1. Intro
   1. – Exercise testing & training are primary components of comprehensive PT management
   2. General Principles of Comprehensive Care:
      1. 1. Teamwork 2. Patient education 3. Exercise testing & training 4. Long-term sustainable lifestyle 5. Follow-up
2. Cardiac and Pulmonary Rehab: EB, Efficacy, & Practicalities
   1. – Pts. Who regularly participate in moderate exercise experience greater control of symptoms & increase functional capacity than those treated with drugs alone; as well as self-management strategies – Cost-containment & increasing accessibility are two primary barriers to participation in cardiac rehab – Women tend to have lower SBP and PP (PR) than men & have more favorable lipid & homocysteine levels; women tend to have more silent ischemic heart disease than men which is more often associated with sleep disturbance in women
3. Pts. w/Chronic Cardiac Dysfnx: Exercise Responses
   1. – Cardiac dysfunction: most common cause = ischemic heart disease & myocardial infarction – The muscle that is infarcted never recovers, so remodeling of the heart occurs, & that alters the heart's electrical functions & mechanical functions. Remodeling takes place over time & with exercise – Ejection fraction (RV) at rest is a poor indicator of cardiac function & exercise capacity – Heart failure can occur in the presence of a normal ejection fraction – Exercises now considered an essential component in the management of individuals with stable heart failure & those who have undergone transplantation – Evaluation of vasomotor reactivity has been proposed as a means of explaining the effects of interventions, including exercise & medications – Aortic wall elasticity modulates left ventricular function & coronary blood flow – Pulse wave velocity is a marker of arterial stiffness & is an independent predictor of VO2peak – moderate aerobic exercise performed alternate days for 20 – 40 minutes is generally accepted as an exercise prescription
   2. Individs w/Chronic Cardiac Dysfnx & Failure
      1. – Chronic heart failure is usually hallmarked by left ventricular dysfunction – Normal: left stroke volume coupled with increased HR leads to greater Q (CO) & greater metabolic demand, as during exercise – As the left ventricle becomes increasingly compromise, individual with heart failure depends more on heart rate to increase cardiac output & peripheral oxygen extraction – Left ventricular ejection fraction during exercise, is not consistently associated with resting ejection fraction, even people with objective signs of MI & increased HRs during exercise – Thus the left ventricular ejection fraction arrest must be interpreted cautiously in the context of exercise & predicted exercise responses
      2. –Goebbels & colleagues (1998) reported that patients with depressed left ventricular function benefit, whereas patients whose left ventricular function has been preserved, such as may occur after myocardial infarction & coronary artery bypass surgery tend to improve spontaneously within 3 months
      3. Benefits of Conservative Mgmt of Pts. w/heart failure
         1. 1. Production of deconditioning, incld: Restoration of normal autonomic balance 2. Potentially, some primary effects on the underlined pathology
      4. Patients with chronic heart failure respond to aerobic exercise favorably, showing improvement in functional class
         1. – Both VO2max & anaerobic threshold improve – There is a reduction in the exaggerated ventilatory response at maximal & submaximal work rates that is usually observed in these patients. As a result, symptoms are reduced – Exercise benefits persist after patients shift from a supervised center-based to a home based program
      5. Exercise training of Pts w/cardiac failure & the role of ventilatory changes in exercise-induced dyspnea:
         1. – The periodic breathing of patients with cardiovascular disease is well known clinically but the mechanism underlying the cycling hyperpnea & hypopnea is not clear – Fluctuations in pulmonary blood flow have been proposed as a mechanism for this periodic breathing – Ventilatory efficiency, the ratios of Ve and VCO2, have yielded important prognostic information – when used in combination with VO2, Ve/VCO2 can be useful and defining a high risk group that should be prioritized for heart transplantation – At rest ppl with more severe heart failure have more restrictive lung pathology & impaired gas exchange – During exercise they have increased that space, impaired gas exchange & greater submaximal ventilatory responses than individuals whose disease is less severe – Exercise limitation in patients with chronic heart failure correlate with reduced FEV1 & FVC, implicating airway resistance in the increased work of breathing and exercise intolerance – Exercise-induced perfusion defect has been identified; areolar capillary membrane conductance has been identified as the best lung function predictor of VO2peak in patients with chronic heart failure – Impairment in ventilatory efficiency is associated with reduced exercise tolerance & pulmonary artery pressures – Pulmonary vasoconstriction has been implicated in leading to pulmonary hypertension & areolar hypoperfusion – Exertional dyspnea observed in patients with heart failure is not the result of abnormal ventilatory function
