Natalia Fernandez, PT, MS, MSc, CCSUniversity of Michigan Health Care System

Department of Physical Medicine and Rehabilitation.

Clinical Decision MakingExaminationEvaluationDiagnosisPrognosis

Set up Interventions

Clinical Decision MakingMed Dx: CAD Med Dx: COPD

Use of Hypothesis Testing and AlgorithmsMed Dx and History of Cardiopulmonary

DiseaseLab and Diagnostic Test ResultsPT DxType of activity, specifics of activity, timeResponse to exercise/mobility/ADL

Vital signs – rest, activity, recovery EKG changes Need and time to stop, rest Observed signs – color changes

Subjective responses Concerns – Fatigue, SOB Rate of Perceived Exertion

DeTurk & Cahalin - pg 368-369, Fig 12-4 & pg 370, Fig 12-5

Musculoskeletal, Integument, & Neuromuscular Considerations

Musculoskeletal Osteoporosis & Spinal Deformities Ankylosing Spondylitis Idiopathic Scoliosis Pectus Deformities Shoulder Hypomobility

Integument Sarcoidosis Systemic Lupus Erythematosus Scleroderma Sjogren Syndrome

Neuromuscular Stroke Traumatic Brain Injury Spinal Cord Injury Multiple Sclerosis Parkinsons Guillain-Barre Syndrome Post Polio Syndrome

Nagi (Disablement) ModelDisability Inability to shop for family

Functional limitation Limited walking distance Impairment Impaired aerobic capacity

Pathology Myocardial Infarction

APTA, Guide PT Practice, 1st ed.1997.

Therapeutic Exercise for Cardiopulmonary Practice Patterns

Aerobic capacity/endurance conditioning or reconditioning

Balance, coordination, and agility trainingBody mechanics and postural stabilizationFlexibility exercisesGait and locomotion trainingRelaxationStrength, power, and endurance training

for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles

Pattern A: Prevention and RiskInclusion Criteria

Risk Factors or Consequences of Pathology DiabetesFamily history of heart diseaseHypercholesterolemia or hyperlipidemiaHypertensionObesitySedentary lifestyleSmoking

Impairments, Functional Limitations, or Disabilities

Decreased functional work capacityDecreased maximum aerobic capacityDyspnea on exertionSedentary job role

Pattern A: Prevention and RiskTher Ex

Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

Aquatic programsGait and locomotion training - Walking and

wheelchair propulsion programs

Increased workload over timeTask-specific performance training

Flexibility exercises Muscle lengtheningRange of motionStretching

Body mechanic and ergonomics trainingBreathing exercisesPosture awareness training

Pattern A: Prevention and RiskTher Ex

Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic,

complementary exercise approachesStrength, power, and endurance training

Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices)

Aquatic programs Standardized, programmatic,

complementary exercise approaches Task-specific performance training

Pattern A: Prevention and Risk Patient Education

DiseaseAtherosclerosisHyperlipedemiaHypertensionDiabetes

DietExerciseSmokingHealth & WellnessFitness

Pattern B: DeconditioningInclusion Criteria

Risk Factors or Consequences of Pathology Acquired immune deficiency syndromeCancerCardiovascular disordersChronic system failureInactivity Multisystem impairmentsMusculoskeletal disordersNeuromuscular disordersPulmonary disorders

Impairments, Functional Limitations, or DisabilitiesDecreased enduranceIncreased cardiovascular response to low level work

loadsIncreased perceived exertion with functional activitiesIncreased pulmonary response to low level work loadsInability to perform routine work tasks due to

shortness of breath

Pattern B: DeconditioningTher Ex

Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

Aquatic programsGait and locomotion training - Walking and wheelchair propulsion programs Increased workload over time

Balance, coordination, and agility training Developmental activities trainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise approaches

Breathing exercisesBody mechanics, ergonomics, and postural stabilization

Body mechanics training Postural control and awareness training

Flexibility exercises Muscle lengthening Range of motion Stretching

Pattern B: DeconditioningTher Ex

Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise

approachesWheelchair training

Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise

approaches Strength, power, and endurance training for head and neck, limb,

pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises (including

concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics)

