202430 EHR519 Week 2 Meeting the client part B.pdf

Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any furth...

Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any further reproduction or communication of this material by you may be the subject of copyright protection under this act. Do not remove this notice 1  Major signs & symptoms suggestive of CVD Pain, discomfort (or anginal equivalent) in the chest, neck, arms……or other areas that may result from myocardial ischemia SOB at rest or mild exertion Dizziness or syncope (reduced perfusion of the brain) Orthopnoea & Paroxysmal nocturnal dyspnoea Ankle oedema Palpitations rapid or forceful heart. Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Known heart murmur 2 Unusual fatigue or SOB with usual activities Major signs & symptoms suggestive of CVD Pain, discomfort (or anginal equivalent) in the chest, neck, arms……or other areas that may result from myocardial ischemia constricting, squeezing, burning (general heaviness) in the substernal or anterior mid-thoracic, in one or both arms, shoulders, neck, cheeks and teeth… in the forearms fingers and interscapular regions Onset provoked by exercise, exertion excitement or stress S & S against ischemic origin Dull ache or sharp stabbing pains in the sub-mammary or left hemithorax area aggravated by breathing Onset after a bout of exercise or provoked by a specific body movement SOB at rest or mild exertion Dyspnoea = abnormal uncomfortable awareness of breathing principal symptom of both cardiac (LVD) and pulmonary disease (COPD) Dizziness or syncope (reduced perfusion of the brain) Often from cardiac disorders reducing Q – severe CAD – hypertrophic cardiomyopathy – aortic stenosis 3 – malignant ventricular dysrhythmias Major signs & symptoms suggestive of CVD Pain, discomfort (or anginal equivalent) in the chest, neck, arms……or other areas that may result from myocardial ischemia constricting, squeezing, burning (general heaviness) in the substernal or anterior mid-thoracic, in one or both arms, shoulders, neck, cheeks and teeth… in the forearms fingers and interscapular regions Onset provoked by exercise, exertion excitement or stress S & S against ischemic origin Dull ache or sharp stabbing pains in the sub-mammary or left hemithorax area aggravated by breathing Onset after a bout of exercise or provoked by a specific body movement SOB at rest or mild exertion Dyspnoea = abnormal uncomfortable awareness of breathing principal symptom of both cardiac (LVD) and pulmonary disease (COPD) Dizziness or syncope (reduced perfusion of the brain) Often from cardiac disorders reducing Q – severe CAD – hypertrophic cardiomyopathy 4 – aortic stenosis – malignant ventricular dysrhythmias Major signs & symptoms suggestive of CVD Pain, discomfort (or anginal equivalent) in the chest, neck, arms……or other areas that may result from myocardial ischemia constricting, squeezing, burning (general heaviness) in the substernal or anterior mid-thoracic, in one or both arms, shoulders, neck, cheeks and teeth… in the forearms fingers and interscapular regions Onset provoked by exercise, exertion excitement or stress S & S against ischemic origin Dull ache or sharp stabbing pains in the sub-mammary or left hemithorax area aggravated by breathing Onset after a bout of exercise or provoked by a specific body movement SOB at rest or mild exertion Dyspnoea = abnormal uncomfortable awareness of breathing principal symptom of both cardiac (LVD) and pulmonary disease (COPD) Dizziness or syncope (reduced perfusion of the brain) Often from cardiac disorders reducing Q – severe CAD – hypertrophic cardiomyopathy 5 – aortic stenosis – malignant ventricular dysrhythmias  S & S of CVD Continued…….. Orthopnoea Dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (LVD) Paroxysmal nocturnal dyspnoea Occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD) Ankle oedema Bilateral = characteristic of HF or bilateral chronic venous insufficiency Unilateral = often lymphatic blockage Generalised = nephrotic syndrome or hepatic cirrhosis Palpitations rapid or forceful heart. Sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever) Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Onset during ambulation, disappears 1-2 mins of rest PAD increased prevalence of CAD Known heart murmur Some innocent but may indicate valvular disease or other CVD Rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death 6 Unusual fatigue or SOB with usual activities Can be benign, may also signal the onset of, or change in CVD  S & S of CVD Continued…….. Orthopnoea Dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (LVD) Paroxysmal nocturnal dyspnoea Occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD) Ankle oedema Bilateral = characteristic of HF or bilateral chronic venous insufficiency Unilateral = often lymphatic blockage Generalised = nephrotic syndrome or hepatic cirrhosis Palpitations rapid or forceful heart. Sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever) Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Onset during ambulation, disappears 1-2 mins of rest PAD increased prevalence of CAD Known heart murmur Some innocent but may indicate valvular disease or other CVD Rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death 7 Unusual fatigue or SOB with usual activities Can be benign, may also signal the onset of, or change in CVD  S & S of CVD Continued…….. Orthopnoea Dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (LVD) Paroxysmal nocturnal dyspnoea Occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD) Ankle oedema Bilateral = characteristic of HF or bilateral chronic venous insufficiency Unilateral = often lymphatic blockage Generalised = nephrotic syndrome or hepatic cirrhosis Palpitations rapid or forceful heart. Sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever) Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Onset during ambulation, disappears 1-2 mins of rest PAD increased prevalence of CAD Known heart murmur Some innocent but may indicate valvular disease or other CVD Rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death 8 Unusual fatigue or SOB with usual activities Can be benign, may also signal the onset of, or change in CVD  S & S of CVD Continued…….. Orthopnoea Dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (LVD) Paroxysmal nocturnal dyspnoea Occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD) Ankle oedema Bilateral = characteristic of HF or bilateral chronic venous insufficiency Unilateral = often lymphatic blockage Generalised = nephrotic syndrome or hepatic cirrhosis Palpitations rapid or forceful heart. Sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever) Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Onset during ambulation, disappears 1-2 mins of rest PAD increased prevalence of CAD Known heart murmur Some innocent but may indicate valvular disease or other CVD Rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death 9 Unusual fatigue or SOB with usual activities Can be benign, may also signal the onset of, or change in CVD  S & S of CVD Continued…….. Orthopnoea Dyspnoea at rest in a recumbent position, quickly relieved by sitting or standing upright (LVD) Paroxysmal nocturnal dyspnoea Occurs 2-5 hours after the onset of sleep, relieved by sitting on bedside (LVD) Ankle oedema Bilateral = characteristic of HF or bilateral chronic venous insufficiency Unilateral = often lymphatic blockage Generalised = nephrotic syndrome or hepatic cirrhosis Palpitations rapid or forceful heart. Sudden tachycardia, bradycardia, ectopic beats, SV changes from valvular regurgitation (anxiety, high Q, anaemia, fever) Intermittent claudication = pain in the lower limbs during exercise from a lack of blood supply (atherosclerosis) Onset during ambulation, disappears 1-2 mins of rest PAD increased prevalence of CAD Known heart murmur Some innocent but may indicate valvular disease or other CVD Rule out hypertrophic cardiomyopathy and aortic stenosis = high risk of exercise related sudden cardiac death 10 Unusual fatigue or SOB with usual activities Can be benign, may also signal the onset of, or change in CVD  Red flags (must know) New-onset or definite change in pattern of shortness of breath or chest pain Complaint of recent syncope (consciousness) or near syncope Neurologic symptoms suggestive of transient ischemic attack (vision or speech disturbance) Recent fall Lower leg pain and bluish discolouration at rest Severe headache Pain in a bone area Unexplained resting tachycardia or bradycardia SBP >200mmHg or 110mmHg Pulmonary rales or active wheezing 11 Graded exercise Testing: Indications and Purposes Three main categories of clinical exercise testing. 