician
- Experience of technician
- Rxn time of technician
- Flexed elbow
- Improper steth placement or pressure
- Not having cuff at heart level
- Certain physiologic abnormalities
- Background noise
Allowing pt to hold treadmill handrails
Pre-hypertensive
120-139 or 80-89
encourage lifestyle modification but no drugs unless compelling indication
Pre-hypertensive
120-139 or 80-89
encourage lifestyle modification but no drugs unless compelling indication
stage one hypertension
140-159 or 90-99, encourage lifestyle change, anti - hypertensive drugs indicated, drugs for compelling indications, one anti hypertensive drug as needed
stage two hypertension
> /- 160 or >/- 100, encourage lifestyle change, anti hypertensive drugs indicated, 2 drug combo indicated
measure resting BP pre-exercise - SBP < 180 and/or DBP <110 - symptomatic
do not start exercise
measure resting BP pre-exercise - SBP < 180 and/or DBP <110
SBP >90, proceed
measure resting BP pre-exercise - SBP < 90 and/or DBP <110
assess symptoms
verify meds
hydrate
wait 5-10 mins
measure resting BP pre-exercise - SBP >180 and/or DBP > 110
assess symptoms, verify meds, rest for 5-10 mins
Cardio resp fitness - 1-4
- Body's ability to take in, transport and utilize o2 in the exercising m. to produce ATP during prolonged PA - aerobic metabolism ○ Aerobic fitness/endurance ○ Aerobic capacity ○ Exercise capacity ○ Functional capacity
Cardioresp fitness measured as
max o2 intake - VO2 max
absolute vs relative VO2max
○ O2L/min vs O2ml/kg/min - bigger person might just have a bigger heart
§ Other limiting factors to exercise
Metabolic equivalent - 4
- An index of energy expenditure
- The ratio of the rate of energy expended during an act to the rate of energy expended at rest - based on resting metabolic rate
- One MET is the rate of exercise expenditure while sitting at rest - body size and age should be in consideration but isnt
○ 3.5mL/kg*min - can get VO2 with factor of 3.5
Compendium of PA
aerobic fitness -
predictor of?
peak at?
predictor of how long you will live - Peaks at early 20s ○ Lose 10% every decade after that § 50/55 women menopause men lose testosterone and both lose lots of m. mass □ Then decline accelerates
health related QOL
perception of well being and absense of disease - beliefs goals and expectations - meaning of life
9 Factors to consider when choosing a test
- Purpose - info used for?
- Health status - co morbidities
- Safety concerns? - ACSMs ex management for persons with chronic diseases and disabilities
- Physician supervision? Speed dial or appt?- physician is the brain - you still have to do work for the pt
- Max vs submax
- Length of test
- Willingness of pt - familarity - someone whos nevver walked on a treadmill
- Cost of test
- Facilities and equipment?
Aerobic ex and COVID 19 - 6
- Screen your pts for COVID 19
- Wear a mask and perform hand hygiene, frequent cleaning, heavy breathing, sneezing, coughing
○ Exercising with masks, greater distance between ppl - - During ex social distance >/- 3 meters
- Additional PPE required <3m from pt (if not wearing a mask
- Sanatize everything within the pts’ bubble - clean everything within 3m of them
- Can still do chest compression and use AED
Cover your face
3 purpose of aerobic exercise testing
diagnosis
prognosis
eval of ex response
diagnosis
Determine presence of disease (i.e. ischemic heart disease)
prognosis - 3
○ Predict risk of CV events/mortality
○ Eval of severity of disease - more severe lower fitness
Assess response to therapy/intervention - how much they can to do make a plan, symptoms then what you wanna monitor
eval of ex response - 3
○ Determine functional capacity/ex tolerance
○ Symptoms
○ Help guide ex prescription/plan
Principles of ex testing - 4
- Protocol should accommodate ind’s ability to perform the ex
○ Lower impact/less demanding - If using a multi stage protocol, intensity should increase gradually in 2-3 mins stages - metabolism to stabilize and reach a steady state - not solely anaerobic
- Increments in work rate should be chosen to test time ranges bw 8-12 mins
- Typically, HR, BP and ratings of perceived exertion are measured and symptoms
○ ACSM’s guidelines for ex testing and prescription
Gen testing procedures - 9
- Review how pt is feeling - health status change?
