rehab Flashcards
Explain the physiotherapy management of a patient who has undergone a Cardiac Artery Bypass Graft (CABG) from pre-op to end of rehabilitation. (50 marks)
What is it?
- Open heart surgery, graft attached to aorta and below blockage
- Used due to severe CV disease, multiple arteries affected by atheroscleoris, complex blocked vessels
Management:
Cardiac rehabilitation
Long term program involving evaluation, prescribed exertion, modification of cardiac risks, education and counselling.
Aims to limit the physiology and psychological effects, reduce risk of sudden death or MI, controls cardiac symptoms, stabilise atherosclerotic process, enhance psychosocial and vocational states
Phase 1:
Pre discharge - seen by cardiac rehab team, given info, gentle mobilisation and functional activities, risk modification
Phase 2:
Outpatient setting, symptoms reviewed, lifestyle modifications, gruadually increase walking and activity, assessed for phase 3 suitability
Phase 3:
Post discharge, between week 2-6 post discharge, 1-2 sessions per week for 6-12 weeks, dependent on risk stratification
Session includes warm up to prevent ischaemia, targetting all major joints and muscles. CV conditioning, to increase CV fitness, balance between aerobic and strength training. Active recovery, prevents sudden changes in BP and CO. Cool down to prevent hypotension and arrythmias. Education component.
Phase 4:
Longer term, occurs in local community setting, ongoing exercises.
Explain the principles of exercise prescription for increasing cardiopulmonary endurance (aerobic) with reference to exercise physiology. (50 marks)
Aerobic endurance is the ability to exercise at moderate intensity for extended periods. Cardiorespiratory system provides nutrients and oxygen to working muscles. Aerobic system is slowest in terms of producing ATP, but yields most ATP per molecule of fuel used. Uses oxygen to oxidise fats to create ATP. Higher aerobic endurance means they can work for longer without needing to respire anaerobically.
Principles:
FITT
Frequency: 3-5 times per week as per ACSM. Promotes progressive overloading of muscular structures, allows for hypertrophy, forces used systems to work for longer and more often.
Intensity:
Low - moderate intensity is best for improving aerobic endurance, so HR max (220-age) should be within 50-76% according to ACSM.
Time:
150 mins of moderate intensity aerobic activity each week - min of 30mins each time (e.g. 5x30 min sessions per week) as per ACSM.
Type:
No specific guidlines but recommended to do functional and specific exercises in relation to the goals. Strength/ weight training is better for hypertrophy whereas cardio exercises e.g. bike/running/ swimming are best for aerobic endurance. Target the building of type 1 slow twitch fibres
Progressive overload can be acheieved by overloading any one of the FITT principles
Explain the expected physiological effects of an eight-week endurance training (aerobic) exercise programme with particular reference to the cardio-vascular, respiratory and neuro-muscular systems. (50 marks)
Cardiovascular:
- Cardiac hypertrophy, increased size of heart muscles, allows for more blood to fill chambers, greater preload therefore greater contraction as per Frank-Starling Law
- Thicker layer of myocardium, stronger contraction
- Resting HR decreased due to increased SV
- Increased cardiac reserve (diff between resting HR and max HR)
- Increased SV both at rest and during exertion
- Increased cardiac output during exertion (increased range
- Increased plasma levels, more RBC growth, more blood volume, more haemoglobin, more capacity to carry O2 from lungs
- Increased capillary beds within muscles, lungs. Increase O2 diffusion capacity
- Larger O2 diameter, reduced lumen, increased blood flow
Respiratory:
- Increase strength in respiratory muscles (diaphragm, intercostals and accessory muscles) so stronger contractions made
- Decreased resp rate at rest, more O2 in per breath so less breaths needed
- Increased tidal volume due to stronger muscles
Neuro-muscular:
- Increased nerve to muscle connections, hypertrophy of neuromuscular junctions - more NMJs, stronger and quicker contractions, causes improvements in motor fitness e.g. coordination, balance, reactions
- Increased strength - increased recruitment of motor units
- Skeletal muscle hypertrophy
Discuss the specific factors that should be considered when prescribing exercise for patients following myocardial infarction. (50 marks)
What is MI?:
- Heart attack, occuring as a result of tissue death of cardiac muscle, scar tissue formation.
- Heat supplies itself with blood via coronary arteries, reduced blood flow via atherosclerosis/ thrombus can cause reduction in blood flwo causing myocardium layer to die.
- Site and degree of infarct depends on location of obstruction.
- Heart needs to work harder to make up for lost area, causes increased HR can lead to heart failure.
Specific factors:
- Arrutjmias can be triggered by exercise, higher risk in first 4 weeks
- Heart failure can occur if patients don’t respond well to increased load
- Angina if exertion exceeds O2 supply
- Surgical interventions should be taken into consideration (post op instructions)
- Medication
- Increased HR at rest and during exertion (will reach max sooner than usual)
- Intensity should be equated to baseline, gradual overload
- Proper warm up, training and cool down
- Signs and symptoms should be monitored during exercise
- Patient should be made aware of possible effects of exercise
Discuss the specific factors that should be considered when prescribing exercise for patients with Chronic respiratory disease. (50 marks)
What?:
Chronic respiratory diseases are ones that affect the airways and other structures of the lungs including asthma, COPD, lung cancers. Exercise is beneficial for patients with these.