      6. Ventilatory exercise parameters, including VO2peak, Ve/VO2, and Ve/VCO2= strong predictors of mortality
         1. – Submaximal respiratory gas index is have been proposed is be more sensitive than peak VO2 for assessing functional impairment & for predicting survival in ambulatory patients with chronic heart failure – Ventilatory capacity is not likely to limit exercise performance in patients with stable chronic heart failure – Ventilatory & heart rate responses = strong & powerful predictors of mortality in these patients, & they are superior to the use of VO2peak – Inspiratory capacity varies inversely with pulmonary capillary wedge pressure in individuals with chronic heart failure & is a strong independent predictor of functional capacity
      7. –Pts with severe chronic heart failure have a reduced ratio of increase in VO2 to increase in work rate during incremental exercise – The reduced DO2 due to severely compromise cardiac output is not fully compensated by an increase in oxygen extraction – These patients do tend to show improved exercise response through improve peripheral oxygen extraction – changes in Q performance may reflect the Frank sterling effect rather than changes in contractility – Low Q does not necessarily result in lower exercise capacity. This phenomenon has been attributed to unique mechanism that regulates arteriovenous oxygen content difference to optimize DO2 to the tissues in patients with severe heart failure – At peak exercise, fractional oxygen extraction in the muscle is greater in patients with chronic heart failure than healthy people in proportion to the level of the patient's impairment – This observation supports importance of peripheral adaptation to aerobic training in patients with heart failure
      8. Heart failure can be categorized as either diastolic or systolic
         1. – Diastolic = may be the dominant form and elderly people – In diastolic failure, the Frank sterling mechanism is impaired, causing reduced maximal cardiac output, heart rate, stroke volume, & left ventricular filling pressure. Vascular stiffness is also increased
      9. Exercise testing is important means of establishing the prognosis of an individual with chronic heart failure
         1. Peak VO2 pulse (VO2/HR), & lean body mass adjusted for O2 pulse= useful prognosticators
      10. Prediction of the prognosis of individuals with chronic heart failure can be improved with a two-step exercise test protocol which combines maximal & low intensity exercise to improve accuracy & reproducibility
          1. – A distance of less than 300 m walked in a 6 minute walk test has been reported to be a useful prognostic marker of subsequent cardiac death in individuals with mild to moderate heart failure – Exercise testing it also been reported to provide a good prognostic value in determining the postoperative outcomes (mitral & aortic regurgitation) – The combination of a VO2 @ an anerobic threshold (gas exchange threshold) of less 11 mL/kg/min & a Ve vs VCO2 slope of more than 34=better predictor of mortality at 6 months than is VO2max, & it may provide a guide when prioritizing patients for heart transplantation – Submaximal & endurance tests & determining the anaerobic threshold have been advocated over maximal test for clinical evaluation of patients with heart failure because they are relatively easy to perform, are associated with less risk, & are more valid index ease of a patient's capacity for daily activity
      11. – Individuals with heart failure have a higher incidence of glucose intolerance compared with healthy individuals (20% lower) – After anaerobic exercise program, glucose uptake can increase by 25%. – Exercise training of patients with impaired left ventricular function is associated with improved ventilatory function. In addition to improve cardiac output, long-term high-intensity exercise resulted in reduced ventilatory that space & improved ventilatory efficiency – Low intensity exercise and individuals with chronic heart failure have been shown to improve autonomic tone & reactivity to vagal & sympathetic stimulation – Regular endurance exercise increases oxidative enzymes in the working muscles & is associated with a shift from type II to type I fibers – The skeletal muscle adaptations are independent of peripheral circulation adaptations – Adaptation to resistance muscle training reflects changes in the myosin heavy chain of peripheral skeletal muscle & a shift from slow aerobic to fast glycolytic & fast oxidative characteristics. These findings are associated with VO2peak, O2pulse & Tidal Vol – Skeletal muscle appears to adapt to central impairment of oxygen transport in heart failure
      12. Different types of exercise stress (aerobic or resistance) have differential effects on the heart & circulation
