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Natalia Fernandez, PT, MS, MSc, CCS University of Michigan Health Care System Department of Physical Medicine and Rehabilitation. Clinical Decision Making Examination Evaluation Diagnosis Prognosis Set up Interventions Clinical Decision Making Med Dx: CAD Med Dx: COPD Use of Hypothesis Testing and Algorithms Med Dx and History of Cardiopulmonary Disease Lab and Diagnostic Test Results PT Dx Type of activity, specifics of activity, time Response to exercise/mobility/ADL Vital signs – rest, activity, recovery EKG changes Need and time to stop, rest Observed signs – color changes Subjective responses Concerns – Fatigue, SOB Rate of Perceived Exertion DeTurk & Cahalin - pg 368-369, Fig 12-4 & pg 370, Fig 12-5 Musculoskeletal, Integument, & Neuromuscular Considerations Musculoskeletal Osteoporosis & Spinal Deformities Ankylosing Spondylitis Idiopathic Scoliosis Pectus Deformities Shoulder Hypomobility Integument Sarcoidosis Systemic Lupus Erythematosus Scleroderma Sjogren Syndrome Neuromuscular Stroke Traumatic Brain Injury Spinal Cord Injury Multiple Sclerosis Parkinsons Guillain-Barre Syndrome Post Polio Syndrome Nagi (Disablement) Model Disability Functional limitation Impairment Pathology Inability to shop for family Limited walking distance Impaired aerobic capacity Myocardial Infarction APTA, Guide PT Practice, 1st ed.1997. Therapeutic Exercise for Cardiopulmonary Practice Patterns Aerobic capacity/endurance conditioning or reconditioning Balance, coordination, and agility training Body mechanics and postural stabilization Flexibility exercises Gait and locomotion training Relaxation Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles Pattern A: Prevention and Risk Inclusion Criteria Risk Factors or Consequences of Pathology Diabetes Family history of heart disease Hypercholesterolemia or hyperlipidemia Hypertension Obesity Sedentary lifestyle Smoking Impairments, Functional Limitations, or Disabilities Decreased functional work capacity Decreased maximum aerobic capacity Dyspnea on exertion Sedentary job role Pattern A: Prevention and Risk Ther Ex Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time Task-specific performance training Flexibility exercises Muscle lengthening Range of motion Stretching Body mechanic and ergonomics training Breathing exercises Posture awareness training Pattern A: Prevention and Risk Ther Ex Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Strength, power, and endurance training Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices) Aquatic programs Standardized, programmatic, complementary exercise approaches Task-specific performance training Pattern A: Prevention and Risk Patient Education Disease Atherosclerosis Hyperlipedemia Hypertension Diabetes Diet Exercise Smoking Health & Wellness Fitness Pattern B: Deconditioning Inclusion Criteria Risk Factors or Consequences of Pathology Acquired immune deficiency syndrome Cancer Cardiovascular disorders Chronic system failure Inactivity Multisystem impairments Musculoskeletal disorders Neuromuscular disorders Pulmonary disorders Impairments, Functional Limitations, or Disabilities Decreased endurance Increased cardiovascular response to low level work loads Increased perceived exertion with functional activities Increased pulmonary response to low level work loads Inability to perform routine work tasks due to shortness of breath Pattern B: Deconditioning Ther Ex Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time Balance, coordination, and agility training Developmental activities training Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches Breathing exercises Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control and awareness training Flexibility exercises Muscle lengthening Range of motion Stretching Pattern B: Deconditioning Ther Ex Gait and locomotion training Developmental activities training Gait training Implement and device training Standardized, programmatic, complementary exercise approaches Wheelchair training Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics) Aquatic programs Conditioning and reconditioning - Strengthening or Resistive Standardized, programmatic, complementary exercise approaches Pattern C: Airway Clearance Inclusion Criteria Risk Factors or Consequences of Pathology Acute lung disorders Acute or chronic oxygen dependency Bone marrow/stem cell transplants Cardiothoracic surgery Change in baseline breath sounds Change in baseline chest radiograph Chronic obstructive pulmonary disease (COPD) Frequent or recurring pulmonary infection Solid-organ transplants (eg, heart, lung, kidney) Tracheostomy or microtracheostomy Impairments, Functional Limitations, or Disabilities Dyspnea at rest or with exertion Impaired airway clearance Impaired cough Impaired gas exchange Impaired ventilatory forces and flow Impaired ventilatory volumes Inability to perform self-care due to dyspnea Inability to perform work tasks due to dyspnea Pattern C: Airway Clearance Ther Ex Aerobic capacity/endurance conditioning or reconditioning activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time Body mechanics, ergonomics, and postural stabilization Posture awareness training Postural control training Flexibility exercises Muscle lengthening Range of motion Stretching Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Pattern