week 1 Flashcards
1
Q
COVID and decreased physical activity
A
- significant decreases observed in all types of physical activity across all age groups
2
Q
physical activity in hospital and SNF
A
- upright (standing/walking) in hospital: 5%
- 12% of time in SNF
3
Q
barriers for implementation of optimal practice patterns
A
- reimbursement-based vs evidence-based practice
- limited incentives for high-quality transitional care (few ACOs)
- fear of adverse events, penalties, or litigation
- current emphasis is on returning patients to PLOF (often low)
- lack of awareness of more effective clinical care strategies
4
Q
reimbursement-based practice
A
- acute care
- SNF - prior state (PPS)
- SNF - current state (PDPM)
- home health care - current state (PDGM)
5
Q
limited incentives for high-quality transitional care
A
- historically very limited coordination of care across settings (hospital -> SNF -> home health)
- changes that have prioritized transitional care:
- improving medicare post-acute care transformation (IMPACT) act
- accountable care organizations
- bundled care
6
Q
fear of litigation
A
- practice of “negative defensive medicine” prevalent in many settings, especially older adults
- mobility is often avoided by nursing and CNAs because it is unnecessary fall risk
- “do no harm principle” too extreme?
- falls more quantifiable and more closely tied to financial penalties and are more likely to result in “fault” than deconditioning
- so we avoid supervised and unsupervised mobility to decrease risk of falls – at risk of deconditioning
7
Q
threshold of independence
current emphasis on returning patients to PLOF
A
- independently standing from chair
8
Q
lack of awareness of more effective clinical care strategies
A
- safe dosage of exercise for medically complex patients
- high-intensity is necessary but perceived as unsafe
- older adults underdosed
9
Q
updating practice patterns for older adults following hospitalization
A
- shift from conservative, low-intensity interventions –> high-intensity interventions
- based on American college of sports medicine (ACSM) guidelines and the american geriatrics society (AGS)
10
Q
high-intensity prescription
A
- achieving muscle overload
- providing a stronger and different stimulus every time
- objectively assessing progression daily
- creating conditions for safe physiological adaptation
- high resistance with low reps: T2 fibers, power, strength, hypertrophy
- low resistance with high reps: T1, postural endurance
11
Q
improving the lives of older adults - bottom line
A
- high-intensity rehabilitation has the potential to improve physical function across all settings
- greater function, greater independence, less risk – better lives
12
Q
anaerobic metabolism
A
- does not require oxygen
- utilizes only carbohydrate (glucose)
- occurs in the cytoplasm of the cell
- by-product is lactic acid
- yields net 2 ATPs per molecule of glucose
- less efficient
- types of cells: connective tissue cell (bone, cartilage, RBCs - no mitochondria), skeletal muscle (fast twitch fibers)
13
Q
aerobic metabolism
A
- requires oxygen
- utilizes carbohydrates, fats, and proteins
- occurs in the mitochondria
- by-products: water and CO2
- yields 36 ATPs per molecules of glucose
- more efficient
- types of cells: heart, CNS/PNS, skeletal muscle (slow twitch fibers)
14
Q
comparing anaerobic and aerobic metabolism
A
- anaerobic: 2 ATP/molecule of glucose
- aerobic: 36 ATP/molecule of glucose
15
Q
endurance - major factors
A
- oxygen consumption
- VO2 max: max capacity of a person’s body to transport and use O2 during incremental exercise - reflects physical fitness
- maximal
- peak
- variation
- 4-6% in persons with no known impairments
- 6-10% in persons with CP impairments
16
Q
endurance or aerobic capacity testing
A
- evaluation of a person while performing work
- gold standard - oxygen consumption (VO2)
- ways to measure
- VO2 = CO x a-v O2 difference
- VO2 = volume of O2 entering lungs minus volume leaving lungs (used more often)
17
Q
anaerobic threshold (AT)
A
- point at which you are no longer capable of performing work solely aerobically (start to perform anaerobically so build up of lactic acid)
- usually about 55% of max VO2
- with training increases (>55%)
- with detraining decreases (<55%)
18
Q
relationship of VO2 to METs
A
- 1 MET = requirement of O2 of tissue of body at rest
- 1 MET = 3.5 mLO2/Kg x min
- with activity VO2 increases and therefore METs increase
- any activity that burns 3-6 METs is considered moderate-intensity physical activity
- any activity that burns > 6 METs is considered vigorous-intensity physical activity
19
Q
factors affecting peak VO2
A
- age
- sex (men > women)
- genetics (muscle fibers type)
- body composition (fat:muscle)
- endurance training
- various diseases that affect oxygen transport
- VO2 improves with training
- loss of muscle mass contributes to age-related VO2 changes
20
Q
oxygen consumption and disability
A
- social security administration uses the criteria that < 18 mL/kgxmin (5 METs) is considered disabled – or struggles functioning independently
- 18-20 range important for independence
21
Q
before exercise capacity testing
A
- prelim screen
- history
- lab values
- resting measurements - BP and HR
- physical exam
22
Q
risks of exercise testing
A
- muscle soreness
- diaphoresis
- SOB
- angina
- MI
- stroke
- death
23
Q
risks and exercise testing
A
- for persons with CAD, risk of complications like MI or death are 60-100 times greater during exercise testing than in usual activity
- actual risk of death is very low (0.5/10,000) due to appropriate screening and adherence to methods of conducting tests
24
Q
sub-maximal test
A
- low level graded exercise test (LLGXT)
- field testing - time, distance
- other - walk, bike, activity
25
standardized procedures for exercise testing
* explanation of procedure
* avoid maximal activity for 24 hours prior