Aquatic programsConditioning and reconditioning - Strengthening or ResistiveStandardized, programmatic, complementary exercise

approaches

Pattern C: Airway ClearanceInclusion Criteria

Risk Factors or Consequences of Pathology Acute lung disordersAcute or chronic oxygen dependencyBone marrow/stem cell transplantsCardiothoracic surgeryChange in baseline breath soundsChange in baseline chest radiographChronic obstructive pulmonary disease (COPD)Frequent or recurring pulmonary infectionSolid-organ transplants (eg, heart, lung, kidney)Tracheostomy or microtracheostomy

Impairments, Functional Limitations, or DisabilitiesDyspnea at rest or with exertionImpaired airway clearanceImpaired coughImpaired gas exchangeImpaired ventilatory forces and flowImpaired ventilatory volumesInability to perform self-care due to dyspneaInability to perform work tasks due to dyspnea

Pattern C: Airway ClearanceTher Ex

Aerobic capacity/endurance conditioning or reconditioning activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics, and mechanical or electromechanical devices

Aquatic programsGait and locomotion training - Walking and wheelchair

propulsion programs Increased workload over time

Body mechanics, ergonomics, and postural stabilizationPosture awareness training Postural control training

Flexibility exercises Muscle lengtheningRange of motionStretching

Relaxation Breathing strategies Movement strategies Relaxation techniques Standardized, programmatic, complementary exercise

approaches

Pattern C: Airway ClearanceTher Ex

Strength, power, and endurance training for head and neck, limb, pelvic-floor, trunk, and ventilatory muscles

Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric,and plyometric – using manual

resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices)

Aquatic programsStandardized, programmatic, complementary exercise approachesTask-specific performance training

Balance and coordination trainingDevelopmental activitiesNeuromuscular relaxation, inhibition, and facilitation

Pattern D: CV Pump DysfunctionInclusion Criteria

Risk Factors or Consequences of Pathology/Pathophysiology (Disease, Disorder, or Condition)

AngioplastyAtrioventricular blockCardiomyopathyCardiothoracic surgeryComplex ventricular arrhythmiasComplicated MI (failure); uncomplicated MI (dysfunction)Coronary artery diseaseDecrease in ejection fraction (EF) on exercise testing (EF of 30-

50% with dysfunction; < 30% with failure) DiabetesHypertensive heart diseaseValvular heart disease

Impairments, Functional Limitations, or DisabilitiesAbnormal heart rate response to increased oxygen demandAbnormal pulmonary response to increased oxygen demandDecreased ability or the inability to perform activities of daily

living (ADL) because of symptomsChange in baseline breath sounds with activityFlat or falling blood pressure response to increased oxygen

demand (failure)

Pattern D: CV Pump DysfunctionTher Ex

Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics

Aquatic programsGait and locomotion training - Walking and wheelchair

propulsion programs Increased workload over time

Balance, coordination, and agility training Developmental activities trainingMotor function (motor control and motor learning) training or

retrainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise

approachesTask-specific performance training

Breathing exercises Body mechanics, ergonomics, and postural stabilization

Body mechanics training Postural awareness training

Flexibility exercises Muscle lengthening Range of motion Stretching

Pattern D: CV Pump DysfunctionTher Ex

Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise

approachesWheelchair training

Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise

approaches Strength, power, and endurance training

Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices )

Standardized, programmatic, complementary exercise approaches

Task-specific performance training

Pattern E: Resp Pump DysfunctionInclusion Criteria

Risk Factors or Consequences of Pathology Elevated diaphragm and volume loss on chest radiographNeuromuscular disordersPartial or complete diaphragmatic paralysisPoliomyelitisPulmonary fibrosisRestrictive lung diseaseSevere kyphoscoliosisSpinal cord injury

Impairments, Functional Limitations, or DisabilitiesAbnormal or adventitious breath soundsAbnormal increased respiratory rate and decreased tidal

volume at restAirway clearance dysfunction secondary to ventilatory

pump impairmentDecreased to severely impaired strength and endurance of

ventilatory musclesDyspnea with self-careDyspnea with work tasksDys-synchronous or paradoxical breathing at rest or with

activity

Pattern E: Resp Pump DysfunctionTher Ex

Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics,

Aquatic programsGait and locomotion training - Walking and wheelchair propulsion

programs Movement efficiency and energy conservation trainingIncreased workload over time

