Cardiopulmonary Week 2 PDF

Patient History Part 1 Neeti Pathare, PT, MSPT, PhD Objective Perform an accurate history by gathering data from a patient’s chart, performing a personal interview and observing the patient/client. The Interview Establish a good patient–therapist rapport. The patient...

Patient History Part 1 Neeti Pathare, PT, MSPT, PhD Objective Perform an accurate history by gathering data from a patient’s chart, performing a personal interview and observing the patient/client. The Interview Establish a good patient–therapist rapport. The patient must be allowed to explain the history in his or her own words and at a comfortable pace. The interviewer must be careful not to allow personal feelings about the patient’s grooming, appearance, demeanor, or behavior during the interview to unduly question the validity of the chief complaints. Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc.  SYSTEMS TEST & EXAMINATION HISTORY REVIEW MEASURES 1.Appropriate for PT? 2.Appropriate Do the examination for PT + findings support your consultation original hypotheses? 3.Inappropriate YES: Proceed for PT – refer? NO: Revisit/Revise PT PLAN OF INTERVENTION INTERVENTION DIAGNOSIS & EVALUATION CARE PROGNOSIS Is patient making functional progress toward goals when outcome measures are re-examined? YES: Continue episode of care OUTCOMES OUTCOMES NO: Consider revising treatment approach/patient goals OR consider referral to appropriate health care provider  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Social History, Activities, & Participation Family History Current Condition(s) General Demographics Patient Goals General Health Status Symptoms Growth & Development Review of Systems Living Environment Medical/Surgical History Social Determinants of Health/Habits Medications & Allergies Social Services Questions Other Clinical Tests (Lab, Imaging, etc.) Self Report Contextual Factors Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Patient/Client History Patient Client History Relevant social history Self-abusive social habits; excessive drinking of alcohol, smoking, use of illicit drugs Copyright © 2017 by Elsevier, Inc. All rights reserved. Family History Look for family history of diabetes, hypertension, CAD, or rheumatic fever Occupational history Identifying type of work aids in setting realistic goals Home environment and family situation Supportive family versus negative home environment for rehab success; sternal precautions, driving, CPR Medical Chart Review Diagnosis and date of event Need to know primary and secondary diagnoses Date of event determines acuteness Copyright © 2017 by Elsevier, Inc. All rights reserved. Risk factors for heart disease HTN, smoking, elevated cholesterol, family history, stress, sedentary lifestyle, older age, obesity, diabetes Surgical procedures Understanding of specific surgical approaches and procedures is important Extent of surgery predicts activity performance impairments Hospital course Review physicians’ and other caregivers’ notes, order sheets to reveal pertinent information on clinical course Medical Chart Review Radiological studies Chest radiographs, CT scan, MRI, and scintigraphy Copyright © 2017 by Elsevier, Inc. All rights reserved. Oxygen therapy and other respiratory treatment Amount, device of O2 Clinical laboratory data Provide objective information regarding clinical status Cardiac enzymes, blood lipids, CBC count, BUN, creatinine, arterial blood gases, culture and sensitivity, coagulation studies, electrolyte, glucose tolerance Medical Chart Review Electrocardiogram and serial monitoring Copyright © 2017 by Elsevier, Inc. All rights reserved. Provide information on state of heart muscle and rhythm Cardiac catheterization data Provides information about anatomy of coronary arteries Provide dynamic assessment of cardiac muscle Vital signs Daily recordings often kept in graphics section of chart HR, temperature, BP, RR—look for trends Patient History Part 2 Neeti Pathare, PT, MSPT, PhD Objective Perform an accurate history by gathering data from a patient’s chart, performing a personal interview and observing the patient/client.  Symptoms Pain : chest pain, ischemic pain Copyright © 2017 by Elsevier, Inc. All rights reserved. Dyspnea/Dyspnea on exertion Patient Client History/ Cough Medical Chart Review Palpitations Syncope Fatigue Edema Claudication Hoarseness  Chest Pain Pain Chest Pleuritic Anginal pain Pericardial wall pain chest pain  Differentiation of nonanginal discomforts from angina Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Anginal Pain Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. Classic cardiac—chest pain, tightness, pressure, shortness of breath, palpitations, indigestion, burning 2. Characteristically demonstrated by patients using their entire hand or closed fist against the anterior chest wall. Anginal Pain Location and description of pain vary depending on underlying pathology Anginal Pain Location and description of pain vary depending on underlying pathology  Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. Can be elicited by palpation of trigger points, or applying pressure over joints such as costo-sternal junction Chest Wall Pain 2. It does not occur during but rather after exertion. 