Specific factors:
- Social factors including embarrassment, fear/ protectiveness, fear of breathlessness
- Individualised programs: baseline function, capacity, habitual activity levels, infection status and inflammation should all be taken into account when designing exercise programms, patients should be given a risk category
- Intensity should be minimum 50% of max work rate, although symptom tolerated max work is advised. Patient less likely to be able to exercise at high levels of intensity due to reduced O2 intake
- Duration, recommended 20-30 minutes, lower O2 levels means patient is unlikely to be able to exercise anaerobically for extended periods
- Types should include both strength and endurance training
- Goal setting can improve motivation and engagement
- Medical contraindications e.g. active infection of Cystic Fibrosis
- Patients with COPD should be evaluated using graded exercises tests, ECG and pulse oximetry, if results are remarkable should be seen by specialists
- Patients with asthma should make sure their condition is controlled before becoming physically active
Discuss the factors that would influence your choice of exercise test for measuring/estimating aerobic fitness (V02 max). (50 marks)
What is it?
VO2 max is a measure of max CV fitness, calculated by the amount of O2 consumed. VO2 max = cardiac output x arteriovenous O2 difference. Higher VO2 max = more O2 your body can be processed = higher CV fitness
Factors:
- Test types: Max or Sub max (% of max HR the patient will do), Lab or field (where test will be carried out), externally or self paced (how the test is controlled), incremental/ fixed intensity (if the intensity will change throughout), time/ symptom limited
Optimal conditions for a VO2 max test would be: Lab based (e.g. Cardiopulmonary exercise test), maximal test, externally paced, incremental, symptom limited.
Factors that may affect our results include: gender (women have a lower max than men due to physiology (smaller lungs and heart)), age (younger generally have a higher VO2 max), genetics, altitude (lower air pressure means less O2 available), temperature (O2 consumed easier at higher temps)
Discuss the factors which may influence the rehabilitation of an elderly below knee amputee and explain their implications for physiotherapy. (50 marks)
Below knee amputations are as a result of problems at the lower leg, ankle or foot. The goal is to remove affected tissue to create a less painful and more useful limb.
Factors:
- Surgical complication: surgeries can come with infection, nerve/ blood vessel damage, blood clots. After surergy patients may experience these issues/ phantom limb pain which can cause issues with their rehabilitation
- Age/ comorbidities: Someone with a better baseline before surgery is likely to yield better results post surgery than someone who is less fit, this is due to their ability to start physio earlier, have quicker healing times and less comorbidities.
- Lifestyle factors: Diet, fitness, general heath
- Smoking, decreases healing times, can cause post-op complications, less suitable for physio
- Cognition: visual/ hearing sisues affect gait/ transfer/ exercises training meaning more time is spent on each section before progression is made
- Prosthetics: Designing and learning prosthetics can prove challenging and complications around this can cause further delays in rehab.
- Amputation often leads to knock on effects such as LBP, OA in contralateral limb, atrophy on affected leg, fear of falling
- Care of residual and contralateral limb, 1/6 require a contralateral amputation
Discuss the role of the physiotherapist in the management of patients undergoing lower limb amputation. (50 marks)
Pre-op:
- Aims to build rapport and manage expectations
- Review of function: ROM/ strength
- Prehab
- Discuss home set up/ mobility aids
Acute post op:
- Chest physio, ACoB
- Transfer training on day 1
- Exercises including core, residual/ contralateral limb, upper limbs, maintenance of ROM
Pre-posthetic:
- Walking aid training to improve mood, reduce swelling on residual limb, balance benefits
Prosthetic prescription:
- May be required to assist in cast appt to assist with mobility guidance, static balance and weight bearing
Prosthetic training:
- Education about skin integrity, weight bearing
- Gait training promoting symmetry, equal weight bearing, balance
Discharge management:
- Education, coping strategies, training for resuming functional activities
Justify a programme of rehabilitation for a 78-year-old woman following an above-knee amputation from the 1st day post operation to her return to full functional potential. Include specific examples of exercise progression in your answer. (50 marks)
Pre-programme considerations:
- Cause of amputation ? lifestyle choices, ? trauma ?prehab
- Full assessment of physical and psychological condition
Early stage exercises:
- Begin from day 1/ as soon as possible with basic bed exercises
- Exercises should promote a full range of movement to prevent the formation of any adhesions
- Goal should be to maintain/ build muscle mass in supporting muscle groups to build a platform to progress onwards from
- When possible patient should be encouraged to attempt to sit up on edge of bed to work on balance which may be difficult due to changes in centre of mass. Obs should be monitored when sat up and O2 should be kept nearby.
- Exercise can be progressed from sitting to edge of bed with some support to less, and also by removing some support when sat up in terms of balance, i.e. using 1 hand instead of 2
Next stage:
- Once the patient is more confident with their balance, and they have suitable upper limb strength, transfer practice can begin.
- Begin with the use of slide boards from bed - chair, and can be progressed to pivot transferring if possible
- Once the patient is confident with this, sit to stand practice can begin, beginning with full UL usage and decreasing this as possible
- Standing balance can then be taught, when standing swelling is more likely in residual limb, could use compression sock/ PPAM to reduce oedema
- Standing should be promoted as it decreases likelihood of DVTs
Next stage:
- Prosthetic training if patient wants this
- Strengthening the hip muscles is important here
- PPAM aid to practice weight bearing and gait pattern
Next stage:
- Using the prosthetic
- Must be able to transfer alone, be fully cognitive, have motivation, have dexterity
- Can use femurette which is FWB to more closely mimic a prosthetic to practice
- Progressions on balance e.g.closing eyes in P bars etc.
- Once prosthetic fitted, further gait training and walking progression can occur
Final stage:
- Higher level rehab e.g. stairs training etc.
