Final Flashcards
(158 cards)
1
Q
What are the 4 parts of pre-screening?
A
- Informed consent
- Patient history
- Exercise preparticipation health screening
- Cardiovascular (CV) Risk Factor Analysis
1
Q
What are the 6 components of patient history?
A
- Characteristics
- Relevant medical Hx
- Current state
- Current physical activity
- Current blood work
- Health behaviours
2
Q
What is light, moderate and vigorous intensity?
A
Light intensity – 30-39% heart rate reserve (HRR) or VO2 reserve (VO2R), RPE 9-11
Moderate intensity – 40-59% HRR or VO2R, RPE 12-13
fVigorous intensity – greater or equal to 60% HRR or VO2R, RPE greater or equal to 14
3
Q
What is the CV risk stratification?
A
Low = asymptomatic or equal or less than 2 risk factors
Moderate = asymptomatic or greater or equal to 2 risk factors
- Depending on what symptoms are might get medical clearance
High = symptomatic, known CV, metabolic or renal disease
- Need medical clearance first
4
Q
What is the criteria for the age risk factor?
A
Men 45 and older
Women 55 and older
5
Q
What is the criteria for the family history risk factor?
A
Myocardial infarction, coronary revascularization or sudden death before 55 in father or other male first degree relative or before 65 in mother or other female first degree relative.
6
Q
What is the criteria for the cigarette smoking risk factor?
A
Current or quit in the last 6 months or exposure to environmental tobacco.
7
Q
What is the criteria for the physical inactivity risk factor?
A
Not meeting the minimum of 500-1000 MET min of mod/vig or 75-150 min/week of mod to vig
8
Q
What is the criteria for the BMI/waist circumference risk factor?
A
BMI of 30 or higher or waist girth of >102cm for men and > 88cm for women
9
Q
What is the criteria for the BP risk factor?
A
Systolic of 140 or higher and/or diastolic of 90 or higher based on an average of 2 or more readings on 2 or more occasions or on antihypertensive medications.
10
Q
What is the criteria for the lipids risk factor?
A
LDL-C - greater or equal to 130mg (3.37 mmol/L) or HDL-C less than 40mg (1.04mmol/L) in men and les than 50mg (1.30mmol/L) in women or non-HDLC less than 130 (3.37mmol/L) or on lipid-lowering medication.
If total serum cholesterol is all that is available use more than 200mg (5.18mmol/L).
11
Q
What is the criteria for the blood glucose risk factor?
A
Fasting plasma glucose equal or greater than 100mg (5.5mmol/L) or 2 hour plasma glucose values in oral glucose tolerance test (OGTT) greater or equal to 140mg (7.77mmol/L) or HbA1C greater or equal to 5.7%
12
Q
What is the negative risk factor and its cuttoff value?
A
HDL-C
greater or equal to 60mg (1.55mmol).
13
Q
What are the normal BP ranges?
A
- Systolic (SBP): 100-140 mmHg
- Diastolic (DBP): 60-90 mmHg
Hyper is above and hypo is below!
14
Q
What is fat free mass made of?
A
Water
Protein
Minerals
Muscle
Bone
15
Q
What is essential fat and how much should we have?
A
- Essential Fat - found in the heart, lungs, liver, spleen, kidneys, intestines, muscles, etc.
- Required for normal physiological functioning
- Males – 3-5%
- Females – 8-12% (5-9% is sex-specific)
Within the cells
Women have a lot more essential than men but also have more body fat in general even though they have a lower body mass.
16
Q
What is storage fat?
A
Adipose tissue
* Subcutaneous (stored just beneath skin)
* Visceral (stored deep in the body; surrounds organs)
17
Q
How lean is too lean?
A
- Males – below 3%
- Females – below 8-12%
Those values are based on your essential fat %. Can’t lose essential fat as physiological processes stop working. In females the cycle stops.
18
Q
What are the BMI categories and the risk of developing health problems?
A
<18.5 = underweight - elevated risk
18.5-24.9 = healthy weight - average
25-30 = overweight = elevated
30-34.9 = obese class 1 = high
35-39.9 = obese class 2 = very high
> 40 = obese class 3 = extremely high
19
Q
What is gyroid and android obesity?
A
Gynoid Obesity:
- fat distributed around the hips and thighs
Android Obesity:
- fat distributed around the trunk (specifically waist)
20
Q
What are the obesity waist girth cutoffs?
A
Males: > 102 cm
Females: > 88 cm
21
Q
What are the obesity waist/hip ratios?
A
Males: > 0.95 cm
Females: > 0.85 cm
- Waist girth obesity might better describe android and waist/hip might better describe gynoid
22
Q
What are the waist circumference risk categories for women?
A
Very low = <70
Low = 70-89
High = 90-109
Very high = >110
23
Q
What are the waist circumference risk categories for men?
A
Very low = <80
Low = 80-99
High = 100-120
Very high = >120
24
Where can you take waist circumference?
With individual standing, arms at sides, feet together, and abdomen relaxed, take a horizontal measure at the narrowest part of waist (below xiphoid process and above umbilicus) ***(ACSM recommended, we will use this approach in this course)
Is a horizontal measure directly above the iliac crest (WHO and NIH recommended)
25
Where do you take hip circumference?
At the maximal girth of the gluteals. Participants will be standing, with feet slight apart (~10 cm) and weight evenly distributed between legs.
26
What fat is skin folds looking at?
Measuring subcutaneous fat as an indicator of overall body fat percentage
27
When do we need to take duplicate skin fold measures?
Take duplicate measures and re-take if not within similar range (0.4-2 mm depending on caliper model)
28
What are the 7 skin fold sites and where we take them?