3. It may worsen with inspiration but is associated with trunk motions.  Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Pleuritic chest pain Pleuritic chest pain originates from the parietal pleura or endothoracic fascia but not the visceral pleura, which have no pain receptors.  1. Pericardial chest pain is also midline, Deep breathing, coughing, swallowing, Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. movement, and lying down may make it worse. 2. If the central tendon of the diaphragm is involved, the pain Pericardial Chest Pain may be referred to the left shoulder or scapular area. 3. The patient may report that each heartbeat affects the pain. Sitting up and leaning forward or lying on the right side often relieves the pain. Dyspnea one of the most common reasons for patients to seek medical attention. Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Paroxysmal Orthopnea Nocturnal Dyspnea Dyspnea that occurs when Transfer of fluid from extravascular the patient is in the recumbent tissues into position the bloodstream during sleep Need for two or three pillows under Strong predictive the head to rest at night value as a sign of CHF CHF Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Angina and Dyspnea Scales  Cough 1. CHF; due to pulmonary edema 2. Thoracic Aortic aneurysm; dry, non-productive due to compression of trachea or bronchi 3. Certain Medications; ACE Inhibitors Palpitation 1. The presence of an irregular heart-beat 2. Can be caused by a benign condition such as mitral valve prolapse 3. Can also be caused by serious heart condition such as CAD, heart block or ventricular aneurysm 4. Can be due to PAC, PVC, SVT, A Flutter, A fib, V tach Cardiac Syncope Fainting episode Cardiac causes: 1. Arrhythmias 2. LV failure or outflow obstruction seen in Aortic stenosis, etc 3. RV outflow obstruction or failure; Pulmonary stenosis, Pulmonary HTN 4. Orthostatic hypotension, Valsalvas maneuver, etc https://www.heart.org/en/health- topics/arrhythmia/symptoms-diagnosis--monitoring-of- arrhythmia/syncope-fainting  https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure Fatigue 1. Fatigue induced by minimal activity or exertion may be cardiac in origin 2. Fatigue of cardiac origin is often accompanied by other associated signs, but in the early stages of disease, fatigue may be the only symptom 3. Look for abnormal responses to exercise, fatigue that lasts longer than expected 4. Seen in Poor LV functions (CAD, CHF, HTN, Valvular, Cardiomyopathy, myocarditis) 5. perfuse the entire body adequately, including the skeletal muscles.  Pedal Edema CHF is a common cause Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. of bilateral pedal edema 2. Occasionally, patients may complain only about an increase in abdominal girth, which results from ascites 3. If the edema is a result of a poorly functioning left ventricle, mitral stenosis, or cor pulmonale, it usually follows dyspnea on exertion 4. Patients with CHF and altered renal function commonly report edema of the ankles and lower legs while upright during the day but indicate a decrease during the night  https://www.hopkinsmedicine.org/health/conditions-and-diseases/claudication Claudication 1. Leg pain occurs with PVD, arterial or venous 2. Often occurs simultaneously with heart disease 3. Can be functionally disabling 4. Signs include skin discoloration, dry hairless skin, or can occur without physical findings 5. Core temperature and peripheral pulses should be assessed Hoarseness Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. Several cardiovascular conditions can produce hoarseness because the left recurrent laryngeal nerve loops under the arch of the aorta and above the pulmonary artery as it returns to the neck 2. An aneurysm of the arch of the aorta, a dilated pulmonary artery or atrium resulting from an atrial septal defect, or mitral stenosis can cause hoarseness.  SYSTEMS TEST & EXAMINATION HISTORY REVIEW MEASURES 1.Appropriate for PT? 2.Appropriate Do the examination for PT + findings support your consultation original hypotheses? 3.Inappropriate YES: Proceed for PT – refer? NO: Revisit/Revise PT PLAN OF INTERVENTION INTERVENTION DIAGNOSIS & EVALUATION CARE PROGNOSIS Is patient making functional progress toward goals when outcome measures are re-examined? YES: Continue episode of care OUTCOMES OUTCOMES NO: Consider revising treatment approach/patient goals OR consider referral to appropriate health care provider Cardiac: Patient Examination Neeti Pathare, PT, MSPT, PhD Objective Understand the elements of a complete cardiac physical examination, except for conducting the 12 lead ECG.  