Week 5 Flashcards
What is the leading cause of death after a SCI?
- Pneumonia
* Other respiratory conditions
What are the characteristics of the respiratory system function?
- Gas exchange via the lungs
- Ventilatory pump
- Ventilation versus respiration
What happens to the chest during expiration and inspiration?
Expands during inspiration and relax at expiration
What is ventilation?
The moving of air between the lungs and the atmosphere
What is respiration?
The gas exchange that occurs at the level of the alveoli in the pulmonary circulation
We must ____ to respirate
We must ventilate to respirate
What does most people with an SCI have trouble with?
Ventilation, unless they have a pneumonia or something of that nature
What are the muscles of inhlation?
- Diaphragm
- Intercostals, Scalene, Accessory MM
- Abdominals
What are the muscles of exhalation?
- Abdominals (forceful exhalation)
- Intercostals
- Diaphragm (relaxes and causes the ribcage to relax)
What happens when a person has a SCI in regards to breathing?
Weakness or paralysis of muscles responsible for:
• Inspiration
• Expiration
• Cough
What would a weakness of the inspiration muscles cause?
There will be a marked decrease in all lung volumes and capacities, except for residual volumes.
What does the weakness of the inspiration muscles result in?
- Hypoventilation
- Atelectasis
- Secretion and retention
What is the PT evaluation of respiratory function?
- Respiratory muscle strength
- Breathing pattern
- Cough
- Chest mobility
- Postural Alignment
- Breath support for speech
What is tidal volume?
Volume inspired or expired in quiet breath
What is vital capacity?
Volume expired after max inspiration
What is inspiratory capacity?
Volume inspired after norm expiration
What is total lung capacity?
Total volume contained in lungs at max inspiration
What is residual volume?
Volume remaining in lungs after max expiration
What impact does a level C1,2 injury have on respiration?
No diaphragm, minimal SCM, a little bit of trap and erector spinae action. Not compatible with survival, not going to be able to clear airway, they’re going to be ventilator dependent
What impact does a level C3 injury have on respiration?
They have partial diaphragm, most of their SCM, some levator, scalenes, and rhomboids, most require long term ventilation, and unable to clear airway
What impact does a level C4 injury have on respiration?
Almost full diaphragm, no abs or intercostals, sitting compromises inhalation, require assist for airway clearance, vital capacity will be less than a 3rd
What impact does a level C5-8 injury have on respiration?
Full diaphragm, near full accessories, some cough, vital capacity is between a 3rd and half of predicted normal
What impact does a level T1-5 injury have on respiration?
Some intercostals preserved, no abs, no forceful cough
What impact does a level T6-12 injury have on respiration?
Some or most abs, more effective cough
What impact does a level below T12 injury have on respiration?
No significant deficits, but respiration is compromise is still possible
What are the types of ways patients can get mechanical ventilation?
- Positive-Pressure Ventilators (most common)
- Intermittent abdominal pressure ventilators
- Negative-pressure body ventilators
- Biphasic cuirass ventilators
- Phrenic nerve stimulators
What are the other methods of ventilation patients can get?
- Phrenic Nerve Stimulation
- Direct diaphragmatic stimulation
- Non-invasive negative ventilation
- Glossopharyngeal breathing
What are the causes of respiratory dysfunction?
- Muscle weakness/paralysis
- Pulmonary Compliance
- Rib Cage Compliance
What are the characters of pulmonary compliance?
Lung stiffness; reduced in people with tetraplegia
What are the characters of rib cage compliance?
Stiffness of ribcage and its resistance to movement; also
decreased in people of tetraplegia
How is the positive pressure seen in positive pressure ventilators achieved?
By applying a positive pressure higher than the atmospheric pressure at the airway opening, which produces a pressure gradient that generate an inspiratory flow, which in turn results in the delivery of a breath
How does a negative pressure body ventilator work?