Triceps - Vertical fold; posterior midline, at half way point between acromion and olecranon process with arm freely at side of the body. Halfway between boney part of shoulder and elbow
Sub-scapular - Diagonal fold (45 degree angle); 1-2 cm below inferior angle of scapula
Chest/Pectorals -
Diagonal fold; half the distance from axillary fold and nipple (men), a third of the distance from axillary fold and nipple (women)
Midaxillary - Vertical fold; mid-axillary line at level of xiphoid process
Abdominal - Vertical fold; 2 cm to right side of umbilicus
Suprailliac - Diagonal fold (in-line with natural fold); axillary line immediately superior to the iliac crest
- Right above boney part of hip
Thigh - Vertical fold; anterior midline of thigh, midway between proximal border of patella and the inguinal crease (hip)
29
How does BIA work?
Current travels faster through fat-free mass compared to fat mass
* Considerations:
o Hydration
o Skin temperature
o Previous physical activity
o Previous food and beverage intake
* With BIA want to be fully hydrated
Electrodes on hands and feet!
30
What is the FMS scale?
o 3 – can perform without compensation
o 2 – can perform with compensation/imperfection
o 1 – cannot perform
o 0 – there is pain (assess or refer)
31
Mobility vs stability
* Mobility: Freedom of movement surrounding a joint.
* Stability: Ability to control force and movement.
o Stabilizers must always contract in order for mobilizers to move with efficiency
32
What joints are mobile vs stable?
* Joints alternate between mobility and stability
* Dysfunctions at one joint usually show up as pain in the joint above or below
Ankle = mobility (sagittal)
Knee = stability
Hip = mobility
Lumbar spine = stability
Thoracic spine = mobility
Scapula = Stability
GH joint = mobility
* Wrist is mobility – elbow is stability
* Every joint needs both – but have primary needs
33
What are the 7 movements of the FMS?
1. Deep squat
2. Active SLR
3. Hurdle step
4. Lunge
5. Trunk stability push up
6. Rotary stability
7. Shoulder mobility
34
What is the scoring on a deep squat?
3 = upper torso is parallel with tibia or toward vertical, femur below horizontal, knees are aligned over feet, dowel aligned over feet
2 = upper torso is parallel with tibia or toward vertical, femur below horizontal, knees are aligned over feet, dowel aligned over feet, heels are elevated
1 = tibia and upper torso are not parallel, femur is not below horizontal, knees are not aligned over feet, lumbar flexion is noted
35
What is the active SLR scoring?
3 = vertical line of the malleolus resides between mid-thigh and ASIS. The non-moving limb remains in neutral
2. vertical line of the malleolus resides between mid-thigh and joint line. The non-moving limb remains in neutral
1. Vertical line of the malleolus resides below joint line. The non-moving limb stays in neutral.
36
What is the hurdle step scoring?
3 = hips, knees and ankles remain aligned in the sagittal plane. Minimal to no movement in lumbar spine. Dowel and hurdle remain parallel.
2= Alignment is lost between hips, knees and ankles. Movement is noted in lumbar spine. Dowel and hurdle don't remain parallel.
1= Contact between foot and hurdle occurs. Loss of balance is noted.
37
How is the inline lunge scored?
3 = down contacts maintained (head, t-spine, sacrum), dowel remains vertical, no torso movement. Dowel and feet remain in sagittal plane, knee touches board behind heel of front foot.
2= Dowel contacts not maintained, dowel doesn't remain vertical, movement noted in torso. Dowel and feet do not remain in sagittal plane. Knee does not touch behind heel of front foot.
1= Loss of balance is noted or not touching back knee to ground.
38
How are trunk stability push ups scored?
Hands placed shoulder width apart, males-thumbs at level of top of forehead, females-thumbs at level of chin
3= The body lifts as a unit with no lag in the spine. Men perform a rep with thumbs aligned with top of head and women perform a rep with thumbs aligned with the chin
2= The body lifts as a unit with no lag in the spine. Men perform with thumbs at chin and women with thumbs at clavicle
1 = men are unable to perform a rep with hands aligned with chin, women unable to with thumbs aligned with clavicle.
39
What is the push up clearing test?
Spinal extension (cobra)
40
What is the squat cleaning test?
Toe touch
41
What Is the rotary stability clearing test?
Childs pose - spinal flexion
42
How is rotary stability scored?
3 = performs a correct unilateral movement
2 = performs a correct diagonal movement
1 = inability to perform a diagonal movement.
43
What is the shoulder mobility clearing test?
Shoulder touch - bilateral - shoulder impingement
44
Shoulder mobility scoring
3 = fists are within one hand length
2= fists are within 1 and a half hand lengths
1 = fists are not within one and a half hand lengths
One arm is abducted and internally rotated, the other is adduction and external
45
Where does HR strap go?
* Straps are placed at level of xiphoid process with sensors on anterior chest wall
o Measures R-waves to calculate HR
46
Where do 3 lead ECG electrodes go?
* Right arm (RA) – The base of the right shoulder against the deltoid border about 2cm below the clavicle but above border of the pectoralis
* Left Arm (LA) – The base of the left shoulder against the deltoid border about 2cm below the clavicle but above border of the pectoralis
* Left Leg (LL) – Left anterior axillary and ~ 8-10th rib (higher orientation helps for better R wave for HR calculation)
47
What are the measurements of an ECG square?
Y axis is 0.5mV or 5mm
X axis is 0.20 seconds
Small box
Y is 1mm or 0.1mV
X is 0.04 seconds
48
What are the 3 ways to calculate HR off an ECG strip?
1. Divide 1500 by # of small squares between two R-waves (most accurate)
2. Divide 300 by # of large squares between R waves
3. Count number of R waves over 10 s and multiple by 6
49
What are the cutoffs for Brady and tachy cardia?
* ≥ 100 b∙min-1= tachycardia
* ≤ 60 b∙min-1 = bradycardia
* 60 – 100 b∙min-1 = normal sinus rhythm
50
What are the relative BP cutoffs for exercise?
o SBP ≥ 250 mmHg
o DBP ≥ 115 mmHg
51
What are abnormal BP responses during exercise?
o Drop in SBP by > 10 mmHg despite increase in workload
o SBP < 10 mmHg of pre-exercise level during exercise
o DBP > 10 mmHg of pre-exercise level during exercise
52
What is rate pressure product?