SYSTEMS TEST & EXAMINATION HISTORY REVIEW MEASURES 1.Appropriate for PT? 2.Appropriate Do the examination for PT + findings support your consultation original hypotheses? 3.Inappropriate YES: Proceed for PT – refer? NO: Revisit/Revise PT PLAN OF INTERVENTION INTERVENTION DIAGNOSIS & EVALUATION CARE PROGNOSIS Is patient making functional progress toward goals when outcome measures are re-examined? YES: Continue episode of care OUTCOMES OUTCOMES NO: Consider revising treatment approach/patient goals OR consider referral to appropriate health care provider Systems Review: CVP System presence of HR RR BP edema Physical Examination Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Start Vital signs Examination of Auscultation Tests and Temperature the chest Measures Physical Examination of the Chest Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Topographic anatomic landmarks: Key structures 1. Sternum, clavicles, suprasternal notch, sternomanubrial angle, costal angle, vertebra prominens 2. Anterior, lateral, and posterior views of the thorax each have three imaginary, vertical topographic lines. Physical Examination of the Chest: Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Visual Inspection of the General appearance level of consciousness body type posture positioning skin tone Semi-Fowler’s position The professorial position  Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Physical Examination of the Chest: Visual Inspection of the Skin Color, cyanosis scars, bruises, or ecchymoses bony landmark prominence Edema incision sites Digital clubbing—chronic tissue hypoxia Digital clubbing Physical Examination of the Chest Visual Inspection; Cyanosis/Clubbing Cyanosis Is a bluish coloration to the lips or nail beds Due to inadequate oxygen levels Caused due to Inadequate Cardiac Output, reduced peripheral perfusion e.g. PAD, or congenital Heart disease with right to left shunting Physical Examination of the Chest: Visual Inspection of the Face in Children Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. Facial characteristics Facial signs of distress 2. Neck Activity of neck musculature Physical Examination of the Chest: Visual Inspection of the Face in Adults Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. 1. Facial characteristics Facial signs of distress 2. Neck Activity of neck musculature Physical Examination of the Chest: Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Visual Inspection of the Jugular Venous Distention Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. The carotid artery is adjacent to the IJ, lying just medial to it. Shine a pen light tangentially across the neck. This sometimes helps to accentuate the pulsations. Bilateral distension is indicative of congestive heart failure Unilateral distention is indicative of a localized problem. Physical Examination of the Chest: Visual Inspection of the Jugular Venous Distention in Detail Physical Examination of the Chest: Visual Inspection 1. Chest wall configuration Normally elliptical in shape Round in infants and those with advanced ages Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Structural defects o Pectus excavatum or funnel chest o Pectus carinatum or pigeon chest o Flail chest o Kyphoscoliosis 2. Breathing patterns Abnormal respiratory patterns Dyspnea o Objective measures of dyspnea 3. Appearance of extremities Observation of fingers, toes, calves of legs Physical Examination: Palpation 1. Tenderness (Chest) Assessed for degree of tenderness and reproducibility Differentiation of chest wall discomfort of organic nature versus a musculoskeletal condition 2. Edema Assessment of edema is performed by pressing two fingers into questioned area for 2 to 3 seconds. If an impression is left, then pitting edema is present. Physical Examination: Palpation Physical Examination: Palpation Degrees of edema are based on the length of time that indentation lasts (1+ to 4+) Edema in the form of a 3 lb weight gain in a day is earliest indicator of fluid retention resulting in swelling of the hands, ankles, feet or abdomen and combined with SOB is a red-flag symptom of CHF Other causes : Fluid overload (kidney problems, post op); Venous disease such as venous valve incompetence, thrombophlebitis Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition the extremities. Pulses through Physical Examination: Palpation Pulses  Copyright © 2017 by Elsevier, Inc. All rights reserved. Test and Measures Guide categories for tests and measures Tests and Measures: CVP 1. Aerobic capacity and endurance Aerobic capacity during functional activities Aerobic capacity during standardized tests protocols; walk tests, ergometry, treadmill tests CVS s/s with exercise