          1. IN HEALTHY PPL: – Static exercise exerts a pressure load on the heart that can be distinguished from the normal hemodynamic response to dynamic exercise, which involves a volume load on the heart. – Static exercise leads to concentric cardiac hypertrophy (left ventricular), & dynamic training is associated with eccentric hypertrophy – Static exercise can produce effects that have been associated with aerobic training – Isotonic exercise using hand weights has been reported to be associated with increases in systolic & diastolic blood pressure, rate pressure product, serum NE, & perceived exertion
          2. – Low to moderately intense strength training may cause fewer cardiovascular complications than aerobic exercise training in individuals who have undergone MI – In general, resistance training with multiple repetitions of moderate weight produces the most beneficial effects – Strength training is considered an integral component of a cardiac rehab program in order for patients to optimally perform ADLs
   3. Individs after Heart Transplantation
      1. – Postoperatively, the resting HR for heart transplant recipients is higher than normal – In the early post op period, The peak VO2 & work rate of people who have had heart transplants are 50% of those of healthy people – At ventilatory threshold, the VO2 & work rates were also 50% of normal – Peak HR, which increases for up to 3 minutes after peak exercise, is also significantly lower – This evidence supports the need for mandatory rehab, so as to maximize the benefits of this high risk surgery, including optimizing functional work capacity, return to work & life satisfaction – Rehab begins preoperatively & continues for 1 year after discharge – Response of the denervated heart for exercise requires extended warm-up & cool down periods & limits the maximal heart rate & VO2 that can be achieved – Systolic blood pressure is more appropriate than HR for assessing exercise response & recovery – With respect to predicting the prognosis of patients with heart failure who undergo heart transplantation, VO2peak is considered a superior indicator of submaximal index ease of exercise capacity – Isometric exercise & activities requiring postural stabilization are largely avoided in people who have had heart transplants because of potential hemodynamic stress
   4. Individs w/Left Ventricular Assist Devices
      1. – The Jarvik heart is a left ventricular device designed as a long-term solution for heart failure – Exercise tolerance, myocardial function, & end-organ function all improve 6 weeks after surgery
   5. Individs w/Congenital Heart Disease
   6. Individs w/Intermittent Claudication
      1. Intermittent Claudication (def)
         1. – Is the symptom of exercise-induced muscle ischemia of peripheral arterial disease – A systemic complication of atherosclerosis w/or w/o overt ischemic heart disease
      2. Exercise:
         1. – Pts w/IC must be managed as a pt w/heart disease as well as one w/peripheral arterial disease – Sxs may mask cardiac Sxs – Exercise training can improve exercise tolerance in the absence of improved peripheral blood flow – Exercise responses exhibit a slowed VO2 response related to impaired muscle perfusion – The associated delayed ventilatory response has been associated w/the hyperemic response in the exercising muscle rather than w/ischemia
   7. Individs w/Anemia
      1. – The capacity of the blood to transfer oxygen is determined by the hemoglobin concentration & the binding characteristics of hemoglobin – The adaptations or compensatory mechanisms that these patients develop is mediated by diphosphoglycerate, which decreases the affinity of hemoglobin for oxygen in the tissue
      2. Sickle Cell Anemia:
         1. – These patients have a low VO2peak & a low anaerobic threshold in the presence of a high heart rate reserve but no gas exchange abnormalities – The disease is characterized by restrictive lung pathology, increased areolar dead space, & hypoxemia – Increased dead space may reflect impaired pulmonary capillary perfusion due to the sickle cells
   8. Individs w/ HTN
      1. – HTN has long been linked to type II DM as well as vascular changes typically seen with aging – Chronic sympathetic overdrive associated with hypertension promotes left ventricular hypertrophy, cardiac dysrhythmias, & atherogenesis. Inhibiting sympathetic overactivity may reduce cardiovascular risk
      2. Exercise:
         1. – Regular physical activity & formal exercise program reduces the risk of or modifies HTN; likely thru a decrease in total peripheral vascular resistance – The risk of HTN can be detected by an exaggerated BP response to exercise – Endurance training reduces this exaggerated response & thereby may reduce the risk for developing HTN
   9. Individs w/ Type II DM
      1. – DM is a strong risk factor for coronary artery disease & sudden cardiac death – DM = associated with reduced barrel receptor sensitivity & HR variability, which are also risk factors for morbidity & mortality
      2. Exercise:
         1. – Exercise training improves barrel receptor sensitivity as well as glucose sensitivity, exercise tolerance, & muscle strength – Muscle blood flow may be impaired at the level of microcirculation in the absence of overt peripheral vascular disease – Patients with chronic DM, exercise capacity is compromised by reduced oxygen delivery – A reduction in the arterial venous oxygen difference may contribute to a reduction in VO2peak – Pts w/non-insulin-dependent DM have reduce glucose transport and skeletal muscles, & which may contribute to exercise intolerance – DM= independent risk factor for reduce left ventricular ejection fraction during exercise, as is severity of coronary artery disease
