Chapter 5
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Transcript of Chapter 5
CLINICAL EXERCISE TESTING
To evaluate person’s ability to tolerate increasing levels of work output parameters measured include but are not
limited to ECG hemodynamic response symptomatic ischemia electrical abnomralities exertion related problems
APPLICATIONS
Diagnostic, Prognostic and Therapeutic
Exercise Prescription Occupation Activities of daily living
DIAGNOSTIC TESTING
Not appropriate for the general population
Age, gender, risk factors , symptoms and vigor of exercise will determine test necessity
Geared toward individuals with a higher probability of disease
TESTING FOR DISEASE SEVERITY (PROGNOSIS)
Symptoms, functional capacity and ischemia during exercise are evaluated
Magnitude of ischemic response and at what replicable point does it occurr
Double-Product --SBP x HR= myocardial oxygen consumption
TESTING AFTER AN INSULT
Prior to hospital discharge Submax tests may be used Symptom limited tests done 4 day
post MI Use to gage activity level and
therapy
FUNCTIONAL TESTING
Used for exercise prescription, activity counseling, or disability limitations
Usually described in terms of a percentage of “normal” in units of METS
CLINICAL TEST MODALITIES
Treadmill--yields the highest VO2 and HR
Hand rails--needs and purposes Stop belt--Stop exercise Additional directions for the novice
like???
MORE
Cycle ergometers--lower VO2 (5-25%) and HR
Better HR and BP measures Less expensive, less noise, less space Driven by patient motivation Localized fatigue Arm ergometery-lower VO2 (20-30%)
PROTOCOLS Based on purpose of test, desired
outcomes and the individual Bruce, Ellestad--larger incremental
changes-for healthy Naughton, Balke-Ware, USAFSAM--smaller
incremental changes--for older and deconditioned
Submax tests-used for individuals that are too unstable or high risk to take to max
PROTOCOLS Submax tests are usually terminated based
on a predetermined end point like 120 bpm or a MET level of 5
Even so, most end points are patient specific
Ramp Protocol-- increasingly popular--based on constant and continuous increase in workload-seemingly more accurate in estimations and more individualized
TESTING FOR RETURN TO WORK POST INSULT 15-20% of MI survivors do not return to
work Medical and nonmedical factors
contribute to outcome Job demands, timelines for return to
work, rehab based on job demands, and to determine special work related needs
GXT can provide necessary info but specialized tests can be used also
SPECIALIZED TESTS
Weight carrying tests-evaluates tolerance for dynamic and static lifting
Repetitive lifting--evaluates tolerance to bouts of lifting
MEASURES DURING TESTS
Pretest--ECG, HR, BP, RPE--supine, sitting, standing
Exercise--3-lead ECG every min., 12-lead ECG last 15 sec, of each stage, BP last min. of each stage, RPE last min. of each stage--BP, 12-lead ECG, and RPE at MAX
Posttest--same as during the exercise portion
MEASURING EXPIRED GASES The most accurate way of determining
VO2, functional capacity and VT Not necessary for all clinical testing Most appropriate for: evaluating a
therapeutic intervention, in research, when cause of exercise limitation is uncertain, evaluation for prognosis and need for transplantation, and exercise prescription for cardiac rehab
ECG MONITORING
Quality of ECG very important Skin prep is essential
shave alcohol abrasion
Electrode placement in supine position
10 electrodes for 12 lead
SUBJECTIVE RATINGS
RPE- 0-10 or 6-20 scale Note instructions on p. 105-6 Symptomatic scales are different
rating for angina rating for leg pain rating for dyspnea
POST EXERCISE PERIOD
Healthy individuals do an active and passive recovery
Symptomatic individuals may require supine recovery
Test termination based on absolute or relative indications
EXERCISE TESTING WITH IMAGING
Used to determine extent or distribution of disease
An additional confirmation when ECG changes are hard to interpret
Echocardiography-cheaper than nuclear testing but operator dependent identifies wall abnormalities for ischemia
Nuclear Imaging
-limitations include exposure to radiation, additional equipment and personnel and physician training in nuclear medicine and interpretation
advantages include sharper and improved images over 180 degrees rotation--depicts heart in 3 dimensions so multiple myocardial segments can be viewed separately
PHARMACOLOGIC TESTING
For patients not able to do an exercise test--to establish diagnosis of CAD or evaluating efficacy of CABG
Dobutamine and Thallium are the most used tests
Images obtained are similar to echocardiography
CONSIDERATIONS FOR PULMONARY PATIENT
Degree of dyspnea Cause of dyspnea Distinguish between cardiac or
pulmonary limitations Deconditioning factors such as
obesity, anxiety Exercise induced oxygen
desaturation