or activity; SOB, Fatigue, etc 2. Anthropometric characteristics 3. Circulation; Arterial, Venous, and lymphatic/Cardiovascular and Pulmonary CVS signs : HR, rhythm, sounds, pressures and flow; and superficial vascular responses Physiological changes to position change Examples of Data Used in Documentation Cardiovascular and pulmonary signs, symptoms, and responses per unit of work Gas volume, concentration, and flow per unit of work Heart rate and rhythm per unit of work Oxygen uptake during performance of functional activity Oxygen uptake, time and distance walked or bicycled, and maximal aerobic performance Peripheral vascular responses per unit of work Respiratory rate, rhythm, pattern, and breath sounds per unit of work https://guide.apta.org/examination-evaluation/categories/examination-tests-and-measures-aerobic-capacityendurance Additional Examination: Infants and Children Red Flags: Infant APTA Annual Conference & Exhibition; Baltimore, MD McGee and Anderle. Vital Signs Review: Are You Ready to be a Doctoring Professional? 2009: Poor feeding Poor weight gain Tachycardia Bounding pulses Rhinorrhea Signs of Respiratory Distress – Dyspnea – Flaring nares – Retractions – Irritability Additional Examination: APTA Annual Conference & Exhibition; Baltimore, MD McGee and Anderle. Vital Signs Review: Are You Ready to be a Doctoring Professional? 2009: Infants and Children Red Flags: Toddler/Preschooler Poor weight gain Tachycardia Bounding pulses Unusual tiredness o Dizziness o Anorexia o Fever  SYSTEMS TEST & EXAMINATION HISTORY REVIEW MEASURES 1.Appropriate for PT? 2.Appropriate Do the examination for PT + findings support your consultation original hypotheses? 3.Inappropriate YES: Proceed for PT – refer? NO: Revisit/Revise PT PLAN OF INTERVENTION INTERVENTION DIAGNOSIS & EVALUATION CARE PROGNOSIS Is patient making functional progress toward goals when outcome measures are re-examined? YES: Continue episode of care OUTCOMES OUTCOMES NO: Consider revising treatment approach/patient goals OR consider referral to appropriate health care provider Cardiac Auscultation Neeti Pathare, PT, MSPT, PhD Objectives 1. To identify the locations of correct stethoscope placement for auscultation of all heart sounds 2. Identification of normal S1 and S2 heart sounds 3. Interpretation of the findings related to S1 and S2 heart sounds 4. Interpretation of the findings related to S3 and S4 heart sounds and murmurs Physical Examination of the Chest: Auscultation Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Skill depends on 1. A functional stethoscope; diaphragm and bell 2. Proper technique 3. Knowledge of the different categories of chest sounds o Breath sounds o Extrapulmonary sounds o Voice sounds o Heart sounds Heart sounds Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Topographic landmarks assist in auscultation of heart sounds and murmurs A quiet environment and proper positioning aid auscultation S1 Normal heart sounds S2 Selective listening for each component of the cardiac cycle over five main topographic areas Heart sounds Normal Heart Sounds Gallops Murmurs: Pericardial friction rub S1: closing of the S3: early (diastolic) vibrations from turbulent Sign of pericarditis atrioventricular valves ventricular filling; blood flow S2: closing of the semilunar immediately following S2 Valvular Heart Disease valves and the end of oNormal in children and Systolic versus diastolic ventricular systole young adults oAbnormal in individuals older than age 40 years Key sign in heart failure S4 : rapid ventricular filling that occurs after atrial contraction. oHeard before S1 when present; late in diastole (BELL) oMay be heard in a “normal” individual with left ventricular hypertrophy Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Heart sounds Normal Heart Sounds Gallops S1: closing of the atrioventricular valves S3: early (diastolic) ventricular filling; S2: closing of the semilunar valves and the immediately following S2 end of ventricular systole o Normal in children and young adults o Abnormal in individuals older than age 40 years Key sign in heart failure S4 : rapid ventricular filling that occurs after atrial contraction. o Heard before S1 when present; late in diastole (BELL) o May be heard in a “normal” individual with left ventricular hypertrophy Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc. Heart sounds Murmurs: Pericardial friction rub vibrations from turbulent blood flow Sign of pericarditis Valvular Heart Disease Systolic versus diastolic Copyright © 2012 by Mosby, Inc., an affiliate of Elsevier Inc.  Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Stethoscope Heart Sounds Heart Sounds  Copyright © 2017 by Elsevier, Inc. All rights reserved. Heart Sounds Areas to auscultate for sounds generated from the aortic, pulmonary (pulmonic), tricuspid, and mitral valves. In the normal heart, the mitral area is the apical pulse point and the point of maximal impulse.  