* Reflects the relative changes in the workload placed on the heart during exercise and other forms of stress
* Surrogate for myocardial oxygen uptake
* Rate pressure product mmHg.b.m-1 = HR (b.m-1) x (SBP) mmHg
* Normal range: 25,000 to 40,000 mmHg∙b∙min-1
53
What are some key points from the Ebbeling test?
1. Collect basic data (age, height, mass, sex), estimate age predicted HRmax (220-age), calculate 50% and 70% of HRmax.
3. Have patient/client warm up by walking for 4 min at 0% grade at speed that brings HR between 50% - 70% HRmax (recommended 2 - 4.5 MPH). If HR not within range in first minute, adjust speed accordingly.
4. After warmup, increase grade to 5% (speed stays the same). Collect HR, BP, and RPE between mins 2-4 of this stage.
a. To achieve steady state HR, HR from last 2 min must not differ by more than 5 bpm. If difference greater than 5 bpm, extend test by additional minute and record the SS HR from the new final 2 min.
5. Allow the patient to cool down at a slow walk and 0% grade for 5 min. Collect HR, BP, and RPE at minutes 2 and 4.
54
What are some key points of the PWC170 test?
The 170 is HR which is 85% of 200 predicted max.
4. Have the patient/client warm up for 2-min at workload of 0.5 kp at cadence of 60 rpm (30 W).
5. Following warmup, patient/client will perform 3 stages over 12 minutes
a. Stage 1: Minutes 0-4; aim for a workload to achieve HR of 115 to 130 b∙min-1 (e.g. 0.75 to 1.5 kp or 45-90 W)
b. Stage 2: Minutes 4-8; aim for workload to achieve HR of 140 to 155 b∙min-1 (e.g. 1.5 to 2.5 kp or 90-150 W)
c. Stage 3: Minutes 8-12; aim for workload to achieve HR of 160 to 180 b∙min-1 (e.g. 2.0 to 3.0 kp or 120-180 W)
6. Record HR, BP, and ratings of perceived exertion (RPE) in last minute of each stage.
7. Following test, provide 2-min of active cooldown followed by 3-min passive rest on cycle ergometer.
Note: Adapted target heart rate zones based on 85% of age predicted max
Data can be analyzed using the Nomogram or slope methods
55
How do you convert absolute VO2 to relative?
Absolute X 1000 / body mass (kg)
56
When does SV plateau?
40-60% VO2 max
CO also has that break in the line
57
What are the known concentrations in room air?
Oxygen = 20.93%
CO2 = 0.03-0.04%
58
What is the direct Fick equation?
VO2 = Q(CaO2 - CvO2)
Q= cardiac output
CaO2 = arterial oxygen
CvO2 = venous oxygen
59
What is the Indirect Fick equation rearranged to use met cart data?
VO2 = Ve (FiO2 - FeO2)
Ve = ventilation (L/min)
FiO2 = ambient O2 (20.93%)
FeO2 = Expired air
Can do this with VCO2 values as well!
60
What is RER?
VCO2/VO2
Where a ratio of 0.7 equates to metabolism primarily from fat oxidation, and ≥ 1.00 equates to metabolism primarily from carbohydrates and glycogen.
61
What are the calibration values of the met cart?
o Oxygen % → Calibrate gas to room air (high) and calibration gas (low, ~15-16%)
o Carbon Dioxide % → Calibrate gas to room air (low) and calibration gas (high, ~4-5%)
62
What are the key points of the CSEP treadmill VO2 test?
* General guidelines are females perform test at 7.0 mph and males 8.0 mph
o Adjust speed based on comfort. 5 km race pace is generally the target pace
* Incline starts at 0% and increases by 2% every 2 minutes.
9. Lower the speed to 2-3 mph and incline to 0% and perform at least 5 minute cooldown.
10. Collect metabolic and heart rate data every minute. Collect blood pressure and RPE every two minutes.
63
What are the general indications for stopping an exercise test?
- Onset of engine or angina-like symptoms
- Drop in SSBP greater or equal to 10 with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing
- Excessive rise in BP: SBP >250 and/or DBP > 115
- Shortness of breath, wheezing, leg cramps, or claudication
- Signs of poor perfusion: light headedness, confusion, ataxia, pallor, cyanosis, nausea, cold and clammy skin
- Failure of HR to increase with increased exercise intensity
- Noticeable change in heart rhythm by palpation or auscultation
- Individual requests to stop
- Physical or verbal manifestations of severe fatigue
- Failure of testing equipment
64
How can you confirm VO2 max was reached?
For a test to be considered to have measured V ̇O_2 max, 2 of the 4 following criteria need to be met:
Plateau in V ̇O_2 (≤ 150 mL∙min-1/ ≤ 0.150 L∙min-1) despite increase in workload
Heart rate in final stage is no more than 10 beats∙min-1 below age predicted max heart rate
RER ≥ 1.10 in final stage
RPE ≥ 17 on 6-20 Borg RPE Scale
65
How much can training increase VO2 max?
Training can increase VO2 max by 6 to 25%. More aerobically trained better VO2 max
66
What is the protocol for the modified WHO50 test?
2. Set up participant on bike, and instruct to begin 5 minute warmup at 60W (we will be using the weight-loaded ergometers in lab). Remember that 60W = 1kg weight at 60rpm.The weight tray is 1kg, so warmup is conducted “unloaded”.
4. Participant will exercise at a workload that increases by 25W/min until volitional cessation. If participant is athletic, increase workload by 50W/min.
5. Participant will then perform an unloaded (60W) cooldown for 5 minutes.
- We are going to do 30 watts (half a kg) each time.
- If more athletic can increase by 60 watts at a time.
- in cooldown – if you need to slow down RPM that is okay
- Make sure you stay close to 60 RPM for the test
67
What 6 things is an ECG used to measure?
1. Rate
2. Rhythm
3. Axis
4. Rotation
5. Hypertrophy
6. Infarction
68
What are the types of leads?
