Cardiovascular physical therapy (exerpts)

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IER Book page 146- Some of the flashcards were made in a questions format to facilitate learning Take this section as a test using learn mode or test mode

Anterior MI

ECG changes with MI
A PT working in a hospital is asked to treat a patient with known cardiac problems. When he looks at the ECG strips in the chart, he sees Q waves in leads V1 - V4; what condition is the PT suspecting?

Lateral MI

ECG changes with MI
A PT working in a hospital is asked to treat a patient with known cardiac problems. When he looks at the ECG strips in the chart, he sees Q waves in leads 1, AVL. What condition is the PT suspecting?

Inferior MI

ECG changes with MI
A PT working in a hospital is asked to treat a patient with known cardiac problems. When he looks at the ECG strips in the chart, he sees Q waves in leads II, III, AVF. What conditions is the PT suspecting?

Posterior MI

ECG changes with MI
A PT working in a hospital is asked to treat a patient with known cardiac problems. When he looks at the ECG strips in the chart, he sees Large R waves in leads V1-V3, ST segment depression V1,V2, or V3. What conditions is the PT suspecting?

Hyperkalemia

What condition might be suspected in the following description?
- increased concentration of potassium ios decreased the rate and force of heart contraction
- ECG changes such as: Widened PR intervals, QRS and tall T waves?

Hypokalemia

What condition might be suspected in the following description?
- decreased concentration of postassium ions produce

Hypercalcemia

Increased concentration of calcium ions increases heart actions

Hypocalcemia

decreased concentration of calcium ions decreases heart actions

Orthopnea

Inability to breathe when in a reclining position

Paroxysmal nocturnal dyspnea

Sudden inability to breathe occurring during sleep

Hypoxemia

Abnormally low amount of oxygen in the blood (O₂sat < 90%)

Hypoxia

Low oxygen level in the tissues

Anoxia

Complete lack of oxygen

Cyanosis

Bluish color related to decreased cardiac output or cold; especially lips, fingertips, nail beds

Pallor

Absence of rosy color in light-skinned individuals, associated with decreased peripheral blood flow, PVD

Rubor

Dependent redness wih PVD

Clubbing

Curvature of the fingernails with soft tissue enlargement at base of nail; Associated with chronic oxygen deficiency, heart failure

Stemmer's sign

Dorsal skin folds of the ltoes or fingers are resistant to lifting
Indicative of fibrotic changes and lymphedema

Poor arterial perfusion

A PT examines a patient in the clinic. The PT notices that the superficial temperature of one of the LE is lower compared to opposite side. This condition can be attributed to:

1+

Pitting edema scale
- Barely perceptible identation ( 0 - 1/4 inch pitting)

2+

Pitting edema scale
- Easily identified depression; returns to normal within 15 seconds. (1/4 > 1/2 inch pitting)

3+

Pitting edema scale
- Depression takes 15- 30 seconds to rebound (1/2 > 1 inch pitting)

4+

Pitting edema scale
- Depression lasts for ≥ 30seconds (> 1inch pitting)

Grade 1

A patient presents with intermittent claudication when walking on the treadmill. When asked with regards to his pain in LE, he states it is minimal discomfort. What grade this represent in the intermittent claudication scale?

Grade 2

A patient presents with intermittent claudication when walking on the treadmill. When asked with regards to his pain in LE, he states it is moderate discomfort, and his attention can be diverted with conversation. What grade this represent in the intermittent claudication scale?

Grade 3

A patient presents with intermittent claudication when walking on the treadmill. When asked with regards to his pain in LE, he states he cannot continue because the pain is intense (Patient 's attention cannot be diverted). What grade this represent in the intermittent claudication scale?

Grade 4

A patient presents with intermittent claudication when walking on the treadmill. Shortly after the patient stops the treadmill and states that his pain is excrutiating and unbearable. What grade this represent in the intermittent claudication scale?

Percussion test

What test determines the competence of greater saphenous vein?