S-1 S-2 S-3 S-4 Beginning End Time Early diastole Pre-systolic of systole of Systole Aortic and A-V valve Valve closure reverberates Physiology Pulmonic valve Onset of atrial contraction closure off the dilated ventricle closure Heart Sounds Indicative of Heart Failure High ventricular pressure Can be exercise induced! Significance Normal Normal stronger atrial contraction (Normal in children and is needed trained athletes) Frequency High High Low and hard to hear Low and hard to hear Stethoscope Diaphragm Diaphragm Bell Bell Apex 2nd intercostal Apex Heard best 5thintercostal Just L of xiphoid space space Sound Lub Dup Gallop Gallop  Responses in Vitals with Activity Neeti Pathare, PT, MSPT, PhD Objectives 1. Define normal and abnormal vital sign ranges. 2. Assess appropriateness of changes in vitals with activity.  1. Determine patient’s response to activity 2. Rest (supine), sitting, standing, some type of ADL, and ambulation Copyright © 2017 by Elsevier, Inc. All rights reserved. 3. Measure HR, rhythm (ECG), BP, symptoms, heart/lung sounds before and after Physical Examination: 4. HR measurement—palpation, Activity evaluation ECG, pulse oximeter 5. Abnormal response—very rapid rise with increased workload, very flat rate of rise, decrease 6. Heart rhythm—assess regularity, final interpretation should be done with ECG; assessing for arrhythmia Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Activity Assessment Review  Review: Blood Pressure and PT Considerations Consider holding Vital Sign VS Normal treatment for Systolic < 120 mm Hg Systolic Blood Pressure BP Diastolic < 80 mm Hg Review: Pediatric Blood Pressure Reference Chart http://www.pedscases.com/pediatric-vital-signs-reference-chart  Review: Heart Rate Vital Sign VS Normal Consider holding treatment for Dependent upon Heart Rate HR 60 – 100 beats/minute resting heart rate and age  http://www.pedscases.com/pediatric-vital-signs-reference-chart Review: Pediatric Heart Rate Reference Chart  Review: Respiratory Rate Vital Sign VS Normal Consider holding treatment for: Respiratory Rate RR 12 - 20 breaths/minute < 12 or > 30 breaths/min  http://www.pedscases.com/pediatric-vital-signs-reference-chart Review: Pediatric Respiratory Rate Reference Chart Normal Heart Rate Response Submaximal Maximal Linear increase in HR and Q to correspond Isometric/Static Exercise to the workload Increase of Q and HR is less linear Less pronounced Rhythm should As maximum exertion level is increase in HR remain regular approached, HR takes off! Increase in Contractility; Stroke This is due to low cardiac output Volume, requirements and higher = Increase in Cardiac Output peripheral resistance Rhythm should remain regular  Normal Heart Rate Response The normal HR response to incremental exercise is an increase with progressive workloads per 1 MET As heart rate Due to the demand increases exhaustion may be with maximal imminent exercise Critical HR depends on conditioning level of individual LV filling time is Anaerobic impaired metabolism kicks in SV may decrease Decreased Cardiac due output (Q) to impaired LV filling time Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873–934. Heart Rate Response to Exercise Copyright © 2017 by Elsevier, Inc. All rights reserved. Heart rate response to increased workload in a normal sedentary individual (A) versus a trained individual (B). Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Normal Responses Summary of  Watchie, J. (2003). Monitoring Clinical Response to Exercise. Abnormal Heart Rate Responses Cardiovascular & Pulmonary Section APTA. Tachycardia BLUNTED HEART RATE Disproportionate TO ABNORMAL RHYTHM RESPONSE ACTIVITY Abnormal Heart Rate Responses Tachycardia disproportionate to activity Watchie, J. (2003). Monitoring Clinical Response to Exercise. 1. Usually indicative of deconditioning Cardiovascular & Pulmonary Section APTA. 2. If patient is lightheaded, dizzy: it may be due to orthostatic hypotension 3. Medications? 4. Ineffective heart pumping; Heart failure… rate is trying to compensate 5. Anemia, cardiac disease, pulmonary disease, etc Abnormal Heart Rate Responses Watchie, J. (2003). Monitoring Clinical Response to Exercise. Blunted HR response Cardiovascular & Pulmonary Section APTA. 1. Training effect 2. Medications — beta-blockers, antihypertensives, antiarrhythmics 3. Chronotropic Incompetence 4. If not taking medications needs to be evaluated for severe coronary disease  Abnormal HR response Watchie, J. (2003). Monitoring Clinical Response to Exercise. Abnormal rhythm response Cardiovascular & Pulmonary Section APTA. 1. Increase in frequency of dysrhythmias is a major concern 2. Dysrhythmias could result in gradual decrease in palpable pulse: EKG necessary  HR following exercise (HR recovery) 1. The rate of decline in HR following