* Bipolar Leads (Limb Leads)
o Leads: I, II, III from RA, LA, and LL
o Looks in ‘vertical’ plane
* Augmented Unipolar Leads (Limb Leads)
o Leads: aVF, aVR, aVL from RA, LA, RL, LL
o Looks in ‘vertical’ place
* Precordial (Chest) Leads
o Leads: V1, V2, V3, V4, V5, V6
o Looks in horizontal plane
69
When looking at leads how are you viewing them?
If looking at someone’s heart, you are standing at the positive end and looking towards the negative direction.
70
What is Einthoven's triangle?
Looking at bipolar limb leads
- Right shoulder always negative
- Left leg is always positive
- Left shoulder is positive in lead 1 but negative in lead 3
Lead 1 is top one
Lead 2 is right side of heart (left side of triangle)
71
What are the 3 augmented unipolar leads?
Wilson's Triangle
Imaginary negative point in centre of Einthoven's triangle.
Get aVR, aVL and aVF.
- Imagine a random spot in center of heart usually this is AV node. From here you project 3 diff unipolar leads outward, and this is how you get the 3 different angles. Assuming the central position is negative b/c you want to look into the heart (your eyes are at pos end). Go from seeing heart every 60 degrees to every 30 (180/6). Every 30 degrees you can see a view of the heart.
- Named after which side you’re ‘looking’ from
- Fake circle in the middle of the heart is negative so all the unipolar leads looking in are positive.
72
Explain the horizontal chest leads
V1-V6
- V1 & V2: orient over right Sid of heart
- V3 & V4: orient over inter ventricular septum
- V5 & V6: orient over left side of heart
- Also using the dot in the center. Imagine that to be negative and leads 1-6 leads are positive.
- Looks at horizontal plane
73
What leads show you a right ventricle view?
V1, avR
74
What leads show you a left ventricle view?
V5, V6, 1, avL
75
What leads show you an inferior view?
2, 3, avF
76
What leads show you an anterior view?
V2, V3, V4
77
How can lead 2 tell us if there is a bundle branch block?
- Bundle branch blocks – when you have your AV node the depol goes down the bundle branches to get to lower heart – if there is a block it takes longer to get the depol to the bottom. Looking to see if there is a slowdown in rate between the left and right ventricle – this could be indicative of a bundle branch block and this can be seen during a stress test. Lead 2 is arguably the most important lead to look at during a clinical test – this is b/c V2 basically goes through both the SA and AV node. If there is a block in both branches, then will see a longer interval between the P and QRS complex in both leads. If time is increased from ‘standards’ then there is something wrong – could be blockage from SA to AV node or there is a block further down and it’s bundle branches. If it’s 1st degree block (blocks from SA to AV) would see different heart rates.
o B/c ventricles do have a low heart rate that would be shown
78
Where do we landmark limb leads?
* Right arm (RA) – The base of the right shoulder against the deltoid border about 2cm below the clavicle but above border of the pectoralis.
* Left Arm (LA) – The base of the left shoulder against the deltoid border about 2cm below the clavicle but above border of the pectoralis.
* Right Leg (RL) – Right anterior axillary line halfway between costal margin of the illiac crest.
* Left Leg (LL) – Left anterior axillary line halfway between costal margin of the iliac crest.
o Just above hip bone
79
Where do we landmark chest leads?
* V1 - Fourth intercostal space, right sternal border.
* V2 - Fourth intercostal space, left sternal border.
* V3 - Midway between V2 and V4.
* V4 - Fifth intercostal space, left midclavicular line.
* V5 - Level with V4, left anterior axillary line.
* V6 - Level with V4, left mid axillary line.
80
What is the cutoff for a wide or narrow QRS complex?
Narrow < 0.12s or 3 small boxes
Wide > 0.12s or 3 small boxes
81
What are Premature Atrial Contractions (PACs)?
* PACs are common and occur by an early beat arising somewhere in the atria other than the SA node
* Typically left untreated:
o Can lead to atrial flutter or atrial fibrillation
* PACs interrupt the SA node or conduction of the AV node may be blocked
* Have a different shape from other p-wave (contour) or timing is too early
- Have a random heart beat originating in the atria in a part that isn’t he SA node
- Can have the start of the P wave at the SA node and then another one right away. Might have it preceding normal p wave so that will increase HR.
- Looking for hitched p wave or two little bumps back to back.
- Atrial fibrillations quivering of the atria – is when you have a bunch of PAC’s in a row that are consistent and don’t stop. This is survivable it’s ventricular fibrillation that is more problematic.
- Atria is only responsible for 15-20% of blood flow so not as big of a deal.
82
What ways might a PAC appear on an ECG?
1. Premature P wave immediately after t wave
2. PAC that notches the T wave - it's a P wave but doesn't get conducted to ventricles, which creates a 'skipped' beat, since ventricles don't contract
3. PACs every 2nd bear or bigeminal
83
What is an Atrioventricular Blocks (AV Blocks)?
* P-R interval over 0.2 seconds (1 large square)
* Indicates either conduction not moving from SA to AV node. Or ischemia of right coronary artery which supplies AV node
* 2nd and 3rd degree (worst case) are absolute contraindications to stopping test
84
Explain the degrees of an AV block
1st degree – just extends the interval between p wave and r wave – slow conduction delayed conduction between SA and AV node. A lot of time between p and QRS. Least serious one. Delay in conduction to delay in QRS
2nd:
- P wave to QRS is more than 1:1
- Subtypes include beat to beat lengthening of P-R internal until a skipped beat
3rd:
- No relationship between P waves and QRS waves. Work independently.
- – p waves and QRS waves are fairly evenly spaced out. Complete block – ventricular foci (after AV node that can propagate conduction) only fire at 20-40 beats per minute. SA node would be about 80 with no PSNS or SNS innervation. Should have double p waves. SA node signal does not get through.
85
What are the 2 type of atrial arrhythmias?
Premature Atrial Contractions (PACs)
Atrioventricular Blocks (AV Blocks)
86
What are the 4 types of ventricular arrhythmias?