Percussion test

What test is being explained?
- In standing, palpate one segment of vein while percussing ven approximately 20 cm higher. If pulse wave is flet by lower hand, the intervening vals are incompetent

Trendelenburg's test

(retrograde filling test) What test is being explained ?
- Patient is positioned in supine with legs elevated 60° (empties venous blood)
- Tourniquet is then placed on proximal thigh (occludes venous flow in the superficial veins)
- Patient is then asked to stand
- Examiner notes if veins fill in normal pattern. Should take approximately 30 seconds.

Falsely elevated, arterial disease, diabetes

ABI Index value > 1.2

Normal

ABI Index value = 1.0 - 1.20

Mild arterial disease, intermittent claudication

ABI Index value = 0.99 - 0.80

Moderate arterial disease, and pain at rest

ABI Index value = 0.79 - 0.50

Severe arterial disease

ABI Index value < 0.50

hypokalemia

leg cramps may also result from diuretic use that reduce K ion concentration. this condition is called:

Swan-Ganz catheter

What the name of the central line catheter that is inserted through vessels into right side of heart,and it is used to measure
- Central venous pressure (CVP)
- Pulmonary artery pressure (PA)
- Pulmonary capillary wedge pressures (PCWP)?

Systole

The period of ventricular contraction

End systolic volume

The amount of blood in the ventricles after systole (≈ 50mL)

Diastole

The period of ventricular relaxation and filling of blood

End diastolic volume

The amount of blood in the ventricles after diastole (≈ 120mL)

Congestive Left heart failure

Gallop or S3, is an abnormal heart rhythm with three sounds in each cycle. It occurs soon after S2. Which condition is S3 is associated with?

CAD, MI, aortic stenosis, chronic hypertension

S4 is associated with ventricular filling and atrial contraction. it occurs just before S1. Which conditions is S4 associated with?

Raynaud's disease

Episodic spasms of small arteries and arterioles. Abnormal vasoconstriction reflex exacerbated by exposure to cold or emotional stress.
Tip of fingers develop pallor, cyanosis, numbness and tingling

Discontinous

When performing Exercise Tolerance Test (ETT) to determine functional capacity of an individual, How ETT should be performed for patients with more pronounced CAD?

HR increases directly proportional to exercise intensity, Rate related shortening of QT interval, decrease R wave and increase Q wave, arrhythmias rare: single PVCs, ST segment depression < 1mm

What are ECG changes with exercise in healthy individuals ?

Significant tachycardia occurs at lower level of exercise, Exertional arrhythmias during exercise and recovery, ST segment depression > 1mm below baseline

What are ECG changes with exercise in individuals with CAD Myocardial Ischemia?

Exercise is contraindicated

What can be safely assumed in term of exercise in individuals with: poor LEFT ventricular function, ischemic changes on ECG (ST segment depression > 1mm) during ETT, Functional capacity < 6 METs, uncontrolled hypertension or arrhythmias?

60-80% of V02 max

How is 70 - 85% of HR max correlates to VO2 max?

60% of HR range

An RPE value of 12 - 13 (Somewhat hard) correspond to how much percentage of HR range?

85% of HR range

An RPE value of 16 (Hard) correspond to how much percentage of HR range?

Modify exercise prescription

- HR < THR for a given exercise intensity
- RPE < for a given exercise intensity (exercise is preceived as easier)
- Symptoms of ischemia (i.e., angina) do not appear at a given exercise intensity
If any of this conditions occurs in your plan of care, you should:

Increase duration first, and then intensity

As training progress in rehabilitation, you should:

Resting SBP > 200mmHg or Resting DBP > 110mmHg, Orhosthatic BP drop > 20 mmHg with symptoms, ST segment depression > 2mm, uncontrolled diabetes: glucose level 300mg/dL pr > 250mg/dL with ketones present

What conditions are considered Absolute contraindications to participation in Inpatient and/or Outpatient cardiac rehabilitation program?

DBP ≥ 110mmHg, decrease in SBP > 10 mmHg, significant ventricular/atrial arrhythmias, 2nd-3rd degree AV Block, s/s of exercise intolerance

If a patient is exercising in a Inpatient Cardiac Rehabilitation program, what conditions would lead to exercise discontinuation?