1. Evaluate chest pain to assist in diagnosis of CAD 2. Identify future risk prognosis 3. Evaluation (response to exercise e.g. HR, BP) Diagnostic clinical exercise test for IHD needs specialist attendance Also used for pulmonary diseases, pacemaker or HR response, claudication, disability and PA Prognosis: ST-segment depression: – Magnitude – # of leads identified – Time to onset & recovery from Functional capacity (FC) In metabolic equivalents (METS) or VO2max (1 MET/3.5ml.kg-1.min-1 = 15% risk of CVD related mortality) Respiratory gas exchange (direct measure) Assist in prognosis and timing of cardiac transplants VO2max and VE-VCO2 slope 12 Also used for effectiveness of treatments such as surgery, medication and training  Diagnostic Exercise Testing Patients with a high probability of disease (e.g., typical angina, prior coronary revascularization, myocardial infarction) are tested to assess residual myocardial ischemia, to assess threatening ventricular arrhythmias, and for health prognosis rather than for diagnostic purposes. ACSM Guidelines for Exercise Testing and Prescription 11th ed.  Diagnostic Exercise Testing You need to know these Must consider contraindications Established by the American heart Association (AHA) ACSM Guidelines for Exercise Testing and Prescription 11th ed. Choice of GXT Treadmill Cycle ergometry Arm ergometry ✓ Be electronically driven ✓ Less expensive and requires less ✓ Routinely replaced by ✓ Range: speed (1.6–12.8 km ∙ h−1) space than treadmill testing pharmacological stress testing and grade (0%–20%) ✓ Good for obese, orthopedic, ✓ Good for those with symptoms of ✓ Be able to support a body weight of peripheral vascular, neurologic myocardial ischemia during upper body at least 159 kg limitations. activities, those that have suffered an ✓ Have emergency stop button ✓ Requires adjustable seat, MI and returning to work that uses visible/available to allowing for slight flexion to full significant upper body movements. subject/supervising staff extension ✓ Have handrails for balance and However, stationary cycling is stability; unfamiliar method of exercise for Note: tight gripping of treadmill many, highly dependent on patient handrails can affect accuracy of motivation, test may end estimated exercise capacity and prematurely (before quality of ECG recording; handrail cardiopulmonary endpoint) use should be discouraged or because of localized leg fatigue. minimized to the lowest level where Lower values for VO2max during possible. cycle ergometer testing (vs. treadmill) ranging from 5% to 25%, depending on the participant’s habitual activity, physical conditioning, leg strength, and familiarity with cycling. 15  Exercise Protocol Design The protocol employed during an exercise test should consider the: – purpose of the evaluation, – specific outcomes desired, and – characteristics of the individual being tested (e.g., age, gender, PA status, fitness, experience, orthopedics, symptomatology). Most common exercise test protocols Bruce, Ellestad, Naughton, Balke-Ware Need to consider: modality, ramp vs. step, start load, load increments, stage duration, test duration, onset of “fatigue”, peak metabolism In reality, for cardiopulmonary clients you may need to employ a customised protocol which is tailored to the disease and functional capacity of the client. You still need to standardize for future longitudinal comparison.  Tools to be used During Exercise Testing 12-lead electrocardiogram: for heart rate; varying software and anomaly flagging capabilities Blood pressure: sphygmomanometer and stethoscope; automatic option – consider accuracy! Pulse oximetry: finger or earlobe based – may be integrated into ECG software or single device Scales: perceived exertion, angina, dyspnea, intermittent claudication Charts: normative data; data specific to conditions (i.e. ejection fraction and performance) Your senses: sight (pallor, cyanosis, ataxia) and sound (dyspnea) very important ACSM Guidelines for Exercise Testing and Prescription 11th ed. Angina Dyspnea Four-point dyspnoea scale: 1 = Mild, noticeable to patient but not the observer 2 = Mild, some difficulty, noticeable to observer 3 = Moderate difficulty, but patient can continue 4 = Severe, difficulty, patient cannot continue Intermittent Claudication Four-point peripheral vascular disease scale is used for the assessment of intermittent claudication. 