* avoid for 2-3 hours prior: large meal, nicotine, caffeine (unless it's part of their normal routine)
* repeat submax test if possible
26
general guidelines for submax testing
* warm up: 2-3 minutes
* measure HR, BP, RPE at regular intervals
* end of each stage or every minute
* if HR does not reach steady state during the stage, extend stage 1 minute
* increase intensity in 0.5-2 MET increments
* closely observe for signs/symptoms
* cool-down: low intensity for > 4 minutes
* continue measuring HR, BP, RPE
27
submax test assumptions
1. a steady-state HR is obtained for each exercise work rate (plateau HR in each stage)
2. a mx HR for a given age is uniform (220-age)
3. mechanical efficiency (VO2 at a given work rate) is the same for everyone
4. there is a linear relationship between HR and workload
5. HR will vary depending on fitness level between subjects at any given workload
| submax testing underestimates VO2 max in untrained and overestimates tra
28
advantages of submax testing
1. safer - not true max
2. controlled pace - motivation not a factor
3. not population specific - no pacing advantage
4. quick assessment - faster
5. cost effective
6. do not need highly trained personnel
7. can do mass testing
8. no physician supervision required - if symptom and disease free
29
disadvantages of submax testing
1. VO2 max not directly measured: error rate of 10-20%
2. not a measure of true max HR
30
max testing advantages and disadvantages
* advantages: accuracy
* disadvantages: health risk potential, time, expense (metabolic cart), personnel (MD supervision)
31
symptom limited graded exercise tests
| endurance/aerobic capacity testing
* treadmill: Bruce, modified Bruce, balke, naughton
* cycle ergometer: for balance disorders, obesity, MSK problems
* arm ergometry
* air-dyne
32
short physical performance battery
* predictive: VO2, aerobic capacity (Bruce) - measure ADLs and functoin
* static balance
* gait speed
* 5x sit to stand
33
possible cardiovascular contraindications
* recent MI: 3-6 weeks
* pulmonary embolism or pulmonary infarction < 6 weeks
* if recent DVT detected and pt is on anti-coagulation therapy, then withhold high-intensity training on that limb
* myocarditis endocarditis, pericarditis
* recent cerebral shunting or aneurysm coil
* RHR < 50 or > 100 BPM
* unstable angina - occurs at rest and medication does not relieve
* severe pulmonary hypertension
* severe and symptomatic aortic or valvular stenosis
* fistula on UE for dialysis - no HIRT on involved limb
* uncontrolled hypertension (200-220 is upper limit SBP)
* decompensated CHF
* absent pulses in limbs
* suspected or known dissecting aneurysm
34
retinopathy and HIRT
* avoid increase in BP to avoid progressing retinopathy
* want to be careful, keep BP < 170
35
cancer: possible contraindications
* bone metastasis - concern for pathological fractures
* tumors in targeted strength training area
* medication effects
* side effects of cancer meds: osteoporosis, change in HR, anemia, neuropathy - balance, fatigue, hypoglycemia
36
MSK: possible contraindications
* recent fractures < 6 weeks - can do other limbs
* unstable fractures: no HIRT on involved
* osteomyelitis: no HIRT on involved
* avascular necrosis: no HIRT on involved
* wounds with exposed tendon or muscle on involved joint
* compression fractures - precautions: encourage neutral alignment of joint, more isolated and open chain movements
* WB restrictions with graft or fractures sites: open chain, isometrics only
* marfan syndrome: connective tissue disorder
37
surgical precautions: possible contraindications
* craniotomy < 6 weeks: no bending over, no lifting > 10 pounds, no valsalva
* abdominal precautions < 6 weeks: no sit ups/crunches, no valsalva, no lifting > 10 lbs (can bike, STS)
* sternal precautions < 8 weeks: no UE high intensity, no valsalva, no lifting > 10 lbs
38
other medical conditions: possible contraindications
* acute infection: HR already high, let body heal itself
* chronic infectious disease: mononucleosis, hepatitis, AIDS
* steroids: side effects of HTN, immunosuppression, osteoporosis, muscle weakness and myopathy, thin skin and poor wound healing
* beta-blockers: side effects of hypotension, bradycardia, drowsiness
39
FITT principles
* frequency
* intensity
* time (duration)
* type
40
tissue adaptation: dose response
* intensity adequate for overload to MSK or CP systems to induce adaptations
41
what does high-intensity strengthening do
* improve LE strength
* improves physical function
* improves strength, cognitive function, and ADLs
42
neuromuscular adaptations account for
* neuromuscular adaptations account for 10-15% strength gains per week
43
intensity prescription
* failure is defined as the inability to complete the final rep through full available ROM without significant compensation
44
signs of failure
* sudden increase in speed to overcome resistance
* improper form/significant compensation
* requires one level increase in level of assist
45
resistance training exercise prescription
* frequency: 2-3x/week
* intensity: start 40-60% and progress to 70-80%
* time: 6-8 weeks (for hypertrophy)
* type: strength (free weights, body weight) and functional training (sit to stand, floor transfers)
46
patient education on DOMS
* peaks in 72 hours
* monitor ability to complete daily activities
* you may feel pain most when you: touch the muscle, try to massage the muscle, stretch the muscle, use the muscle
* you should not feel pain when you rest
47
high intensity principles can also be used for
* transfers
* ADLs
* balance and gait activities
* therapeutic exercise/strengthening
48
aerobic training exercise prescription
* frequency: 3-5x/week
* intensity: start 40-60% and progress to 70-80%
* time: 150 minutes/week
* type: treadmill, ground walking, stationary bike
49
parameters to monitor
* O2 saturation
* blood pressure
* heart rate
* dyspnea scale
* claudication scale
