week 1 Flashcards

1
Q

COVID and decreased physical activity

A
  • significant decreases observed in all types of physical activity across all age groups
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2
Q

physical activity in hospital and SNF

A
  • upright (standing/walking) in hospital: 5%
  • 12% of time in SNF
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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
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4
Q

reimbursement-based practice

A
  • acute care
  • SNF - prior state (PPS)
  • SNF - current state (PDPM)
  • home health care - current state (PDGM)
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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
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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
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7
Q

threshold of independence

current emphasis on returning patients to PLOF

A
  • independently standing from chair
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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
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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)
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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
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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
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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)
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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)
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14
Q

comparing anaerobic and aerobic metabolism

A
  • anaerobic: 2 ATP/molecule of glucose
  • aerobic: 36 ATP/molecule of glucose
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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
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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)
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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%)
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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
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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
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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