By producing negative pressure at the chest and abdomen, which then moves across the chest and the diaphragm and causes air to move into the lungs in normal fashion, when the negative pressure stops being applied, the chest return to the atmospheric pressure and the inspired air is then exhaled
What are the disadvantages of the negative pressure body ventilator, in comparison to positive pressure ventilator?
Negative pressure machines are a lot less portable, more difficult to apply, and is infrequently used or contraindicated in soma patients
What are some complications of an acute respiratory problem?
- Prolonged bedrest
- Pain and sedation
- Aspiration
- Paralytic ileus: GI system will temporarily cease to function
- Respiratory muscle fatigue
What is the PT intervention for patients with respiratory problems?
• Positioning • Assisted cough - Manual, mechanical, or self • Breathing pattern • Strength and endurance • Necessary chest wall mobility
How does the lack of abdominals affect expiratory flow?
Weakness impairs ability to forcibly expire and generate high expiratory flow rates
What is needed to generate forced expiration?
High intrathoracic positive pressure
What is the quality of a functional cough?
Loud, forceful; 2 or more/exhalation
What is the quality of a weak functional cough?
Soft, less forceful; 1/exhalation
What is the quality of a nonfunctional cough?
Sigh or throat clearing; no true cough or no explosive force
What are some ways to augment/assist a cough?
- Mechanical inflation of lungs prior to cough (via noninvasive positive airway pressure support)
- Mechanical insufflation-exsufflation
What are other ways of managing secretion in the lungs, if there is no coughing?
- Positioning: sidelying on both sides
- Percussion or vibration
- Suctioning
- Non-invasive airway pressure support
What is the biggest cause of death for survivors of > 30 years and those older than 60 after an SCI?
CVD
What does disruption of the sympathetic nervous system result in?
Increased hypotension
What does decreased arterial pressures result in?
Diminished cardiac ventricular chamber size and function (tetra)
What is the cardiovascular presentation of a paraplegic?
• Normal to slightly increased BP, left ventricular mass,
and cardiac output nd inc
• Lower stroke volume secondary to decreased venous return
They have increased CO and low SV, because they have increased HR
What is circulaory hypokinesis as seen in patients with a SCI?
Significantly lower blood volume and velocity in LE
arterial circulation due to lost autonomic control of blood flow and decreased control by vascular endothelium and results in an increased risk of thrombosis
What are the 3 strikes that patients with a SCI have in regard to their cardiovascular health?
- Reliance on arm exercise
- Lower limb paralysis
- Loss of supraspinal sympathetic nervous control
What are the determinance of VO2 max?
- Cardiac Output (central)
* Arterio-venous oxygen difference (periphery)
What are the exercise prescriptions for a patient with a SCI and a cardiovascular problem?
• Frequency • Intensity: 50-60% max • Time: 20 mins • Type: Upper extremity most of the time - Use HR or RPE
What are some precautions for a patient with a SCI and a cardiovascular problem?
Autonomic dysreflexia, fracture due to osteoporosis, skin breakdown due to lack of sensation
What are some of the cardiovascular response to a neurological dysfunction?
• Severe deconditioning
• VO2 Peak significantly decreased in all neuro dx
• NO RESERVE
• Most with neuro dx don’t have the VO2 peak to meet
demands for daily living of older adult
• Growth hormone insufficiency
• For most with neuro dx, VO2 requirements increase
secondary to gross motor insufficiencies
• Low level of fitness associated with increased
mortality
• Decrease in available motor units . –> decrease in
metabolically active tissue —> decrease in oxidative
potential
How does fiber type change in a person with a brain injury?
Slow fatigue fiber types gets replaced by the fast fibers, so we lose the capacity for slow aerobic conditions and use/have more fast anaerobic muscle fibers
What are the adaptive response to training seen in patients with a neurological dysfunction?
- Increased metabolic efficiency
- Mechanical efficiency
- Improved function
- Lowered energy cost
- Increased exercise tolerance
What are the non fitness benefits of exercise on patients with a neurological dysfunction?