Balance, coordination, and agility training Developmental activities trainingMotor function (motor control and motor learning) training or

retrainingNeuromuscular education or reeducationStandardized, programmatic, complementary exercise approachesTask-specific performance training

Breathing exercises Body mechanics, ergonomics, and postural stabilization

Body mechanics trainingPostural control trainingPostural stabilization activitiesPostural awareness training

Flexibility exercises Muscle lengthening Range of motion Stretching

Pattern E: Resp Pump DysfunctionTher Ex

Gait and locomotion trainingDevelopmental activities trainingGait trainingImplement and device trainingPerceptual trainingStandardized, programmatic, complementary exercise

approachesWheelchair training

Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise

approaches Strength, power, and endurance training for head and neck, limb,

pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises (including

concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights, hydraulics, elastic resistance bands, robotics

Standardized, programmatic, complementary exercise approaches

Task-specific performance training

Pattern F: Respiratory FailureInclusion Criteria

Risk Factors or Consequences of PathologyAdult respiratory distress syndromeAbnormal alveolar to arterial oxygen tension differencesCardiothoracic surgeryChronic obstructive pulmonary disease (COPD)Multisystem failurePneumoniaPre- and post-lung transplant or rejectionRapid rise in arterial carbon dioxide at rest or with activitySepsisThoracic or multisystem trauma

Impairments, Functional Limitations, or DisabilitiesAbnormal or adventitious breath soundsAbnormal vital capacity Airway clearance dysfunctionDyspnea at rest Dyssynchronous or paradoxical breathing patternImpaired gas exchange

Pattern F: Respiratory FailureTher Ex

Aerobic capacity/endurance activities using ergometers, treadmills, steppers, pulleys, weights, hydraulics, elastic resistance bands, robotics

Aquatic programsGait and locomotion training - Walking and wheelchair

propulsion programs Movement efficiency and energy conservation trainingIncreased workload over time

Balance, coordination, and agility training Neuromuscular education or reeducationPosture awareness training

Body mechanics, ergonomics, and postural stabilization Body mechanics training Postural control training Postural awareness training

Flexibility exercises Muscle lengthening Range of motion Stretching

Pattern F: Respiratory FailureTher Ex

Relaxation Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary

exercise approachesStrength, power, and endurance training for head and

neck, limb, pelvic-floor, trunk, and ventilatory musclesActive assistive, active, and resistive exercises

(including concentric, dynamic/isotonic, isometric, and plyometric - using manual resistance, pulleys, weights,

hydraulics, elastic resistance bands, robotics and mechanical or electromechanical devices )

Task-specific performance training

Therapeutic ExerciseAerobic capacity/endurance conditioning

or reconditioningAquatic programs Gait and locomotion training – Walk or W/CIncreased workload over timeMovement efficiency and energy conservation

training

Aerobic Capacity/Endurance Conditioning or Reconditioning

Activity, specific set up, time Improve oxygen demandUse of large muscle groups in a rhythmic fashion, over time

ModeMarching, Walking, Bike, Gardening

IntensityMax HR and take age adjusted50-70% depending on exercise test, age

Frequency4-5 days per week

Duration5-10 min bouts 3x/dayWork up to 30-40 min in one session

For Progression, see DeTurk & Cahalin, pg 447 & 448, Figs 15-7 & 15-8

Aerobic Capacity/Endurance -EvidencePatient Education on Risk or Disease

Exercise, DietDeconditioning

Rate of VO2 max decreases greatest the first week of bedrest1

Longer the bedrest the more diminished the VO2 max1

Use of HR, RPE, and METs

1 Convertinao VA, Med Sci Sports Exer, 1997:29:191

Aerobic Capacity/Endurance -EvidenceGroup-based (8-12 patients) simple aerobic dance

movements (with music)2 days a week for 4 monthsEach session lasted 50 minutes (including warm-up

and cool-down), followed by 15-30 minutes of counseling

The exercise program included three intervals of high intensity, during which patients were encouraged to reach 15-18 on the Borg scale for 5-10 minutes.

6 min walk, resistance on bike, bike time, MN Living with Heart Failure QOL all increased with significance as compared to the control group for 4 and 12 mn.