4. Role of Meds: Augmenters & Attenuators of Outcome
   1. – The timing of Pts' ingestion of the medications in relation to performing and exercise test should be recorded in order to standardize testing procedures from one time to the next; at the very least, it is important to be aware of the confounding effects of a medication that could explain improved or worsened responses
   2. Common meds taken by Cardiac Pts:
      1. Beta Blockers
         1. – Improve the rhythm & contractile force of the heart – Long-term use causes no significant improvement in delayed heart rate recovery which is a predictor of mortality in patients with heart failure – These drugs can contribute to fatigue & exercise intolerance
      2. ACE Inhibitors & ASA
         1. – Angiotensin-Converting Enzyme (ACE) Inhibitors enhance cardiac fnx – Improves diffusion capacity & exercise capacity, an effect mediated thru prostaglandin activity – This activity can be mitigated by aspirin – A change in ASA administration in combo w/ACE inhibitors can worsen exercise tolerance – Exercise: Ventilatory efficiency is improved, as evidenced by a reduction in Ve/VCO2 at submaximal workloads
5. Individs w/Chronic Pulmonary Dysfnx: Exercise Responses
   1. Largest proportion of ppl in pulmonary rehab = have emphysema
   2. Individs w/Chronic Obstructive Lung Disease
      1. – In individuals with severe disease, exercise intolerance may reflect limited peripheral perfusion & oxygen extraction due to the disproportionate demand in the respiratory muscles. These individuals are unable to exercise at an intensity that induces a high level of aerobic conditioning, & the experience early onset dyspnea – With impaired aerobic capacity, anaerobic glycolysis has an increasingly important role in supporting physical activity. This leads to increased blood lactate, which needs to be buffered with bicarbonate, thereby producing additional carbon dioxide. This further increases ventilatory load & dyspnea & leads to further inactivity & deconditioning – The goal of PT is to relieve dyspnea & increase exercise tolerance, hence QOL
      2. – Symptom limited stairclimbing can be used to evaluate cardiovascular & pulmonary reserve; symptom limited stairclimbing test correlate with VO2peak, Ve, HR & respiratory rate in response to a maximal cycle ergometer test – Impaired exercise capacity reflects physical damage to the lungs, including impaired pulmonary vasculature as well as cardiac & skeletal muscle abnormalities – Variability in the ventilatory response to exercise a primary determinant of variability in the exercise capacity of patients with COPD – In the absence of right heart failure, right ventricular and diastolic volume is highly correlated with VO2max & cardiac index in patients with COPD, suggesting that right ventricular and diastolic volume compensates optimally – Management of patients with COPD: individualized training programs based on HR as the gas exchange threshold (anaerobic threshold), as opposed to standard protocols be somebody percent of HRR , produce superior therapeutic outcome; that is, they reduce ventilatory requirements & are safer – 6 minute walk test is useful in the assessment & management of patients with COPD – Based on a walking distance tests come the effect of an exercise program can be predicted on the basis of low pretraining walking distance & higher FEV1 (forced expiration volume in 1 sec) – In patients with low functional work capacity, objective submaximal index ease of training effects are useful – Rigorous training (80% of peak work rate, for 45 minutes, 3x/wk for 6 weeks) results in significant training responses than individuals with severe COPD – With refinement and exercise testing & training procedures & in measurement, changes in peripheral muscles have been found to be associated with the underlying disease. Aerobic training responses reflect both central & peripheral adaptations – Some individuals with COPD have impaired peripheral perfusion & oxygen extraction, which may be explained by the redistribution of cardiac output from the peripheral to the respiratory muscles during increased work rates – Endurance training is associated with increased skeletal muscle activity & recruitment of slow twitch fibers
   3. Individs w/Primary Pulmonary HTN
      1. During incremental exercise, the lungs become less efficient as gas exchangers because of impaired lung perfusion
   4. Individs after Lung Volume Reduction Surgery
      1. – Lung volume reduction surgery is an invasive means of correcting the hyperinflation of the lungs of patients with COPD – Improvement in functional capacity after surgery has been attributed to improve breathing mechanics during exercise, as well as at rest, & to improve respiratory muscle strength – Specifically, higher maximum levels of title volume & Ve are achieved; in turn, these lead to improvements in VO2 & VCO2
   5. Individs w/Interstitial Lung Disease