1. Preventricular Contractions (PVCs)
2. Bundle Branch Blocks
3. Ventricular Tachycardia (V-Tach)
4. Ventricular Flutter and Ventricular Fibrillation
87
What is a Preventricular Contractions (PVCs)?
* PVCs occur when the myocytes in the ventricles initiate the heart contraction
* Wide QRS (> 100 ms)
* Common at rest and during exercise
o Odd ones here and there are no concern
* Bigeminy – PVCs every second heart beat
* Trigeminy – PVCs every third beat
* Couplet – Two PVCs in a row
* Triplet – Three PVCs in a row (ventricular tachycardia)
- QRS is wide – more than 0.1seconds more than 2.5 small boxes.
Indicative of ventricles not pumping properly during exercise if happening a lot. Ventricles aren’t pumping a sufficient amount of blood.
88
What is a Bundle Branch Block?
* Conduction is not spreading and causing a block to either the right bundle branch (RBBB) or left bundle branch (LBBB)
* Both have dyssynchronous ventricle depolarization with wide QRS (>120 ms, > 3 small boxes)
* Need to look at both right and left precordial leads (V1 and V2 for right side, V5 and V6 for left side)
- If you have a block in signal (goes through but slows down) will see it on ECG. One of the ventricles contracts at a later time compared to the other one. Can then have RBB or LBB.
- RBBB- V1 is primary one to look at. Will have two r waves – if double r wave is in V1 than RBBB b/c looking directly into right ventricle. V6 is deep and wide s wave
- LBBB look for notched r wave in V6
- Focus on V1 for RBBB and V6 for LBBB
89
What is Ventricular Tachycardia (V-Tach)?
* Three PVCs in a row or more is considered V-Tach
* Can be unstained (goes on a run or stops)
* Can be sustained (ongoing)
* Sustained is an absolute indicator to stop a stress test
* Can develop into ventricular flutter or ventricular fibrillation (emergency scenarios)
90
Explain ventricular flutter and fibrillation
Flutter = continuous large rhythmical ventricular waves
Fibrillation = continuous chaotic ventricular spikes
- Fibrillation – chaotic electrical signals – randomly pumping – looks like a toddler drew it
- Flutter has one foci, Fibrillation has multiple foci. Need a defibrillator and CPR
- Flutter might not be a shockable rhythm – large depol regions
Flutter heart might still be working
91
What leads do we look at for LVH?
o S-wave depth in lead VI
o R-wave height in V5 and V6 (tallest)
o Positive voltage criteria if voltage total is > 35mm
look at v1 and v5 – positive voltage criteria for LVH – look at the neg drop in 1 to the top of v5 if over 35 then this is hypertrophy
92
What can looking at ST segments tell us?
- Looking for infarctions – heart attack
- STEMI – ST elevated myocardial infarction
93
What are Arrhythmias – ST Segment Deviations?
* Changes in the ST segment can indicate existing heart attack or necrotic heart tissue (elevations) or ischemia or reduced coronary blood flow (depressions)
* Need to determine change based on the isoelectric line (to determine elevation or depression)
* Need to look at ST segment in relation to time based on J point
o J point represents juncture of last portion of QRS and start of ST wave
o Sometimes there is a notch at J point, called J point elevation
94
What is ST Segment Elevation?
* ST segment elevation represents early repolarization
o During exercise can be indicative of ischemia
o Occurs with recent ischemia, pericarditis, and electrolyte abnormalities
* Termed: ST segment elevation myocardial infarction (STEMI)
* > 1 mm (4 small boxes) from isoelectric line
* Absolute contraindication!
o without preexisting Q waves because of prior myocardial infarction (other than aVR, aVL, or V1)
95
What is ST Segment Depression?
* “Positive” stress test indicator
* Called non- ST segment elevation myocardial infarctions (non-STEMI)
* ST segment depression represents a narrowed coronary artery that is unable to adequately supply blood flow at increased workloads
* Depression of the J point and the slope past the J point (typically measured 80 ms after J point)
* Can also be caused by the drug digitalis
96
What are the 3 types of ST segment depression and the criteria?
Horizontal ST Segment Depression
0.2 mV/2 mm (2 small boxes) depression of all points of ST segment
Down-sloping ST Segment Depression
0.2 mV/2 mm (2 small boxes) depression 80 ms (2 boxes) past J point going downwards
Up-sloping ST Segment Depression
0.2 mV/2 mm (2 small boxes) depression at J point, but iso electric at 80 ms past J point
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What are the 4 reasons to use a stress test?
A clinical test used for:
1. Diagnosis – E.g., ischemic heart disease, arrythmia
2. Prognosis – E.g., Risk for adverse event
3. Capacity – E.g., Exercise capacity, BP response
4. Exercise Prescription – (e.g., following myocardial infarction)
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What are the absolute contraindication to stress testing?
*Acute myocardial infarction within 2 days
*Ongoing unstable angina
*Uncontrolled cardiac arrythmia with hemodynamic compromise
*Active endocarditis
*Symptomatic severe aortic stenosis
*Decompensated heart failure
*Acute pulmonary embolism, pulmonary infarction, or deep venous thrombosis
*Acute myocarditis or pericarditis
*Acute aortic dissection
*Physical disability making exercise testing unsafe
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What are the relative contraindications to stress testing?
*Known obstructive left main coronary artery stenosis
*Moderate to severe aortic stenosis with uncertain relationship to symptoms
*Tachyarrhythmias with uncontrolled ventricular rates
*Acquired advanced or complete heart block
*Recent stroke or transient ischemia attack
*Mental impairment with limited ability to cooperate
*Resting hypertension of > 200 mmHg SBP or > 110 DBP
*Uncorrected medical conditions such as significant anemia, electrolyte imbalance, hyperthyroidism
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What are the absolute indications meaning we must stop the stress test?