Persisten dyspnea, dizziness or confusion, angina, severe leg claudication, excessive fatigue, pallor, cold sweat, ataxia, pulmonary rales

Signs & Symptoms of Exercise intolerance

HR > 115bpm

In patients with CHF, exercise HR should be limited to RHR + 10-20bpm. What exercise HR is generally contraindicated in individuals with Congestive heart failure?

Weight gain, edema in LE

Exercise may exacerbate CHF, therefore check for delayed reponses of:

40-60% of functional capacity

Patients with CHF should exercise at low intensity and with interval training (increasing duration with frequent rest periods). What intensity level should CHF exercise in terms of percentage of functional capacity?

Do not remove any cloth or towel, and add additional layers, and elevate the part if possible unless it's deformed or causes pain when elevated

A PT is trying to control external bleeding (arterial bleed) for a football player who has severely injured. The PT attempts to stop the bleeding by putting a clean cloth or towel over it and apply a firm pressure. The PT notices that the blood is soaking through the cloth or towel. What's the next thing he should do to contain the bleeding?

Interval training or discontinous protocol at moderate level

Exercise training for patient with PVD may result in improved functional capacity, improved peripheral blood flow and muscle oxidative capacity. what type of training/protocol is recommended?

40-70% of VO2max, 2-3 times/day, 3-7days/week

A walking program is recommended for patients with PVD. what intensity should it be?

Resistive calf exercises

What is the MOST effective method of increasing blood flow in LE in patients with PVD (arterial disease)?

Modified Buerger-Allen exercises, and resistive calf exercises

What LE exercises are recommended for patients of PVD (arterial disease)?

Modified Buerger-Allen exercises

Name of these exercises for PVD patients (arterial disease)
- Postural exercises + active plantaflexion and dorsiflexion of the ankle

Do not apply compression

A PT is working a hospital and he's given orders to apply compression to a patient with chronic venous insufficiency as part of management of LE edema. The PT looks at the chart and reads the ABI index to be < 0.8 (mild arterial disease) with evidence of cellulitis or infection. What's the Next thing to do?

Discontinue activity, elevate limb and apply cold packs

A patient is presenting with any of the signs of lymph overlad: discomfort, aching or pain in proximal lymph areas (axillar or inguinal), change in skin color as a result of activities being perform in the rehab session. What should the PT do?

Strenous activities such as jogging, and ballistic movements

Activities that are CONTRAINDICATED to patients with lymphedema as they are likely to exacerbate this condition are:?

Work trunk and limb girdle muscles first, then limb muscles from proximal to distal with compression bandage on

What sequence of exercise is indicated for patients with lymphedema?

Pressures > 45mmHg

When using compression pumps what pressures are contraindicated as they can cause lymphatic collapse?

Venous filling time

What test is being explained?
- Patinet in supine, passively elevate LEs to approximately 45° for 1 minute, then place in dependent position.
- note time for veins to refil
- delayed filling (> 15 seconds) is indicative of venous insufficiency

Venous insufficiency

A therapist performs a venous filling time test. Veins takes 25 seconds to refill. This venous filling time may be indicative of what condition?

Normal

A therapist obtains a value of 1.0 of a measure of the Ankle-Brachial index. What does this value represents?

Mild peripheral artery disease

A therapist obtains a value of 0.92 of a measure of the Ankle-Brachial index. What does this value represents?

Moderate peripheral artery disease

A therapist obtains a value of 0.74 of a measure of the Ankle-Brachial index. What does this value represents?

Moderate peripheral artery disease

A therapist obtains a value of 0.56 of a measure of the Ankle-Brachial index. What does this value represents?

Moderate peripheral artery disease

A therapist obtains a value of 0.50 of a measure of the Ankle-Brachial index. What does this value represents?

Severe arterial disease, critical limb ischemia, and for rest pain

A therapist obtains a value of 0.48 of a measure of the Ankle-Brachial index. What does this value represents?