      1. – The functional consequences of the disease: diffusing capacity & areolar arterial oxygen tension difference – these patients have less ability than healthy people to recruit the pulmonary capillary bed during increased exercise stress, so they can desaturate readily – VO2peak is correlated with impairment of gas exchange & circulation, rather than with ventilatory impairment – Changes in gas exchange during exercise will be the most sensitive indicator of physiological limitation in patients with subclinical evidence of interstitial lung disease – However, in terms of prognostic capability, the results of an exercise test for evaluating gas exchange not appear to augment standard pulmonary function testing
   6. Individs after Lung Transplantation
      1. – When exercise responses before & after bilateral lung transplantation are compared, exercise capacity remains low, although improved (explained via a basis of poor oxygen extraction) – Exercise conditioning is required in these patients postoperatively to maximize their functional capacity – Maximum oxygen consumption may remain below that of healthy peers which reflect inadequate adaptation of cardiac output as well as deconditioning
   7. Individs w/Asthma
      1. Before exercise can optimize its therapeutic effect along with a longer cooldown maybe beneficial – These individuals are taught to monitor their unique responses to the medication & is coordination with physical activity & exercise; monitor in be in air (humidity & temperature) to anticipate the potential for bronchoconstriction & respiratory distress
   8. Individs w/Cystic Fibrosis
      1. – Comprehensive PT management, including regular program of exercise, is recognized as a central component of promoting general health & airway clearance – End-of-life usually results from respiratory infection – Exercise program is adjusted during times of exacerbations & then ramped up afterwards
6. Cardiac & Pulmonary Rehab: Common Components
   1. Definition, Purpose, Goals & Outcomes
      1. – Those who meet the criteria for admission to a conventional cardiac & pulmonary rehab program, are within access of a center that offers these programs are evaluated by a multidisciplinary team that establishes the patient's short-term & long-term goals & sets up an overall program that includes exercise prescription, nutritional plan, a smoking cessation program if required, & life skills & stress management instruction – The preadmission workup for cardiac rehab includes a complete history & questionnaire related to current status & health behaviors & individuals goals – A key component of the assessment mission to cardiac or rehab program is an objective assessment of the patient's risk factors, which enables risk factor reduction interventions to be specifically targeted & a lifelong health plan designed & implemented – The exercise program focuses on improving flexibility & strength, as well as aerobic capacity, with the goals of improving the patient's health & capacity to perform ADLs
      2. The core components of cardiac & pulmonary rehab programs:
      3. Specific Rehab Goals:
         1. 1. Service health promotion resource for individual, community & healthcare providers 2. Increase aerobic capacity & muscle strength & endurance consistent with overall health & well-being 3. Improve capacity to perform ADLs & maintain gainful employment 4. Promote self-efficacy and healthy lifestyle behaviors for long-term health & well-being, as well as for 2° prevention 5. Shipped an individual to a lower risk classification 6. Reduce risk for revascularization procedures, medical intervention & physician & hospital visits 7. Promote health & well-being in the patient's family & community 8. Reduced direct & indirect healthcare costs over the short & long-term
   2. Setting & Team Members
   3. Components of PT
      1. ASSESSMENT
         1. – Underlying risk factors & disease must be examined in all patients, irrespective of their primary presenting diagnosis – Review all systems is necessary to determine limitations imposed by musculoskeletal, neurological, endocrine, hematological, or other conditions – The assessment comprises the exam of risk factors, including profiles of the patient's nutrition intake, weight, smoking history, & stress management (including rest & sleep profiles), & as well as physical activity & aerobic capacity – Within 6 – 8 weeks, elements of the assessment are repeated – Predictors of long-term survival of MI include age, left ventricular ejection fraction, DM, HTN, & elevated resting heart rate – Glucose abnormalities in those who do not have DM are common in individuals with heart failure (43%); these findings are associated with greater functional deterioration than found in individuals with heart failure without glucose abnormalities so knowledge of the individuals glucose tolerance is essential at baseline & over time within the rehab program – Clinical depression is associated with ischemic heart disease so individuals referred to cardiac rehab need to be screened for depression, & psychotherapy, counseling, or pharmacotherapy may be indicated – General assessment must also include an assessment of the individuals learning lifestyle – In addition to the goal of shifting an individual into a lower risk category, and other objective is to shift an individual into a higher readiness to change category – Another component of the education is the assessment of the individual's knowledge deficits regarding his/her condition