Nilsson et al, Long-term effects of a group based high intensity aerobic interval training program in patients with chronic heart failure, Am J Cardiol 2008; 102(9):1220-1224

Therapeutic ExerciseBalance, coordination, and agility training

Developmental activities trainingPosture awareness trainingStandardized, programmatic, complementary

exercise approachesTask-specific performance training

Balance, Coordination, and Agility TrainingMode

Massery TechniqueIntensityDurationFrequency

No set parameters

Balance - Evidence

Sensory-specific balance classes were held 3 times per week, for 1 hour each session, over 8-week

Tasks included standing or walking on various support surfaces, such as a rocker

board, foam, or narrow beam Standing in a tandem position, a semitandem position, on one leg, or in

a feet together Progressions to these tasks included simultaneous alterations of

visual and vestibular inputs Instructed to close their eyes, to engage vision with a reading or

tracking secondary task Perform balance tasks with a distracting background Instructed to tilt their head backward or to quickly move their head

side to side and up and down. Results

Less destabilization within the first 5 seconds following vibration with or without a secondary task than there was at baseline or in the falls prevention education group

Training effects were not maintained at the 8-week follow-up.

Westlake & Culham. Sensory-Specific Balance Training in Older Adults: Effect on Proprioceptive Reintegration and Cognitive Demands Physical Therapy. Oct 2007. Vol. 87, Iss. 10; p. 1274

Therapeutic ExerciseBody mechanics and postural stabilization

Body mechanics trainingPostural control trainingPostural stabilization activitiesPosture awareness training

Body Mechanics and Postural StabilizationModeIntensityDurationFrequency

No set parameters

Body Mechanics -EvidencePerfusion study in prone and supinePts were under conditions of

Normal breathing of room airUnassisted breathing of 45% O2Assisted PEEP

Ventral, Middle, Dorsal measurements with ventral more perfuse in prone and dorsal more perfuse in supine

Suki et al, Perfusion, Science Letter. Atlanta: Mar 25, 2008. pg. 2580

Body Mechanics -EvidencePt with ischemia of stable and unstable

anginaValsalva and measured QT of EKGWith valsalsa showed significant difference of

EKG changes of QT segmentAuthors related to carrying or lifting

restrictions of heavy objects with CAD

Balbay et al, Effects of valsalva maneuver on QT dispersion in patients with ischemic heart...Angiology; Nov 2001; 52, 11

Therapeutic ExerciseFlexibility exercises

Improve motion of the chest wall, lengthen anterior chest wall, improve hip and knee flexor shortening

Muscle lengtheningRange of motionStretching

Flexibility ExercisesMode

Isolate muscle or limited jointIntensity

After warmupDuration

Hold with no pain for 30 secFrequency

3-5 days/week

Flexibility - EvidencePt with ankylosing spondylosis3x/wk for 3 months18 stretching exercises of entire spine and

extremities along with aerobic and chest expansion exercises

Significant improvement in cervical and thoracic spine movement AND chest expansion

Ince et al , Effects of a Multimodal Exercise Program for People With Ankylosing Spondylitis, Physical Therapy; Jul 2006; 86, 7

Therapeutic ExerciseGait and locomotion training

Developmental activities trainingGait trainingImplement and device trainingStandardized, programmatic, complementary exercise

approaches

Gait and Locomotion TrainingModeIntensityDurationFrequency

No set parameters

Gait and Locomotion - EvidenceSee aerobic exerciseMassery Pairing

Massery et al, Coordinating transitional movements and breathing in patients with neuromotor dysfunction, NDTA Network, Nov/Dec 1996

Gait and Locomotion - EvidenceCase Report of pt with C6 tetraplegiaTaught breathing strategy and reducing

valsalva with tasks with w/cLean forwardPut foot on footplatePosterior lean for pressure relief

Able to perform tasks with new breathing strategies

Henderson, Application of Ventilatory Strategies to Enhance Functional Activities for an...Journal of Neurologic Physical Therapy; Jun 2005; 29, 2

Therapeutic ExerciseRelaxation

Breathing strategiesMovement strategiesRelaxation techniquesStandardized, programmatic, complementary exercise

approaches

Relaxation

ModeIntensityDurationFrequency

No set parameters

Relaxation -Evidence

Five 60 minute individual treatments with the Papworth method from a respiratory physiotherapist

No significant differences were found between the groups at baseline

SGRQ Symptom mean scores were lower in the Papworth method group than in the control group after treatment and at 12 months

The Nijmegen and HADS scores were also significantly lower in the intervention group than in the control group

Objective respiratory measures did not differ significantly across the groups, apart from breathing rate.