exercise (HR recovery) provides information for 2. A failure of the HR to decrease by at least 12 beats during the first minute or 22 beats by the end of the second minute of active postexercise recovery is strongly linked with an increased risk of mortality in individuals diagnosed with or at increased risk for IHD 3. The failure of HR to recover adequately may be related parasympathetic nervous system dysfunction Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873–934. Lachman S, Terbraak MS, Limpens J, et al. The prognostic value of heart rate recovery in patients with coronary artery disease: a systematic review and meta-analysis. Am Heart J. 2018;199 :163–9. Lauer MS. Exercise electrocardiogram testing and prognosis. Novel markers and predictive instruments. Cardiol Clin. 2001;19(3):401–14.  Normal Blood Pressure Response The normal systolic blood pressure (SBP) response to exercise is an increase with increasing workloads at a rate of ~10 mm Hg per 1 MET Submaximal Linear increase in SBP Maximal DBP: not much change Falls off due to stroke volume Isometric/Static Exercise Younger patients: limitations DBP may decrease More marked slightly with exercise; eg, decreased LV filling time at progressive increase: 10-20 mm Hg high HRs In SBP due to increased PVR and Older patients: CO DBP may increase slightly, 10 mmHg per MET increase 2. DBP increases > 10 mmHg above resting 3. Post exercise DBP remains elevated during recovery or SBP fails to level out in submaximal workload Watchie, J. (2003). Monitoring Clinical Response to Exercise. Cardiovascular & Pulmonary Section APTA. Vital Signs Review: Are You Ready to be a Doctoring Professional? Margaret McGee, PT, PhD, BSN, PCS and Dale Anderle, PT, DPT. PT 2009: APTA Annual Conference & Exhibition Baltimore, MD  Watchie, J. (2003). Monitoring Clinical Response to Exercise. Abnormal BP responses Cardiovascular & Pulmonary Section APTA. Blunted or Flat BP response 1. Medications- antihypertensives or beta-blockers 2. Patients with poor LV function who cannot increase CO to meet the workload needs Abnormal BP responses Hypotensive response 1. In the clinic, if a pt’s SBP falls during exercise by more than 10 -20 mmhg: Caution for orthostatic hypotension 2. Seen more often in elderly patients, diabetes mellitus, autonomic dysfunction, deconditioned or recent bed rest, recent surgical procedure, or with antihypertensive medications. 3. Other signs and symptoms to observe for o Palor o Diaphoresis o Lightheadedness  Abnormal BP responses Hypotensive response 1. Sudden drop following the normal rise in SBP at low intensity workloads 2. Signifies severe cardiac dysfunction (aortic stenosis, CAD, or poor LV function) Watchie, J. (2003). Monitoring Clinical Response to Exercise. Cardiovascular & Pulmonary Section APTA. Vital Signs Review: Are You Ready to be a Doctoring Professional? Margaret McGee, PT, PhD, BSN, PCS and Dale Anderle, PT, DPT. PT 2009: APTA Annual Conference & Exhibition Baltimore, MD Summary of Abnormal Responses to Activity Assessing Postural Hypotension A drop of more than 20 mm Hg systolic and more than 10 mm Hg diastolic accompanied by a 10%-20% increase in heart rate (pulse) indicates postural hypotension A physical therapist monitors the blood pressure of a 28-year-old male during increasing levels of physical exertion. Assuming a normal physiologic response, which of the following BEST describes the patient’s blood pressure response to dynamic exercise? a. Systolic pressure decreases, diastolic pressure increases b. Systolic pressure remains the same, diastolic pressure increases c. Systolic pressure and diastolic pressure remain the same d. Systolic pressure increases, diastolic pressure remains the same  Exercise Testing Neeti Pathare, PT, MSPT, PhD  1. To determine when exercise testing is performed 2. To understand the different types and protocols of exercise testing 3. To understand the termination points of maximal and submaximal testing Objectives 4. To calculate the target heart rate range (THR) for an individual using both the age predictive method and the Karvonen method 5. To interpret an exercise test report 6. To formulate exercise prescription using results from an exercise test  SYSTEMS TEST & EXAMINATION HISTORY REVIEW MEASURES 1.Appropriate for PT? 2.Appropriate Do the examination for PT + findings support your consultation original hypotheses? 