1 = Definite discomfort or pain but only of initial or modest levels (established onset) 2 = Moderate discomfort or pain from which the client's attention can be diverted by a number of common stimuli such as conversation. 3 = Intense pain from which the client's attention cannot be diverted except by catastrophic events 4 = Excruciating and unbearable pain All scales in one!  Termination of the test You need to know these 23 ACSM Guidelines for Exercise Testing and Prescription 11th ed.  Post-exercise Period Regardless of post-exercise procedures (active vs. passive recovery), monitoring should continue for at least 6 min after exercise or until ECG changes return to baseline and significant signs and symptoms resolve. ST-segment changes that occur only during the post-exercise period are currently recognized to be an important diagnostic part of the test. HR and BP should also return to near baseline levels before discontinuation of monitoring. Heart rate recovery (HRR) from exercise is an important prognostic marker that should be recorded. Walking “recovery” with a standardized speed permits longitudinal replication to appraise changes in fitness (i.e.  HRR = greater fitness) Supine recovery  SV, and thus at maximal HR,  CV load and chance of seeing meaningful cardiac activity (via ECG) indicative of CV function  Muscular fitness Strength-promoting exercise reduces all-cause mortality risk beyond aerobic exercise alone Muscular strength = maximal force on one occasion; muscular endurance = successive repetitions against a submaximal load; muscular power = exert force per unit of time ACSM has melded muscular strength, endurance and power into muscular fitness Integral portion of total health and fitness Health-related characteristics such FFM and metabolic rate Bone mass (osteoporosis) Muscle mass (sarcopenia) Glucose metabolism (diabetes) Musculotendinous integrity (LBP) ADL’s (independent living) 26  Muscular fitness Standard conditions for muscle fitness testing: Aerobic warm-up Equipment familiarisation Maintaining strict posture Consistent movement speed Full ROM Use a spotter Traditional = 1RM however, known CVD or pulmonary diseases should be conservative 10-15 RM (approx. training recommendations) – ACSM table 3.11 & 3.12 BP and leg press standards Crunch test moderate abdominal endurance, low abdominal strength & high back injury risk so no longer included 27  Flexibility Flexibility = ability to move a joint through its complete ROM pain free Pain free ROM is important in the ability to carry out ADL’s. Joint flexibility facilitates movement and may prevent injury, however, unequivocal whether pre- activity stretching reduces injury risk associated with PA. Nonetheless, repetitive stretching of non-full ROM joints aid in extending the joint ROM. Several factors affect flexibility e.g. adequate warm-up, joint capsule structure, muscle viscosity and tension of associated muscles and tendons Joints ROM measured in degrees using goniometers and inclinometers and the Leighton flexometer. No a single test to assess total body flexibility, Accurate RM testing requires in-depth knowledge of bone, muscle and joint anatomy. Sit-and-reach test has been found to be unrelated to back pain and questionable as a measure of hamstring flexibility, thus not included 28in the current ACSM edition  Balance Balance is the ability to maintain a desired position Historically not been included in health-related test batteries but is recommended for falls prevention Static and dynamic balance Force plates provide centre of pressure data but not suitable for field tests A static balance task, or the range one can cover while maintaining postural control during a dynamic balance task are indirect and inexpensive alternatives Many balance tests developed; two common ones = Balance Error test and the Y-balance test. Balance test for error; count # of balance errors made while standing in 3 different positions (feet side-by-side, unipedal on non-dominant foot and tandem. Increase difficulty by perfuming on foam base and with eyes closed. Balance on one foot and sliding moveable blocks with their toes in a Y pattern Timed up-and-go (TUG) test assesses dynamic balance and 29 agility of older adults. To Do WATCH ✓ Week 2 Lecture READ ✓ ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription - Chapter 2 and 11 ✓ Ehrman et al. Clinical Exercise Physiology – Chapters 4-5 ENGAGE ✓ Tutorial Assessment 2 case study allocation on I2 30 ✓ Start now