Holloway and West, Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial , Thorax 2007; 62(12): 1039-1042

Therapeutic ExerciseStrength, power, and endurance training for

head, neck, limb, pelvic-floor, trunk, and ventilatory musclesMore efficient motion

Active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)

Aquatic programsStandardized, programmatic, complementary exercise

approachesTask-specific performance training

Strength, Power, and Endurance Training for Trunk, Extremities and Ventilatory Muscles

Mode AAROM, AROM Resistance

Manual Weights

Intensity Incorporate breathing with resistance Resistance may start light and work up

8-12 reps, 1-3 sets Resistance of 1 rep max and then calculate

8-10 reps at 70% of max, 6 reps at 80% of max, 4 reps at 90% of max, 2 reps at 95% max and finally 1 rep at max

High weight, low reps for strength Low weight, high reps for endurance

Duration

Frequency Every other day or rotate muscle groups

Strength - Evidence Systematic review to determine the effect of inspiratory muscle training

(IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis.

Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (413 years

of age) (2) an IMT group was compared to a sham IMT, no intervention or other

intervention group (3) the study used a randomized controlled trial or cross-over design (4) it was published

Results: The search strategy yielded 36 articles Meta-analyses were limited to forced expiratory volume in 1 second (FEV1)

and forced vital capacity (FVC) No difference in effect between the IMT group and the sham and/or

control group. Individual study results were inconclusive for improvement in inspiratory

muscle strength One study demonstrated improvement in inspiratory muscle endurance.

Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for

outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear

Reid et al, Effects of inspiratory muscle training in cystic fibrosis: a systematic review, Clinical Rehabilitation. London: Oct 2008. Vol. 22, Iss. 10-11

Goals and Outcomes Impact on Pathology

Atelectasis Joint swelling, inflammation, restrictionNutrient delivery Osteogenic effects of exercise Pain Physiological responseSoft tissue swelling, inflammation,

restrictionIncreased oxygen demand symptomsTissue perfusion and oxygenation

Goals and Outcomes Impact on Impairments

Aerobic capacity is increased.Airway clearance is improved.Balance is improved.Endurance is increased.Energy expenditure per unit of work is decreased. Gait, locomotion, and balance are improved.Integumentary integrity is improved.Joint integrity and mobility are improved.Motor function (motor control and motor learning) is improved.Muscle performance (strength, power, and endurance) is increased.Postural control is improved. Quality and quantity of movement between and across body

segments are improved.Range of motion is improved.Relaxation is increased.Sensory awareness is increased.Ventilation and respiration/gas exchange are improved. Weight-bearing status is improved.Work of breathing is decreased

Goals and Outcomes Impact on Functional Limitations and DisabilitiesFunctional Limitations

Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved.Level of supervision required for task performance is decreased.Performance of and independence in ADL and IADL with or without devices and equipment are increased.Tolerance of positions and activities is increased.

Impact on disabilitiesAbility to assume or resume required self-care, home management, work (job/school/play), community, and leisure roles is improved.

Goals and Outcomes Risk Reduction/Prevention Health, Wellness, and Fitness

Risk Reduction/PreventionPreoperative and postoperative complications are

reduced. Risk factors are reduced.Risk of recurrence of condition is reduced.Risk of secondary impairment is reduced.Safety is improved.Self-management of symptoms is improved.

Impact on Health, Wellness, and FitnessFitness is improved.Health status is improved.Physical capacity is increased.Physical function is improved.

Goals and Outcomes Impact on Societal Resources& Patient Satisfaction

Societal ResourcesUtilization of physical therapy services is optimized.Utilization of physical therapy services results in efficient use of health care dollars.

Patient/client SatisfactionAccess, availability, and services provided are acceptable to

patient/client.Administrative management of practice is acceptable to

patient/client.Clinical proficiency of physical therapist is acceptable to

patient/client.Coordination of care is acceptable to patient/client.Cost of health care services is decreased.Intensity of care is decreased.Interpersonal skills of physical therapist are acceptable to

patient/client, family, and significant others.Sense of well-being is improved.Stressors are decreased.