      2. INTERVENTIONS
         1. – Exercise program – Smoking cessation program – Weight loss program
      3. EDUCATION
         1. – Pt. is taught the bases of anatomy & physiology of the heart & lungs health, basic nutrition, physical activity & exercise, analysis of lab tests, effects of smoking, effects of medication, etc – Lifestyle recommendations need to be reinforced regardless of phase of the program – Tailoring health education information to the needs of program participants is essential if true behavior change is to be effected over the long-term – Promoting self-efficacy & perceived control are central to education strategies developed by physical therapists
      4. EXERCISE PROGRAM
         1. – A reduction in respiratory rate in patients with chronic heart failure improves pulmonary gas exchange, reduces dyspnea, & increases exercise performance
      5. GOALS: SHORT TERM
         1. – STGs are aimed at developing & learning strategies for healthier living & reducing cardiovascular & pulmonary risk factors – LT strategies are an extension of STGs & address the sustainability of health & fitness consistent with patients' needs, wants & capabilities for the rest of their lives – A PT outcome= to minimize, reduce or eliminate the need for medication in the short term & long-term
      6. GOALS: LONG TERM
         1. – At the point of entry into PT (acute, subacute, or chronic, with cardiovascular dysfunction as a primary or secondary diagnosis), a long-term plan with goals, outcomes, & follow-ups is integral to the management plan overall
      7. Comprehensive PT Mgmt & Lifelong Health Plan
7. Cardiac Rehab: Specific Components
   1. Phases
      1. PHASE I
         1. – Refers to inpatient care (medical & surgical) & the pre-discharge exercise test
      2. PHASE II
         1. – Refers to a supervised exercise program lasting 3 – 6 months – Usually takes place in a community center where patients can be monitored during exercise & education by the rehab professions can be ongoing – A trial of home based phase II programs for high risk patients after cardiac surgery produced the same results as were found in the control group, which received general guidelines to increase activity levels
      3. PHASE III
         1. – Refers to the maintenance phase, during which the patient is responsible for exercising mostly at home – Lasts from 6 – 12 months
      4. PHASE IV
         1. – Refers to an unsupervised community program – Pt= ready for this phase within 9 – 12 months – Patients may be referred to cardiac rehabilitation when they are stable & not in conjunction with an acute event
   2. Smoking Cessation
      1. – The risk for MI is 3x higher in patients who continue to smoke after a cardiac event – When patients quit, the risk for re-infarction is reduced to that of non-smokers prior to the first infarction
   3. Nutrition & Weight Control
      1. – Individuals with cardiovascular dysfunction are at risk for fluid & electrolyte imbalances & related ECG irregularities, so these aspects of nutrition need to be included – Patients with chronic heart failure rely on fat substrate during exercise band on cards, which may contribute to increase catecholamines & free fatty acid levels. These changes may compensate to protect muscle glycogen stores – However, given that fat metabolism is not energy-efficient, this shift may contribute to exercise intolerance
   4. Psychosocial Issues
      1. Stress management & life skills training are fundamental to rehab programs in minimizing undue sympathetic arousal & impact on the cardiovascular & pulmonary systems
   5. Risk Reduction
      1. Prevention & rehab programs aim to reduce and individuals cardiac risk factor category See Table 24-4 p 396
   6. Physical Activity & Exercise: Special Considerations
      1. MONITORING
         1. – An individual with primary cardiovascular dysfunction or its risk factors requires particular attention to his/her hemodynamic status – Serial lipid profiles, BP, resting HR, & body weight or monitor regularly, & interventions are modified accordingly – BP can be abnormal and individuals with exercise-induced left ventricular systolic dysfunction, which leads to unstable hemodynamic status – The absolute & roll to changes in HR, BP, RPP, arterial saturation, & perceived exertion are particularly important – Exercise-induced silent myocardial ischemia is an important indicator of increased risk for cardiovascular disease & stroke in men when they are compared with those without silent ischemia – Delayed HR recovery is a predictor of mortality, irrespective of angiographic evidence of disease severity
      2. EXERCISE TESTING
         1. PURPOSE/DESIGN TO:
            1. – Used for Dx, assessment of functional work capacity, assessment of the outcome of one or more interventions, including a training program, & prognosis – Exercise Testing Protocol is designed to stress the patient's oxygen transport system – ventilation, heart, circulation, & muscles – progressively & in an integrated manner
         2. – The great exercise test, or maximal stress test, is usually a short (8 – 12 minutes), progressively ramped, symptom limited exercise test conducted on a treadmill or cycle ergometer; a submaximal test may be preferred at times – Exercise is the single best way to assess the integrated function of the patient's oxygen transport system and others & their capacity for oxygen transport – Individuals with unexplained dyspnea are at risk for ischemia & cardiac events. Exercise echocardiography provides independently derived information that identifies patients at risk – Exercise testing has a role in predicting surgical outcomes. VO2peak & exercise duration a good parameters for evaluating functional class & postoperative status and people who have undergone valve repairs or valvuloplasty
      3. EXERCISE TRAINING
         1. – Sessions begin with a warm-up defined by a work rate intermediate between the target training zone & rest. Warm-up exercise has a protective effect against left ventricular dysfunction and individuals with angina – Improvement and walking tolerance & distance is a primary goal because it is a hallmark of independence & mobility, particularly with advancing age, & it is coupled with the upright position & its associated gravitational stress – If the goal is to improve the patient's functional needs, activities that are closest to those needs are chosen – If improving aerobic fitness & maximum functional capacity is the goal, exercise that involves more limbs would be the best choice – Conventionally, the exercise intensity for patients with heart disease is set at a proportion of oxygen uptake reserve or heart rate reserve, which suggests a critical threshold for training effects – Peak functional capacity depends on muscle strength & endurance and individuals with chronic heart failure – The hemodynamic response to resistance muscle training depends on the isometric & postural stabilization component, in addition to the load or resistance used, the muscle mass activated, the number repetitions in the set, & the duration of each contraction, as well as the involvement of the Valsalva maneuver – Upper body work warrants greater emphasis – Eccentric muscle contractions are associated with higher muscle tension & less metabolic demand. For low risk individuals who have ischemic heart disease without angina, inducible ischemia, or left ventricular dysfunction, eccentric exercise can be recommended; these patients can perform high load resistance exercise with minimal cardiovascular stress
      4. LT PLAN
         1. Detailed in Chap 31
   7. Long Term Plan
      1. Detailed in Chap 31
8. Pulmonary Rehab: Specific Components
   1. Phases
      1. See table 24-3 below
   2. Smoking Cessation
   3. Nutrition and Weight Control
   4. Psychosocial Issues
      1. Although chronically poor blood gases can affect psychological & cognitive function, the remediation of any source of depression can independently improve function
   5. Risk Reduction
      1. – Carbohydrate rich foods, known to increase carbon dioxide production, have been targeted as a food group that should be eliminated in patients with COPD. Small changes in carbs have a major effect on VCO2, exercise tolerance & breathlessness – Reduction of pulmonary & cardiac risk factors in an individual with primary lung dysfunction is essential
   6. Physical Activity & Exercise: Special Considerations
      1. MONITORING
         1. – Similar to those of patients with cardiac dysfunction because heart & lungs are interdependent – Ventilatory parameters, such as breathing pattern, arterial saturation as gauged by pulse oximetry, & subjective sense of breathlessness, are particularly important, as are HR, BP & ECG readings
      2. EXERCISE TESTING
         1. – The exercise test may be selected to evaluate aerobic capacity or the strength & endurance of peripheral or respiratory muscles – Upper body work is integrated into the overall program judiciously & monitored accordingly. Upper body strengthening can reduce rating of perceived exertion & breathlessness & bus warrants being assessed & trained – Exercise test to assess cardiovascular & pulmonary conditioning may be maximal or submaximal & may involve modalities such as a treadmill or ergometer – Is essential to monitor dyspnea in these patients & to correlate the dyspnea rating with objective measures – Pulse oximetry is routinely monitored along with HR & BP – Exercise testing can be used to diagnose exercise-limiting factors
      3. EXECISE TRAINING
         1. – Walking in conjunction with breathing control is particularly useful for patients with pulmonary dysfunction – Lengthening (eccentric) muscle contractions are associated with reduced energy costs, so such exercise has important therapeutic implications for individuals with poor aerobic capacity – However, eccentric muscle work in the form of downhill walking or cycling in a negative- work ergometer alters breathing patterns toward a tendency to breathe rapidly & shallowly