*ST Elevations (>1.0mm) in leads without preexisting Q waves because of prior myocardial infarction (other than aVR, aVL, or V1)
*↓ in SBP > 10 mmHg, despite increase in workload, and other signs of ischemia
*Moderate to severe angina (3-4/4)
*Central nervous system symptoms (e.g. ataxia, dizziness, near syncope)
*Signs of poor perfusion
*Sustained tachycardia or other arrythmia, including second or third degree AV block, that interferes with maintenance of normal cardiac output during exercise
*Technical difficulties monitoring ECG or BP
*Patient requests to stop
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What are relative indications for stopping a stress test?
*Marked ST displacement (horizontal or down sloping of >2mm, measured 60-80 ms after J point in an individual with suspected ischemia)
*↓ in SBP > 10 mmHg, despite increase in workload, and with absence of ischemia
*↑ chest pain, fatigue, shortness of breath, increases in claudication
*Arrhythmias other than sustained ventricular tachycardia, including multifocal ectopy, ventricular triplets, supraventricular tachycardia, and bradyarrhythmias that have the potential to become more complex or to interfere with hemodynamic stability
*Exaggerated hypertensive response (systolic blood pressure >250 mm Hg or diastolic blood pressure >115 mm Hg)
*Development of bundle-branch block that cannot be distinguished from ventricular tachycardia
*Oxygen saturation drops below 80%
- If you see ST displacement at high intensity exercise this could be normal if athletic population but if you think someone has a heart abnormality might decide to stop.
- Chest pain is seen with angina so use that scale. With atherosclerosis have high resting BP to begin with so a high BP might not be a reason to stop right away.
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What causes J point elevation and depression?
Elevation - Caused by infarction (heart attack), or myocarditis (inflammation of cardio myocytes it’s an injury).
Depression – J point is below isoelectric line. Caused by ischemia
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What is strength?
The ability of a muscle or group of muscles to generate muscular force; the ability to do work
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What is Maximal strength?
The ability to produce a maximal voluntary contractions against a resistance for one contraction.
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What is strength endurance?
The ability to effectively maintain sub maximal force for extended periods
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What is speed-strength (power)?
The ability to do work in a short period of time
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What is an isotonic contraction?
Change in muscle length
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1RM bench press protocol key points
3. Goal is to determine 1-RM within 4 trials with rest periods of 3 to 5 minutes between sets.
4. Select an initial weight that is within individuals perceived capacity (~50-70% of max). Perform 1-5 reps. All repetitions should be performed at same speed of movement and range of motion for consistency.
5. Progressively increase resistance 5-10% from previous successful attempt and perform 1 repetition each increase until individual cannot complete the selected repetition(s). May have to reduce weight if a lift was unsuccessful.
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How do you normalize 1RM?
Weight pressed/body mass in pounds. The higher the number the better
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What is the protocol for 1RM leg press?
3. Goal is to determine 1-RM within 4 trials with rest periods of 3 to 5 minutes between sets.
4. Select an initial weight that is within individuals perceived capacity (~50-70% of max). Perform 1-5 reps. All repetitions should be performed at same speed of movement and range of motion for consistency.
5. Progressively increase resistance 10-20% from previous successful attempt and perform 1 repetition each increase until individual cannot complete the selected repetition(s). May have to reduce weight if a lift was unsuccessful.
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How many reps for predictive 1MRM?
Aim to have client reach failure at a resistance of less than or equal to 10 reps. If more than 10 can be performed you will have to increase resistance.
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What are the average number of reps and approx % 1RM?
1 = 100
2 = 95
3 = 93
4 = 90
5 = 87
6 = 85
7 = 83
8 = 80
9 = 77
10 = 75
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What is the cutoff for hand grip?
Minimum cut off of 21 kg is the minimum grip strength needed for older adults. Adults close to this range are 8 times more likely to have strength related muscular injuries
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What is the arm curl protocol?
1. Client is seated in a chair with back straight and feet flat on the floor. Women use a 5 lbs dumbbell and men use an 8 lbs dumbbell in their dominant hand.
- Upper arm in contact with trunk the whole time.
* Count # of complete repetitions. If forearm is more than halfway up, then count as complete repetition.
For sit to stand If the client is more than halfway up, then count as complete repetition.
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What is power?
Muscular power is the rate of performing work
Power is calculated as:
Power=Force*Velocity
Force=Mass*Acceleration
Acceleration=Velocity/Time
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What causes DOMS?
Above anerobic threshold you have lactic acid build up – it’s generation of hydrogen ions and microtears responsible for DOMS not lactic acid.
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What is the pathway for age associated injury?
Muscle pathology = loss of motor units, change in fibre type, muscle fibre atrophy, reduced neuromuscular activation, slowed rate of activation.
Impairment = reduced velocity of movement, force, and subsequent power output
Functional limitation = prolonged chair rise and stair climb time
Disability = change in societal/environmental role
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How does training impact the power velocity curve?
- Lots of ways you can train – blue curve is standard. If someone is strength trained they maximize velocity at low velocity – fiber type goes to type 2x so get more force but fatigue quicker. At lower amounts of velocity will shift right. As you increase in velocity won’t be as much of an adaptation.
- Someone doing speed training – train the other end of that curve. Become more efficient in developing forces at higher velocities. Because training in that higher velocity you develop higher force at those velocities but aren’t improving force generation at lower velocity.
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Muscle Power and Aging study - Clarke 2010
* Compared muscular power during isokinetic knee extensions at 60, 90, 180 and 240 degrees/sec
o middle-aged (n=29, 40-55 yrs)
o older adult (n=28, 70-85 yrs)
o older adult mobility-limited (n=32, 70-85 yrs)
* Also normalized data to muscle cross sectional area (cm2)
- Isokinetic – joint is moving – concentric and eccentric – isokinetic = constant speed
- Doing knee extensions at various degrees per second so looking at speed.
- Trying to plot a force velocity curve.
- Loss of muscle/ less muscle mass contributes to reduced power and is part of the spectrum for mobility impairment.
- Power was most impaired at faster speeds which requires the most amount of muscular power.
- Left isn’t taking into account size of muscles – right is power generated per area.
- Healthy people had more generation in power as speed goes up – reduced in ppl who are older but healthy. Greater velocity the greater the reduction in power in those who are mobility limited.