C: Airway Clearance Ther Ex Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric,and plyometric – using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices) Aquatic programs Standardized, programmatic, complementary exercise approaches Task-specific performance training Balance and coordination training Developmental activities Neuromuscular relaxation, inhibition, and facilitation Pattern D: CV Pump Dysfunction Inclusion Criteria Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition) Angioplasty Atrioventricular block Cardiomyopathy Cardiothoracic surgery Complex ventricular arrhythmias Complicated MI (failure); uncomplicated MI (dysfunction) Coronary artery disease Decrease in ejection fraction (EF) on exercise testing (EF of 30-50% with dysfunction; < 30% with failure) Diabetes Hypertensive heart disease Valvular heart disease Impairments, Functional Limitations, or Disabilities Abnormal heart rate response to increased oxygen demand Abnormal pulmonary response to increased oxygen demand Decreased ability or the inability to perform activities of daily living (ADL) because of symptoms Change in baseline breath sounds with activity Flat or falling blood pressure response to increased oxygen demand (failure) Pattern D: CV Pump Dysfunction Ther Ex Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time Balance, coordination, and agility training Developmental activities training Motor function (motor control and motor learning) training or retraining Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches Task-specific performance training Breathing exercises Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural awareness training Flexibility exercises Muscle lengthening Range of motion Stretching Pattern D: CV Pump Dysfunction Ther Ex Gait and locomotion training Developmental activities training Gait training Implement and device training Standardized, programmatic, complementary exercise approaches Wheelchair training Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Strength, power, and endurance training Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices ) Standardized, programmatic, complementary exercise approaches Task-specific performance training Pattern E: Resp Pump Dysfunction Inclusion Criteria Risk Factors or Consequences of Pathology Elevated diaphragm and volume loss on chest radiograph Neuromuscular disorders Partial or complete diaphragmatic paralysis Poliomyelitis Pulmonary fibrosis Restrictive lung disease Severe kyphoscoliosis Spinal cord injury Impairments, Functional Limitations, or Disabilities Abnormal or adventitious breath sounds Abnormal increased respiratory rate and decreased tidal volume at rest Airway clearance dysfunction secondary to ventilatory pump impairment Decreased to severely impaired strength and endurance of ventilatory muscles Dyspnea with self-care Dyspnea with work tasks Dys-synchronous or paradoxical breathing at rest or with activity Pattern E: Resp Pump Dysfunction Ther Ex Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Movement efficiency and energy conservation training Increased workload over time Balance, coordination, and agility training Developmental activities training Motor function (motor control and motor learning) training or retraining Neuromuscular education or reeducation Standardized, programmatic, complementary exercise approaches Task-specific performance training Breathing exercises Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural stabilization activities Postural awareness training Flexibility exercises Muscle lengthening Range of motion Stretching Pattern E: Resp Pump Dysfunction Ther Ex Gait and locomotion training Developmental activities training Gait training Implement and device training Perceptual training Standardized, programmatic, complementary exercise approaches Wheelchair training Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics Standardized, programmatic, complementary exercise approaches Task-specific performance training Pattern F: Respiratory Failure Inclusion Criteria Risk Factors or Consequences of Pathology Adult respiratory distress syndrome Abnormal alveolar to arterial oxygen tension differences Cardiothoracic surgery Chronic obstructive pulmonary disease (COPD) Multisystem failure Pneumonia Pre- and post-lung transplant or rejection Rapid rise in arterial carbon dioxide at rest or with activity Sepsis Thoracic or multisystem trauma Impairments, Functional Limitations, or Disabilities Abnormal or adventitious breath sounds Abnormal vital capacity Airway clearance dysfunction Dyspnea at rest Dyssynchronous or paradoxical breathing pattern Impaired gas exchange Pattern F: Respiratory Failure Ther Ex Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics Aquatic programs Gait and locomotion training - Walking and wheelchair propulsion programs Movement efficiency and energy conservation training Increased workload over time Balance, coordination, and agility training Neuromuscular education or reeducation Posture awareness training Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural awareness training Flexibility exercises Muscle lengthening Range of motion Stretching Pattern F: Respiratory Failure Ther Ex Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices ) Task-specific performance training Therapeutic Exercise