- Verify meds/ that they have taken them
- Ensure pt is wearing comfortable clothing and appropriate footwear - tell them to prepare before hand - closed toe shoes
- Familiarize participant with protocol/equipment/consent form
- Obtain resting vitals - i.e. HR, BP, O2 stat
- Monitor vitals and RPE as appropriate during test (HR last 10-15 seconds of each stage, BP last 30-60 seconds, Re LAST 10-15 SECONDS - then active recovery - walk to get their HR and BP back to normal - presyncope or syncope if stopped too quickly
○ BP in 30 seconds or less - PT’s appearance and symptoms should be monitored regularly
- Cont low level ex until HR and BP stabilize but not necessarily until they reach pre-ex values
Recheck vitals in recovery for at least 5 mins unless abnormal
13 general indications for stopping a test
- Onset of mod=severe angina or angina-like symptoms (>/- 3/5 on standard angina scale) ○ Track numbers to see if there is any change
- Increase nervous system symptoms - ataxia, dizziniess, or near syncope
- Signs of poor perfusion - i.e. light-headedness, confusion, pallor, cyanoisis, nausea, or cold and clammy skin)
- Shortness of breathe, wheezing, leg cramps, claudication
- Physical or verbal manifestation of severe fatigue
- Drop in SBP >/- 10mmHg with an increase in work rate, or if SBP decrease below value obtained in same position prior to testing
- Excessive rise in BP:SBP>250mmHg and or DBP >115 mmHg
- Failure of HR to increase with increase in ex intensity
- O2sat - 80, normal >/- 95%
- HR > age predicted max (i.e. 220-age) - accurate within 10 beats - closer - closer to being done the test - good to use 85% of max
- Failure of the testing equipment
- Participant requests to stop
Participant has completed the protocol
when to measure BP
5 mins after pt comes in
6 abnormal BP response to ex
- Hypertensive SBP >/- 250
- Exaggerated response SBP >/-210 in men, 190 in women
- Hypotensive
○ Decrease in SBP below pretest values
Or drop in SBP >10 after initial increase - blunted
SBP during ex is slower compared to normal
diastolic BP
○ Peak DBP >90 or an increase >10 pretest resting values is abnormal
post ex response
SBP should return to resting values or lower within 6 min of recovery
max effort - 2 -2
○ Cardipulmonary ex testing
§ Directly measure VO2max
○ Symptom limited testing
Ex tolerance test/ex stress test
submax tests and VO2
○ Estimated/extrapolated VO2max based off of HR response or time
field tests
Max or submax
CP ex testing advantages - 2
○ Gold standard for assessing ex capacity
○ Direct measurement of VO2 used during exercise using a metabolic cart
CP ex testing limitations - 4
○ Specialized equipment required
○ Staffing - number and training - BP at the same time, calibration, how to
○ Time consuming
Cost
CP ex testing typically used in 3
○ Athletes - NHL
○ Research
Select clinical pop. - pulmonary. Heart failure, congenital heart disease
symptom limited testing
stress test, ex tolerance test - push them till they develop symptoms
Symptom limited vs CPET
○ No metabolic cart to directly measure VO2
symptom limited advantages - 2
○ Max test limited by symptoms
○ More cost effective than CPET
symptom limited limitations - 2
○ Not optimal for low functioning pts
Tendency to over estimate ex capacity hold on nice and tight with your hands makes it safe but also easier
symptom limited risk of adverse event
1/10000
bruce protocol
aggreive - comorbidities, sedentary or not very fit
bruce protocol mostly used because - 3
§ Physician familarity
§ Efficient use of time
§ Prediction equation for functional capacity
class I functional classification - 3
no limitations with ordinary act more than or equal to 6-7 mets, more than or equal to 6 min Bruce, VO2 more than or equal to 20
clinically fit
class II functional classification - 3
slight limitation with ordinary act - fatigue, palpitations, dyspnea, angina
5-7 METs, 3-6 min Bruce, VO2 14-20
symptoms at higher intensity - mowing grass/ 2 flights of stairs
class III functional classification - 3
marked limitation with less than ordinary act
2-5 METs, less than or equal to 3 min on Bruce, 10-14 VO2
symptoms with lower intensity - little bit of cooking and cleaning
class IV functional classification - 2
symptomatic at rest/ with min exertion
less than 2METs, VO2 <10
2 advantages for submaximal tests
○ Used when max test is not feasible due to time, equipment, sraff, cost
Not max exertion, better tolerated by participants
How to estimate VO2max with submax tests
HR/time
limitation of submax tests
○ Requires assumptions in order to estimate VO2 max - breaking those would affect your results
6 assumptions to estimate VO2 max
- A linear - straight line - relationship exists bw HR, VO2 and workload (i.e. HR 110-150bpm)
1) Stroke volume plateaus in this range - Diff bw actual and predicted max HR is minimal
1) i.e. predicted Hrmax = 220-age, accuracy +/- 10bpm - A steady - state HR is obtained at each work rate in 3-4 min
1) HR in last two min of stage - 5bpm - Mechanical efficiency is the same for everyone at a given workload
- Participant is not on any meds that alter HR response (i.e. beta-blocker)
- Participant is not on high quantities of caffeine, ill or in a high temp environment - all may alter HR response to ex
4 ex of submax tests
- YMCA cycle ergometer test
- Astrand - ryhming cycle ergometer test
- mCAFT step test
- Ebbling Single Stage treadmill test
field test
Involves walk/run a set distance or time
advantages of field tests
○ Easy to administer to large number of participants at same time
○ Little equipment needed
limitations of field tests
○ May be near-max for some ind. (i.e. low CRF)
Inability to monitor for test termination criteria (i.e. BP)
ex of field tests
○ Beep test/incremental shuttle walk test
○ Rockport 1 mile walk test
○ 6 min walk test
10 factors influencing the 6MWT
height weight age corridor length chronic disease (CVD, Pulmonary D, MSK) impaird cognition motivation prev done test medication O2 supplementation
3 advantages of 6MWT
self paced
most ppl can walk
can take breaks as needed
limitations of 6MWT
walking a short distance is non-specific/non-diagnostic
functional class in steps
I > 401
II 301 - 400
III 201 -300
IV < 200
less than 300m in steps in 6MWT
associated with a worse short term prognosis
minimal clinically significant change for 6MWT
25-50m in most chronic conditions