- If you account for muscular atrophy in older population the muscle they do retain has the same general functionality. When you’re mobility limited the quality or functionality of that muscle has diminished in terms of specific muscles. Have atrophy in type 2 fibers.
o Muscle you do have is diminished
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What does jump testing measure?
* Jump testing is an indirect, reliable, and valid method to test lower body power
* Power output can be calculated if the mass and the vertical displacement is known.
- Can do vertical jump and horizontal distance.
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What is vertical displacement?
* Vertical displacement = jump height – starting height (if using vertec, tape)
* Vertical displacement = jump height if using jump mat or push systems
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What is the senior test for power?
8 foot up and go
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Push up endurance test key points
1. Patient/client will start lying prone on a mat. The male starting position is ‘down’ position and females in the ‘knee pushup’ position. (Note can alter based on skill).
a. Males: fingers forward and under shoulder, back straight, head up, toes are pivot points
b. Females: same as above, however, lower legs in contact with mat, ankles plantar flexed and knees are pivot points.
2. Patient/client must perform pushup by straitening the elbows and returning to the ‘down’ position. Individuals back must be straight at all times.
3. Maximal number (#) of pushups performed consecutively without rest is counted as score.
4. Test is stopped when the individual strains forcibly or is unable to maintain the appropriate technique within two repetitions.
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What requires you to stop a plank endurance test?
Two deviations in form warrant test termination. Correct form after first deviation.
a. Hip sag/elevation > 2 inches
b. Inability to maintain correct form
c. Pain (immediate termination)
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How do we do the back extension endurance test?
- Back Extension Screening Test:
o Client lies in a prone position
o Perform a single leg straight-leg extension with the right then the left leg in combination with extension of the opposite arm
1. Have client lie down in the prone position on the plinth
2. Have the client shift so that the iliac crest is positioned at the edge of the bed
3. Have subject relax (hanging down, hands on floor) until test begins.
4. Client crosses arms on chest.
5. Client lifts up until parallel to the floor with the shoulders, back, and head aligned. Client should be instructed to contract abdominals for added support.
6. Maintain as long as possible for a maximum of 180s.
* Termination Criteria:
o If torso drops below horizontal (following one warning)
o If client wants to stop
o If client experiences pain and discomfort
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What is classified as abnormal alignment?
* To be classified as abnormal alignment, must produce physical functional limitations.
* Functional limitations can occur anywhere along the kinetic chain at adjacent or distal joints through compensatory motions or postures.
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Where is the central line of gravity?
1. Through the mastoid process and C5
2. Anterior to T4
3. Through the body of L3 and S2
4. Slightly posterior to the hip joint
5. Slightly anterior to the knee joint
6. 3-4cm anterior to the ankle joint
center of gravity is located at the body of L3
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What is lower cross syndrome?
Lower cross – lower and middle abdominals are weak, glutes are weak and hamstring might be as well. Glute activation goes down when you sit which we do a lot. Think of your pregnant women weight shift. Front of pelvis gets pulled down so bowl shifts up in the back. Weakness in glutes and hamstrings can’t pull it back into normal.
Underactive/weak - abdominals, hamstrings, glute med, glute max
Overactive/tight = illiopsoas, rectus femurs, lunar extensors
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What is upper cross syndrome?
Elderly ppl
- Upper cross – weakness that develops – serratus anterior important for breathing and tightness of core. Pec major and minor tightness causes internal rotation of shoulders – protraction as well. Makes it harder to stabilize movements with their backs.
Underactive/weak = deep cervical flexors, rhomboids, middle trapezius, lower trapezius, serrates anterior
Overactive/tight = pec major/minor, subscapularis, upper trap, elevator scapula, latissimus dorsi
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What are the 2 phases of walking for each foot?
Stance phase = 60-65% walking cycle
Swing phase = 35-40% walking cycle
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Explain stance phase
* Occurs when foot is on ground and weight bearing
* Acts as shock absorber and allows for advancement of the body
5 stages of stance phase
1. Initial Contact (heel strike)
2. Load response (foot flat)
3. Mid Stance (single leg stance)
4. Terminal Stance (heel off)
5. Pre-swing (Toe Off)
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Explain the swing phase
* Occurs when foot is non weight bearing and moving forward
* Allows toes to clear ground and swing leg advance forward
3 sub-stages of stance phase
* Initial swing (acceleration) Foot is lifted off floor
* Mid Swing (swing leg is adjacent to weight bearing leg)
* Terminal Swing (deceleration) slows down and preps for floor contact
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What is compliance?
* Measure of stretch or distensibility
* Ease at which lungs and chest wall can stretch and expand. Should balance with elasticity
* Influenced by:
o Elasticity of lungs and chest wall
o Surface Tension of alveoli
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What is elasticity?
* Measure of recoil and ability to resist stretch
* Ease at which lungs and chest wall can recoil back to resting position. Should balance with compliance
* Influenced by:
* Elastic fibres in connective tissue of lungs
* Surface Tension of alveoli
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What is tidal volume (TV)?
Tidal Volume (TV)
The amount of air entering or leaving the lungs in a single breath
At rest = ~500mL
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What is Inspiratory Reserve Volume (IRV)?
The extra volume of air that can be maximally inspired over and above tidal volume
Average value = ~3000mL
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What is expiratory reserve volume (ERV)?
Extra volume of air that can be actively expired by maximally contracting the expiratory muscles
Average value = ~1000mL
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What is residual volume (RV)?
Residual Volume (RV)
The minimum volume of air remaining in the lungs even after a maximal expiration
Average value = ~1200mL
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What is inspiratory capacity (IC)?
The max volume of air that can be inspired at the end of a normal quiet expiration (IC = IRV + VT)
Average value = ~3500mL
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What is vital capacity (VC)?
Max volume of air that can be moved out during single breath after max inspiration (VC = IRV + VT + ERV)
Average value = ~4500mL
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What is functional residual capacity (FRC)?