Aerobic capacity/endurance conditioning or reconditioning Aquatic programs Gait and locomotion training – Walk or W/C Increased workload over time Movement efficiency and energy conservation training Aerobic Capacity/Endurance Conditioning or Reconditioning Activity, specific set up, time Improve oxygen demand Use of large muscle groups in a rhythmic fashion, over time Mode Marching, Walking, Bike, Gardening Intensity Max HR and take age adjusted 50-70% depending on exercise test, age Frequency 4-5 days per week Duration 5-10 min bouts 3x/day For Progression, DeTurkmin & Cahalin, 447 & 448, Figs 15-7 & 15-8 Work upsee to 30-40 in one pg session Aerobic Capacity/Endurance -Evidence Patient Education on Risk or Disease Exercise, Diet Deconditioning Rate of VO2 max decreases greatest the first week of bedrest1 Longer the bedrest the more diminished the VO2 max1 Use of HR, RPE, and METs 1 Convertinao VA, Med Sci Sports Exer, 1997:29:191 Aerobic Capacity/Endurance -Evidence Group-based (8-12 patients) simple aerobic dance movements (with music) 2 days a week for 4 months Each session lasted 50 minutes (including warm-up and cool-down), followed by 15-30 minutes of counseling The exercise program included three intervals of high intensity, during which patients were encouraged to reach 15-18 on the Borg scale for 5-10 minutes. 6 min walk, resistance on bike, bike time, MN Living with Heart Failure QOL all increased with significance as compared to the control group for 4 and 12 mn. Nilsson et al, Long-term effects of a group based high intensity aerobic interval training program in patients with chronic heart failure, Am J Cardiol 2008; 102(9):1220-1224 Therapeutic Exercise Balance, coordination, and agility training Developmental activities training Posture awareness training Standardized, programmatic, complementary exercise approaches Task-specific performance training Balance, Coordination, and Agility Training Mode Massery Technique Intensity Duration Frequency No set parameters Balance - Evidence Sensory-specific balance classes were held 3 times per week, for 1 hour each session, over 8-week Tasks included standing or walking on various support surfaces, such as a rocker board, foam, or narrow beam Standing in a tandem position, a semitandem position, on one leg, or in a feet together Progressions to these tasks included simultaneous alterations of visual and vestibular inputs Instructed to close their eyes, to engage vision with a reading or tracking secondary task Perform balance tasks with a distracting background Instructed to tilt their head backward or to quickly move their head side to side and up and down. Results Less destabilization within the first 5 seconds following vibration with or without a secondary task than there was at baseline or in the falls prevention education group Training effects were not maintained at the 8-week follow-up. Westlake & Culham. Sensory-Specific Balance Training in Older Adults: Effect on Proprioceptive Reintegration and Cognitive Demands Physical Therapy. Oct 2007. Vol. 87, Iss. 10; p. 1274 Therapeutic Exercise Body mechanics and postural stabilization Body mechanics training Postural control training Postural stabilization activities Posture awareness training Body Mechanics and Postural Stabilization Mode Intensity Duration Frequency No set parameters Body Mechanics -Evidence Perfusion study in prone and supine Pts were under conditions of Normal breathing of room air Unassisted breathing of 45% O2 Assisted PEEP Ventral, Middle, Dorsal measurements with ventral more perfuse in prone and dorsal more perfuse in supine Suki et al, Perfusion, Science Letter. Atlanta: Mar 25, 2008. pg. 2580 Body Mechanics -Evidence Pt with ischemia of stable and unstable angina Valsalva and measured QT of EKG With valsalsa showed significant difference of EKG changes of QT segment Authors related to carrying or lifting restrictions of heavy objects with CAD Balbay et al, Effects of valsalva maneuver on QT dispersion in patients with ischemic heart...Angiology; Nov 2001; 52, 11 Therapeutic Exercise Flexibility exercises Improve motion of the chest wall, lengthen anterior chest wall, improve hip and knee flexor shortening Muscle lengthening Range of motion Stretching Flexibility Exercises Mode Isolate muscle or limited joint Intensity After warmup Duration Hold with no pain for 30 sec Frequency 3-5 days/week Flexibility - Evidence Pt with ankylosing spondylosis 3x/wk for 3 months 18 stretching exercises of entire spine and extremities along with aerobic and chest expansion exercises Significant improvement in cervical and thoracic spine movement AND chest expansion Ince et al , Effects of a Multimodal Exercise Program for People With Ankylosing Spondylitis, Physical Therapy; Jul 2006; 86, 7 Therapeutic Exercise Gait and locomotion training Developmental activities training Gait training Implement and device training Standardized, programmatic, complementary exercise approaches Gait and Locomotion Training Mode Intensity Duration Frequency No set parameters Gait and Locomotion - Evidence See aerobic exercise Massery Pairing Massery et al, Coordinating transitional movements and breathing in patients with neuromotor dysfunction, NDTA Network, Nov/Dec 1996 Gait and Locomotion - Evidence Case Report of pt with C6 tetraplegia Taught breathing strategy and reducing