- Impact on cognition
- Impact on mood/behavior
- Impact on recovery
What are the components of exercise the improves depression in patients with neurological disorders?
- Needed to be exercise that met PAGs
- Moderate to vigorous intensity
- 3-5 days per week
What were the effects of exercise maintenance after a TBI?
• Decreased score on BDI
• Maintained improvement over time
• Increased physical activity
• Exercise greater than 90 minutes per week resulted in
lower BDI and higher perceived QOL and mental health
• 52% of subjects were exercising greater than 90 minutes per week at 6 months
What are the effects of exercise on the cognition of patients with a TBI?
• > 50% of TBI survivors still experiencing cognitive problems several years
post TBI
• Vigorous training: 3 times/wk x 30 minutes on treadmill x 12 wks, supervised
• Improved cognitive function with aerobic training in TBI
- Processing speed, executive function, overall cognition
• Aerobic exercises associated with physical adaptations and positive cortical functions like angiogenesis and neurogenesis
According to the “exercise is brain food” paper, which type of exercise had the highest tropinin levels relased?
Low level intensity exercise
What are the effects of aerobic training in patients with a neurological problem?
- Aerobic exercise-induced increase in BDNF
- Increased BDNF may facilitate motor learning and neuroplasticity
- Also a benefit to cognitive function
- Improves efficiency and reserve
- Priming for Neuroplasticity
What happens with unrestricted exercise in the immediate acute phase of a concussion?
May increase risk of subsequent injury and/or delay recovery
At what point is SOME lever of exercise be beneficial for a concussion?
Once beyond acute injury stage
What are the characteristics of cognitive rest in a person that has sustained a concussion?
- Increased cognitive activities post concussion increase symptom recovery time and prolong recovery
- Reduction in brain stimulating activity
- “prolonged cognitive rest and reduction of school events have the potential to exacerbate symptoms or cause negative mental health issues”
- Key is during acute phase; symptoms are guide
What are the characteristics of vestibular and oculomotor impairments in a person that has sustained a concussion?
• Occurs in approx 60% of athletes
• Vestibular: peripheral or central
• Vestibular issues: benign paroxysmal positional vertigo (BPPV), vestibuloocular reflex (VOR) impairment, visual motion sensitivity, balance
dysfunction, cervicogenic dizziness, and exercise-induced dizziness.
• Vestibulo-ocular: dizziness, vertigo, blurred/unstable vision, nausea, difficulty with busy environments
• Vision Therapy
• Pharmacological interventions
• May predict prolonged recovery
What are the effects of endurance post BI?
• In sample of stroke survivors 1 year post stroke, only
50% could complete 6 minute walk
• Those who completed the walk did so at only 40% of
predicted distance
• Strong relationship between endurance as measured by 6 minute walk and community integration
• Increasing endurance could reduce handicap!!!
According to the “physical fitness for survivors of stroke based on best available evidence” what are the recommended exercise training intensity guidelines for stroke survivors?
- If a graded exercise program is performed, we should target 50-80% max HR
- If no graded exercise program is performed, work at a 40- 70% of predicted HR
- Use borg scale/10 point scale and target a level of 4 (moderate)
How do we find our predicted HR?
220-age
Where is exercise most effective in patients with MS?
More peripheral
Dyskinesia is a pathology of what?
Basal ganglia
What are the forms of dyskinesia that is common in Huntington’s disease?
Chorea most common; also bradykinesia, dystonia, myoclonus, tics
What are the forms of dyskinesia that is common in Parkinson’s disease?
Resting tremor; also bradykinesia
What are the forms of dyskinesia that is common in Essential tremor?
Action tremor seen in at least 1 arm during 4 tasks, interfering with one ADL
What are the forms of dyskinesia that is common in cerebral palsy?
Choreoathetoid, dystonia
What are the forms of dyskinesia that is common in stroke?
Chorea, dystonia, parkinsonism