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
Q
standardized procedures for exercise testing
A
- 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
Q
general guidelines for submax testing
A
- 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
Q
submax test assumptions
A
- a steady-state HR is obtained for each exercise work rate (plateau HR in each stage)
- a mx HR for a given age is uniform (220-age)
- mechanical efficiency (VO2 at a given work rate) is the same for everyone
- there is a linear relationship between HR and workload
- HR will vary depending on fitness level between subjects at any given workload
submax testing underestimates VO2 max in untrained and overestimates tra
28
Q
advantages of submax testing
A
- safer - not true max
- controlled pace - motivation not a factor
- not population specific - no pacing advantage
- quick assessment - faster
- cost effective
- do not need highly trained personnel
- can do mass testing
- no physician supervision required - if symptom and disease free
29
Q
disadvantages of submax testing
A
- VO2 max not directly measured: error rate of 10-20%
- not a measure of true max HR
30
Q
max testing advantages and disadvantages
A
- advantages: accuracy
- disadvantages: health risk potential, time, expense (metabolic cart), personnel (MD supervision)
31
Q
symptom limited graded exercise tests
endurance/aerobic capacity testing
A
- treadmill: Bruce, modified Bruce, balke, naughton
- cycle ergometer: for balance disorders, obesity, MSK problems
- arm ergometry
- air-dyne
32
Q
short physical performance battery
A
- predictive: VO2, aerobic capacity (Bruce) - measure ADLs and functoin
- static balance
- gait speed
- 5x sit to stand
33
Q
possible cardiovascular contraindications
A
- 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
Q
retinopathy and HIRT
A
- avoid increase in BP to avoid progressing retinopathy
- want to be careful, keep BP < 170
35
Q
cancer: possible contraindications
A
- 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
Q
MSK: possible contraindications
A
- 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
Q
surgical precautions: possible contraindications
A
- 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
Q
other medical conditions: possible contraindications
A
- 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
Q
FITT principles
A
- frequency
- intensity
- time (duration)
- type
40
Q
tissue adaptation: dose response
A
- intensity adequate for overload to MSK or CP systems to induce adaptations
41
Q
what does high-intensity strengthening do
A
- improve LE strength
- improves physical function
- improves strength, cognitive function, and ADLs
42
Q
neuromuscular adaptations account for
A
- neuromuscular adaptations account for 10-15% strength gains per week
43
Q
intensity prescription
A
- failure is defined as the inability to complete the final rep through full available ROM without significant compensation
44
Q
signs of failure
A
- sudden increase in speed to overcome resistance
- improper form/significant compensation
- requires one level increase in level of assist
45
Q
resistance training exercise prescription
A
- 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
Q
patient education on DOMS
A
- 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
Q
high intensity principles can also be used for
A
- transfers
- ADLs
- balance and gait activities
- therapeutic exercise/strengthening
48
Q
aerobic training exercise prescription
A
- frequency: 3-5x/week
- intensity: start 40-60% and progress to 70-80%
- time: 150 minutes/week
- type: treadmill, ground walking, stationary bike
49
Q
parameters to monitor
A
- O2 saturation
- blood pressure
- heart rate
- dyspnea scale
- claudication scale