Compression therapy with caution

A therapist obtains a value of 0.92 of a measure of the Ankle-Brachial index. What does this value represents in terms of using compression therapy?

Compression therapy is contraindicated

A therapist obtains a value of 0.78 of a measure of the Ankle-Brachial index. What does this value represents in terms of using compression therapy?

Compression therapy is contraindicated

A therapist obtains a value of 0.49 of a measure of the Ankle-Brachial index. What does this value represents in terms of using compression therapy?

Normal

ABI Index value = 1.0 - 1.20

Compression therapy with caution

ABI Index value = 0.99 - 0.80; Compression therapy recommendation?

Compression therapy is contraindicated

ABI Index value = 0.79 - 0.50; Compression therapy recommendation?

Compression therapy is contraindicated

ABI Index value < 0.50; Compression therapy recommendation?

Myocardial perfusion imaging

Diagnostic test use to diagnose and evaluate ischemic heart disease, myocardial infraction

Decreased stroke volume, cardiac output and ejection fraction, but also increased end diastolic ventricular pressures

Impaired ventricular function results in:

Heart failure

Defined as a condition in which the heart is unable to maintian adequate ciruculation of the blood to meet the metabolic needs of the body.

Congestive heart failure (CHF)

Defined as a condition in which the heart is unable to maintian adequate ciruculation of the blood to meet the metabolic needs of the body. When with this condition edema is present is called?

Left heart failure or forward HF)

Defined as whe blood is not adequately PUMPED into systemic circulation;due to an inability of LEFT ventricle to pump,increases in ventricular end-diastolic pressure and left atrial pressure with:
- Increased pulmonary artery pressures, and pulmonary edema
- Pulmonary signs & symptoms: cough, dyspnea, orthopnea(shortness of breath (dyspnea) which occurs when lying flat)
- Weakness, fatigue

Right heart failure or backward HF

Defined as when blood is not adequately RETURNED from the systemic circulation to the heart;due to failure or RIGHTventricule, increased pulmonary artery pressures, with:
- Peripheral edema: weight gain, venous stasis
- Nausea, anorexia

Right sided heart failure

These signs & symptoms are associated with what type of heart failure (right/left)?
- Nausea, anorexia
- Weight gain, ascites, Right upper quadrant pain
- Increased right arterial pressure (RAP), Central venous pressure (CVP)
- Jugular venous distention
- Peripheral edema

Left sided heart failure

These signs & symptoms are associated with what type of heart failure (right/left)?
- Fatigue, cough
- Shortness of breath, Dyspnea on exertion
- Orthopnea, Paroxysmal Nocturnal Dyspnea (PND)
- Diaphoresis
- Cheyne-Stokes respirations (advanced failure)

Cheyne-Stokes respirations

Defined as a period of apnea (no breathing) lasting for 10 - 60 seconds followed by gradually increasing depth and frequency of respirations; accompanies depression of frontal lobe and diencephalic dysfunction. May also be seen in advance left sided heart failure

Nitroglycerin

Identify the following medication based on description?
- Decrease preload through peripheral vasodilation, reduce myocardial oxygen demand
- Reduce chest discomfort (angina)
- may also dilate coronary arteries, improve coronary blood flow
(nitrates)

Beta-adrenergic blockers

Identify the following medication based on description?
- reduce myocardial demand by reducing heart rate and contractility; control arrhythmias, chest pain, reduce blood pressure
e.g., propanolol[inderal]

Calcium channel blockers

Identify the following medication based on description?
- Inhibit flow of calcium ions, decrease heart rate, decrease contractility,dilate coronary arteries, reduce BP, control arrhythmias, chest pain.
e.g., Cardizem, Procardia,diltiazem

Antiarrhythmics

Identify the following medication based on description?
- Four main classes., Alter conductivity, restore normal heart rhyth,control arrhythmias, improve cardiac output
e.g., quinidine, procainamide

Digitalis (cardiac glycosides)

Identify the following medication based on description?
- Increases contractility and decreased heart rate (bradycardia)
- Mainstay in the treatment of CHF (e.g., digoxin)

Diuretics

Identify the following medication based on description?
- Decrease myocardial work (reduce preload and afterload)
- Control hypertension (e.g., furosedide [lasix],hydrochlorothiazide[Esidrix]

Aspirin

Identify the following medication based on description?
- Decreases platelet aggregation; may prevent myocardial infarction, considered a blood thinner.