The volume of air in the lungs at the end of a normal passive expiration (FRC = ERV + RV)
Average value = ~2200mL
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What is total lung capacity (TLC)?
The max volume of air that the lungs can hold (TLC = VC + RV)
Average value = ~5700mL
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Why do we use spirometry?
* Assess capacity apart of annual health assessment
* Diagnose (e.g. obstructive vs. restrictive) pulmonary disorders
* Monitor therapeutic intervention, rehabilitation, or pharmacological effectiveness
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When do we use spirometry?
Diagnosis = normal vs abnormal, screen/measure for pulmonary disease
Monitoring = assess intervention, assess affect of drugs, injuries, toxic substances
Evaluation = assess rehab, insurance claims, legal claims
Public health = epidemiology, research
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In a normal person how much have you exhaled in 3 seconds?
Some people have obstructive lung pathologies so it takes them longer to exhale so do 6 seconds – by 3 seconds in a normal person you have exhaled 97% but in someone with this only 70%
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Spirometry outcome variables:
1. Forced Vital Capacity (FVC)
* Amount of air a person can exhale following maximal inspiration
* Measure of vital capacity
* FVC should be ~= to VC
2. Forced Expiratory Volume in first second (FEV1)
* Measure of maximal rate of air flow out of lungs in 1 second
3. FEV1 / FVC Ratio
* Provides a measure of flow versus volume
* Most commonly used to determine obstructive disorders
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What are normal FEV1 values?
o FEV0.5 = 55% of FVC
o FEV1 = 80% of FVC
o FEV3 = 97% of FVC
* Sub-normal FEV1 (under 70% FVC) indicate obstructive disorder: Some form of obstructive pulmonary disease
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What are normal spirometry values?
1. FVC ≥ 80%
* Based on age, height, and sex
2. FEV1 of ~80%
* Based on age, height, and sex
* Typically, < 70% indicates obstructive pulmonary disorder
3. FEV1 / FVC Ratio > 0.8
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Who should do respiratory muscle training programs?
* Respiratory muscle training programs recommended, even with “normal results”, for smokers older than 45, especially if:
o Symptoms of dyspnea, chronic cough, wheezing, excessive mucus production
Already at risk of developing disorder/disease
Training is a proactive approach
Want to reduce likelihood of developing disease
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What are the disease severity for FEV1%?
All categories have FEV1/FVC of less than 0.70
Mild = FEV1 % of 80% or higher of predicted
Moderate = 80-50 (including) %
Severe =50-30% (including)
Very severe = less than 30%
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What is asthma?
Acute condition
* Chronic inflammation disorder (heterogenous)
* Causes acute airway resistance (obstructive disorder)
* Episodic bronchial hyperresponsiveness
* Variable airflow limitation
* Recurring wheeze
* Dyspnea
* Chest tightness (non-cardiovascular)
* Coughing (night and morning)
* Exercise induced broncoconstriction
- O2 saturation goes down – 80 is the cut-off but realistically if hitting low 90’s that’s when you should consider stopping.
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What are the exercise test considerations for asthmatics?
* Cardiorespiratory fitness (6-minute walk in moderate to severe individuals)
* Pulmonary function (pre and post)
* Oxyhemoglobin saturation (pulse oximeter)
* Spirometer
* Oxyhemoglobin saturation ≤ 80% as absolute cut-off
* Use of prescribed bronchodilator may be beneficial prior to testing to prevent exercise induced bronchoconstriction (~15-min prior)
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What is Exercise Induced Bronchoconstriction?
* Narrowing of airway caused by exercise
* ↑ risk in individuals with asthma (occurs in individuals without diagnosis as well)
* ↑ risk with environmental triggers such as cold air, dry air, and polluted air
* Symptoms similar to asthma
o Condition can be exacerbated by pre-existing asthma
* Treated with bronchodilator (B2 – agonist)
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How do we diagnose Exercise Induced Bronchoconstriction?
* Based on changes in lung function and not symptoms
* Criteria varies but typically ≥ 15% decrease in FEV1 from baseline up to 30 minutes following exercise is used
- Asthma can also do this
- Ppl with asthma also have this
- Need to get a test to confirm it’s asthma.
* Exercise causes a refractory period for exercise induced bronchoconstriction (avoid exercise 4 hours before)
* For training, a 10-15 min variable intensity (high intensity included) warm up is recommended prior to exercise to prevent exercise induced bronchoconstriction
Do an exercise test with a 2-4 minute warm up then a 4-6 minute test of vigorous activity at 80-90% HRmax then measure FEV1 during passive recovery.
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What is an obstructive pulmonary disorder?
Flow is decreased due to increase airway resistance
e.g. emphysema, chronic bronchitis, COPD
RATE is the issue
Flow rate during forced expiration reduced, but volumes unaltered, or marginally changed
FRC and RV greater, but VC smaller because rate of expiration too low, therefore TLC normal if enough time given to fully expire
FEV1 reduced more than FVC, so FEV1/FVC percentage much lower than normal 80 percent
- Rate of air flow is decreased and it’s because of airway resistance – breathing out of a straw.
- Asthma, chronic bronchitis, emphysema – can still exhale just takes longer but can exhale as much
(e.g. emphysema, chronic bronchitis)
FEV1/FVC less than or equal to 70%. FVC may be normal
Increase resistance, decreased elasticity, increased compliance
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What is a restrictive pulmonary disorder?
Volume is decreased due to lung and/or chest wall not being able to expand enough (↓ compliance)
e.g. tuberculosis, pulmonary fibrosis (scarring)
Volumes during forced expiration reduced, but rate of change unaltered, or marginally changed
Lungs less compliant than normal, and patient breathes at lower lung volume
Greatly reduced VC, but FEV1/FVC percentage normal or even elevated
- Restrictive – volume is decreased but rate stays the same – pulmonary fibrosis or tuberculosis. Rate of flow doesn’t change too much but your capacities drop.
Pulmonary fibrosis
FEV1/FVC greater or equal to 70% but FVC is less than or equal to 80% predicted
decrease compliance, increase elasticity
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