3.Inappropriate YES: Proceed for PT – refer? NO: Revisit/Revise PT PLAN OF INTERVENTION INTERVENTION DIAGNOSIS & EVALUATION CARE PROGNOSIS Is patient making functional progress toward goals when outcome measures are re-examined? YES: Continue episode of care OUTCOMES OUTCOMES NO: Consider revising treatment approach/patient goals OR consider referral to appropriate health care provider  Entry-Level Physical Therapist Skills 1. Should be able to interpret the result of treadmill stress test 2. Perform submaximal tests; 6MWT, shuttle test 3. Goal of this lab: To interpret a result of exercise test  Review: Submaximal Exercise Testing Primary purpose for submaximal testing is to 10th edition, Lippincott Williams & Wilkins, Baltimore, MD, 2017. ACSM: ACSM's Guidelines for Exercise Testing and Prescription, 1. a. Estimate VO2max, or b. Determine functional response to exercise 2. Modes of submaximal testing a. Field tests b. Treadmills c. Cycle ergometers d. Step testing 3. Select mode based on a. Fitness program for the patient b. Musculoskeletal limitations Exercise Testing Recommendations A 48-year-old female desires to start an exercise program in your facility. Following an initial questionnaire and interview you find that she has no personal history of heart disease, but her father died following a heart attack at the age of 60. In addition, she has a resting BP of 145/85. Her total cholesterol is 220 with an HDL of 69. She is not obese. She currently walks 30 minutes 4 times per week, but does not strength train. 1. According to ACSM this person is at low risk, at moderate risk, at high risk, or none of the above ? A 48-year-old female desires to start an exercise program in your facility. Following an initial questionnaire and interview you find that she has no personal history of heart disease, but her father died following a heart attack at the age of 60. In addition, she has a resting BP of 145/85. Her total cholesterol is 220 with an HDL of 69. She is not obese. She currently walks 30 minutes 4 times per week but does not strength train. A. Undergo medical exam prior to starting a vigorous program with a physician available to supervise max exercise B. Undergo medical exam prior to starting a vigorous program but no physician is necessary for max exercise C. No medical exam prior to vigorous program but a physician is necessary for max exercise D. No medical exam prior to vigorous program and no physician is necessary for max exercise. Exercise Testing Copyright © 2017 by Elsevier, Inc. All rights reserved. Used in diagnosis and Involves systematically and Informal testing is performed management of patients with progressively increasing O2 to screen for exercise CAD demand, evaluate the programs responses Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Indications Exercise Testing Maximal versus Submaximal Maximal Symptom limited or Submaximal nowadays 85% Hrmax Predicted Hrmax Used prior to hospital discharge; 4–6d after Usually More than acute MI. Sometimes 14d after acute MI this is not done now Usually a predetermined endpoint; ~70– Low risk individuals 75% Heart rate Max Measure functional capacity and diagnose CAD Exercise Testing Considerations Safety in exercise testing PT must have clear understanding of rationale for terminating a test Safety is key Determinant of safety is knowledge and experience of the examiner conducting the test Contraindications to testing Essential to safe testing is knowing who should be tested Copyright © 2017 by Elsevier, Inc. All rights reserved. Hillegass: Essentials of Cardiopulmonary Physical Therapy, 4th Edition Absolute and relative contraindications to exercise testing Criteria for Termination of Maximal and Low-Level/ Submaximal Testing  Copyright © 2017 by Elsevier, Inc. All rights reserved. Testing protocols 1. Most common tests involve use of stationary bicycle or treadmill 2. Two most common protocols include Balke and Bruce  Modified Bruce Protocol 1. Standard Bruce protocol, starts; 5 METs, with larger increments between stages than other protocols 2. Two 3-minute warm up stages at 1.7 mph and 0% grade and 1.7 mph and 5% grade 3. Most often used in older individuals or those whose exercise capacity is limited by cardiac disease Noonan V , Dean E PHYS THER 2000;80:782-807 ©2000 by American Physical Therapy Association 4. Very commonly used  Interpretation of results 1. Final summary should Worksheet for interpretation of exercise test results. define outcome of test 2. Positive result if the patient develops signs and symptoms of ischemia during stress, eg, ST-segment depression and angina 3. Time completed 4. Limiting factors: Tells us for what S/s to watch 5. Chest pain ?? Important 6. ECG changes: Tells us for what to watch 7. Maximal HR achieved: To design therapy 8. BP response, Heart sounds: Tells us what to watch out for 9. VO2 max 10. If abnormal, explanation should be included Calculation of THR THR (Range) method A and B 1. MHR x.6 2. MHR x.85 Calculation of THR using Karvonen Method When stress test Low end of range = [ (MHR From GXT results) – RHR) x.6 ] + RHR results available High end of range = [ (MHR From GXT results) – RHR) x.85 ] + RHR When stress test results Low end of range = [ (MHR Age adjusted) – RHR) x.6 ] + RHR not available High end of range = [ (MHR Age adjusted) – RHR) x.85 ] + RHR Pediatric