Heteroptics

Cardiac transplantation is used in end-stage myocardial disease e.g., cardiomyopathy,ischemic heart disease, valvular disease. When transplantation involves leaving the natural heart and piggy-backing the donor heart this is called?

Orthotopic

Cardiac transplantation is used in end-stage myocardial disease e.g., cardiomyopathy,ischemic heart disease, valvular disease. When transplantation involves removing te diseased heart and replacing it with a donor heart, this is called?

Ventricular assist devices (VADs)

Defined as an implanted device (accessory pump) that improves tissue perfusion and maintians cardiogenic circulation;used with severely involved patients e.g., cardiogenic shock unresponsive to medications, severe ventricular dysfunction

Arteriosclerosis obliterans

(atherosclerosis): Chronic, occlusive arterial disease of medium and large sized vessels, the result of peripheral atherosclerosis.
- Associated with hypertension and hyperlipidemia; patient may also exhibit CAD, Cerebrovascular disease, diabetes
- Pulses: decreased or absent
- Color: pale on elevation,dusky red on dependency
- Early stages: Intermitten claudication. Pain described as burning,searing,aching, tightness or cramping
- Late stages: Ischemia and rest pain; ulcerations and gangrene, trophic changes
- Affect primarily the lower extremities.

Thromboangiitis obliterans

(Buerger's disease): Chronic, inflammatory vascular occlusive disease of small arteries and also veins
- Occurs commonly in young adults, largely males, who smoke.
- Begins distally and progresses proximally in both upper and lower extremities
- Patient exhibit paresthesias or pain, cyanotic cold extremity,diminished temperature sensation, fatigue, risk of ulceration and gangrene

Diabetic angiopathy

Defined as inappropirate elevation of blood glucose levels and accelerated atherosclerosis
- Neuropathy a major problem
- Neurotrophic ulcers, may lead to gangrene and amputation

Raynaud's disease or phonomenon

Defined as episodic spasm of small arteries and arterioles
- Abnormal vasoconstrictor reflex exacerbated by exposure to cold or emotional stress; tips of fingers develop pallor, cyanosis, numbness, and tingling
- Affects largely females
- Occlusive diesease is not usually a factor

Superficial vein thrombophlebitis

Defined as clot formation and acute inflammation in a superficial vein. Localized pain; usually in saphenous in a deep vein

Deep vein thrombophlebitis (DVT)

Defined as clot formation and acute inflammation in a deep vein
- Usually occurs in lower extremity, associated with venous stasis (bed rest, lack of leg exercise)
- Hyperactivity of blood coagulation, and vascular trauma
- Early ambulation is prophylactic, helps eliminate venous stasis

Resistive exercise is contraindicated

A patient would like to beging a resistive training program. Patient has a diagnosis of poor left ventricular function, ischemic changes on ECG during exercise tolerance test (ETT) and his functional capacity is less than 6 mets. What can be said with regards to perform resistive exercise program?

Stop exercise

A patient is taken to the cardiac rehabiliation inpatient center to exercise. If any of the following occurred, what is the next thing to do with regards to exercise?
- Patient's DBP ≥ 110 mmHg
- Decrease in SBP > 10 mmHg
- Significant ventricular or atrial dysrhythmias
- 2° or 3° heart block
- signs & symptoms of exercise intolerance, including: angina,marked dyspnea, and electrocardiogram changes suggestive of ischema such as: ST depression > 1mm

Do not apply compression therapy

A therapist wants to apply compression therapy as part of management of edema on a patient with chronic venous insufficiency. The therapist performs an Ankle-Brachial test. the values is 0.68,which is < .80 according to the index values. What should this therapist do with regards to compression therapy?

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