valsalva with tasks with w/c Lean forward Put foot on footplate Posterior lean for pressure relief Able to perform tasks with new breathing strategies Henderson, Application of Ventilatory Strategies to Enhance Functional Activities for an...Journal of Neurologic Physical Therapy; Jun 2005; 29, 2 Therapeutic Exercise Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise approaches Relaxation Mode Intensity Duration Frequency No set parameters Relaxation -Evidence Five 60 minute individual treatments with the Papworth method from a respiratory physiotherapist No significant differences were found between the groups at baseline SGRQ Symptom mean scores were lower in the Papworth method group than in the control group after treatment and at 12 months The Nijmegen and HADS scores were also significantly lower in the intervention group than in the control group Objective respiratory measures did not differ significantly across the groups, apart from breathing rate. Holloway and West, Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial , Thorax 2007; 62(12): 1039-1042 Therapeutic Exercise Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles More efficient motion Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric) Aquatic programs Standardized, programmatic, complementary exercise approaches Task-specific performance training Strength, Power, and Endurance Training for Trunk, Extremities and Ventilatory Muscles Mode AAROM, AROM Resistance Manual Weights Intensity Incorporate breathing with resistance Resistance may start light and work up 8-12 reps, 1-3 sets Resistance of 1 rep max and then calculate 8-10 reps at 70% of max, 6 reps at 80% of max, 4 reps at 90% of max, 2 reps at 95% max and finally 1 rep at max High weight, low reps for strength Low weight, high reps for endurance Duration Frequency Every other day or rotate muscle groups Strength - Evidence Systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (413 years of age) (2) an IMT group was compared to a sham IMT, no intervention or other intervention group (3) the study used a randomized controlled trial or cross-over design (4) it was published Results: The search strategy yielded 36 articles Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) No difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength One study demonstrated improvement in inspiratory muscle endurance. Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear Reid et al, Effects of inspiratory muscle training in cystic fibrosis: a systematic review, Clinical Rehabilitation. London: Oct 2008. Vol. 22, Iss. 10-11 Goals and Outcomes Impact on Pathology Atelectasis Joint swelling, inflammation, restriction Nutrient delivery Osteogenic effects of exercise Pain Physiological response Soft tissue swelling, inflammation, restriction Increased oxygen demand symptoms Tissue perfusion and oxygenation Goals and Outcomes Impact on Impairments Aerobic capacity is increased. Airway clearance is improved. Balance is improved. Endurance is increased. Energy expenditure per unit of work is decreased. Gait, locomotion, and balance are improved. Integumentary integrity is improved. Joint integrity and mobility are improved. Motor function (motor control and motor learning) is improved. Muscle performance (strength, power, and endurance) is increased. Postural control is improved. Quality and quantity of movement between and across body segments are improved. Range of motion is improved. Relaxation is increased. Sensory awareness is increased. Ventilation and respiration/gas exchange are improved. Weight-bearing status is improved. Work of breathing is decreased Goals and Outcomes Impact on Functional Limitations and Disabilities Functional Limitations Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved. Level of supervision required for task performance is decreased. Performance of and independence in ADL and IADL with or without devices and equipment are increased. Tolerance of positions and activities is increased. Impact on disabilities Ability to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved. Goals and Outcomes Risk Reduction/Prevention Health, Wellness, and Fitness Risk Reduction/Prevention Preoperative and postoperative complications are reduced. Risk factors are reduced. Risk of recurrence of condition is reduced. Risk of secondary impairment is reduced. Safety is improved. Self-management of symptoms is improved. Impact on Health, Wellness, and Fitness Fitness is improved. Health status is improved. Physical capacity is increased. Physical function is improved. Goals and Outcomes Impact on Societal Resources & Patient Satisfaction Societal Resources Utilization of physical therapy services is optimized. Utilization of physical therapy services results in efficient use of health care dollars. Patient/client Satisfaction Access, availability, and services provided are acceptable to patient/client. Administrative management of practice is acceptable to patient/client. Clinical proficiency of physical therapist is acceptable to patient/client. Coordination of care is acceptable to patient/client. Cost of health care services is decreased. Intensity of care is decreased. Interpersonal skills of physical therapist are acceptable to patient/client, family, and significant others. Sense of well-being is improved. Stressors are decreased.