population 1. > 3 years: submaximal treadmill and stair exercise tolerance protocols 2. > 6 years: standardized exercise test protocols; adjustments for motor skill 3. Termination criteria same 4. If FEV1 < 50% predicted value — monitor SaO2  1. Used as noninvasive screening Copyright © 2017 by Elsevier, Inc. All rights reserved. method for detection of coronary disease 2. Greater sensitivity and specificity in males over age 40 years than in females Prognostic value of maximal exercise testing 3. Females tend to demonstrate greater percent of false-negative results 4. Ischemia (ST-segment depression) during early stages is correlated with more severe disease Exercise Testing Exercise testing with ventilatory gas analysis Copyright © 2017 by Elsevier, Inc. All rights reserved. Provides additional information regarding O2 exchange, breathlessness Provides information on cardiac performance, functional limitation, exercise limitation Assessing dyspnea—ventilatory reserve and dyspnea index Exercise testing with imaging modalities Radioactive nuclide perfusion imaging The patient undergoes additional noninvasive imaging immediately after exercise test A small amount of radioactive tracer is injected and combined with exercise test Assess myocardial O2 supply and demand relationship Pharmacological Stress Testing Copyright © 2017 by Elsevier, Inc. All rights reserved. 1. Used when a patient is unable to perform upright exercise on a treadmill or cycle 2. Injection of a pharmacological agent to induce physiological stress 3. Adenosine or dipyridamole-walk protocol Combined low-level treadmill exercise during adenosine infusion Patient Evaluation Neeti Pathare, PT, MSPT, PhD Objectives 1. To understand the elements of a cardiac evaluation. 2. To determine NYHA functional classification and PT practice pattern.  Do the examination findings support your original hypotheses? YES: Proceed NO: Revisit & Revise  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Diagnosis based on primary dysfunction of the human movement system Participation restrictions, activity limitations, and impairments in body structures & function should be considered in accordance with ICF Predicted level of optimal improvement New York Heart Association Functional Classification of Heart Disease CLASS I ORDINARY PHYSICAL ACTIVITY DOES NOT CAUSE NO LIMITATION OF PHYSICAL UNDUE FATIGUE, PALPITATION, OR DYSPNEA; 6—10 METS ACTIVITY SHORTNESS OF BREATH. CLASS II Comfortable at rest, but ordinary Slight limitation 4—6 METS physical activity results in fatigue, palpitation, or of physical activity dyspnea. CLASS III Comfortable at rest, but less than Marked limitation 2—3 METS ordinary activity causes fatigue, of physical activity palpitation, or dyspnea. CLASS IV Symptoms of cardiac insufficiency at rest. Unable to carry out any physical If any physical activity is undertaken, discomfort is < 2 METS activity without discomfort increased.  Guide to PT Practice Patterns  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Amount of time necessary to achieve the level Specified goals in accordance with ICF Statement of intended interventions Duration/frequency of services required to achieve goals Anticipated plans for conclusion of care Outcome Measures Neeti Pathare, PT, MSPT, PhD Objectives 1. To understand the importance of outcome measures in cardiac rehabilitation (CR) 2. To provide commonly used outcome measures in CR 3. To develop clinical reasoning for selection of appropriate outcome measures in CR  Examination Evaluation Intervention Re-Evaluation Systems Test & PT Diagnosis Outcomes History Plan of Care Intervention Review Measures & Prognosis Assessment Standardized Outcome Measures throughout the episode of care Continuation of episode of care Conclusion of episode of care  Copyright © 2017 by Elsevier, Inc. All rights reserved. Importance of Measuring Outcomes 1. Ensuring quality of care is important to CMS and JCAHO 2. AACVPR advises that documentation must include records of expected and observed treatment outcomes in cardiac rehabilitation and pulmonary rehabilitation programs 3. Minimal of at least one health, one clinical, one behavioral, and one service outcome Outcomes in Cardiac Rehabilitation Outcomes in Cardiac Rehabilitation Sample Form of Cardiac Rehabilitation Assessment and Intervention  Copyright © 2017 by Elsevier, Inc. All rights reserved. Outcome Measures in Acute Care  Selection of Data to Measure: Simple form for preparing a patient for the 6-minute walk test. Functional performance Gold standard of measurement for functional Copyright © 2017 by Elsevier, Inc. All rights reserved. exercise capacity is measurement of volume of oxygen consumption (VO2max) Other measures include self-paced walk test, 2MWT, 3MWT, 6MWT, 12MWT, modified shuffle test, treadmill endurance test, 200-meter walk fast test 6MWT—distances