‘Wells Criteria Score for DVT CUNICAL FINDINGS Poms ‘Adive concn ecient engeing, or wihin 4 ‘Simo or pols) Pda gamin centcattersiicinctelome +l Bedriddon recently for 3 days longer or # cere days or longer or major surgery Recently bedvidden for > 3 days or mojor surgery <4 wk +1 Localized lenderess along he distrbuton ofthe deep 4 ‘venous system Enire eg swollen “1 Calf swolng ot lost 3 em larger thon 1 ‘symptomatic sido tig edemo, confined to he sympemati leg “ Previously documented DVT “1 ‘Abersatveciognoseo DVT a ely or more Fly 2 Tot! Ctera Pint Count nicl probability ofa DVT with core: YT Kiely 22 YT wnkaly 2 ‘Wl, Doss hi pao have do win Honan? JAMA, 2006 Jon 11 2952), 199-207, > Cardiac Rehabilitation Cardiac Rehabilitation 223 (4) Graded compression stockings (GCS). {. Don't wse Homans sign to evaluate patients suspected of deep vein thrombosis (DVT) (White N, et al. Phys ‘Ther. 2015), 4, Pulmonary embolism. a, Presents abruptly with chest pain and dyspnea, also. diaphoresis, cough, and apprehension; requires emergency treatment. b.Life threatening: 20% with acute PE die almost immediately; 40% die within 3 months, ¢. Can result in chronic thromboembolic pulmonary hypertension with reduced oxygenation and pul- monaty hypertension. Can lead to right heart dysfunction and failure 5. Chronic postthrombotic syndrome. a. A combination of clinical signs and symptoms that persists after an LE DVI; thrombosis resolution is incomplete. b. Symptoms include pain, intractable edema, limb heaviness, skin pigmentation changes, and leg ulcers. «¢. Leads to reduced quality of life and impaired func- tional mobility. 6. Chronic venous stasis/incompetence. a. Venous valvular insufficiency: from fibroetastic degeneration of valve tissue, venous dilation, b. Classification: (1) Giade t: inila ae superficial veins. (2) Grade I: increased edema, multiple dilated veins, changes in skin pigmentation. (3) Grade IIE: venous claudication, severe edema, cutaneous ulceration, 1g, lull edema, Atlaced 1, Exercise tolerance test (ETT, graded exercise test), a. Purpose: to determine physiological responses dur- ing a measured exercise stress (increasing workloads); allows the determination of functional exercise capac- ity of an individual and detects presence of ischemia, (1) Serves as a basis for exercise prescription, Symp- tom-limited EIT'is typically administered prior to start of Phase Il outpatient cardiac rehabilita- tion program and following cardiac rehabilita- tion as an outcome measure. (2) Used as a screening measure for CAD in asymp- tomatic individuals. (3) ETT with radionuclide perfusion: (a) A pharmacological stress test is used ‘when patient is unable to perform a regu- lar EIT. (b) Common medications used to increase car- diac demand are adenosine (increases heart rate), dobutamine (increases contractility), and persantine (vasodilates) (c) Imaging is used to detect decreased blood flow to myocardium,226 IEE Diflerential Diagnosis: Peripheral Vascular Diseases “TuenarvE0 - Cardiovascular and Lymphatic Physical Therapy CHRONIC ARTERIAL INSUFFICIENCY ‘conc VENOUS INSUFFCENCY Bilogy pba Teal Thranbopobis | Embc ioe Inllerotry proces Win cbarion (bt | feeneree Tifeders Agere dD yoo Verout parison Srating Noakes Dibots eine Inerod ri ander sigh higher in man Gender female Dypdenia Ae Hyperion Inereosed BM Vgpeherncoaia Sedentory Keston ston Ree (acon Amr) Sis yp: tied loan el deol veer beet Poin Severe ml ichiitritet avon Wor wth xc, olive by re Re pin ino seve ive ‘ae fae, comping,eumbnes Pores oe re isd cb pe ordre of fot May ocr high ip, or bloc Decrease or bio! pie Falor of rlot on Seaton Dependent br ek iy dy shin los athe Nal donges Colette Location of poin Vorculor aes’ Acite ‘Acde atari obstucion: distal pein, preset, polo, pulseless, sudden onset Ucerchon ‘and may appecr punched out ‘May develop in tos, Fe, or erees of trauma; pale or yellow fo back eschr, gangrane may devslop gular in shape ligamentous laxity Minimal moderetesteody pin ‘Aching pain in lower log wih prolonged standing or iting {aependenoy Superialpin long cour of via vac comporenterderess Venous dileition or vericsiy Edema: moderaie fo severe, especially cfer probed ‘depondency Hemosiiin dept: a, eymete, emai ‘kin Lipodermalosdeossfibosing ofthe sbcvaneousHssve May lead 0 sosis derma, ellis ‘Acute thrombophlebitis (deep venous tembosis, OV}: al ain, aching, edeme, muscle endemess, 50% asymp female Mey devel ot sides of ares, especially medic mallets ‘long the course of veins; gangrane cbsent pain, shal- low, exudotve, and hove granlsion tsi in he base; regular borders "Ada rom coy, Slog Bae Guide o Phyl amnaten ond Hor Taling, kad, Pode, Lppincot Willons& Wilkins, 2003 b. Testing modes, (1) Treadmill and eycle ergometry (leg or arm tests) allow for precise calibration of the exercise workload, (2) Step test (upright orsitting) can also be used for fitness screening, healthy population. ETT may be maximal or submaximal. (1) Maximal ETT: defined by target endpoint heart rate, Maximal ETTS should only be completed in settings with ACLS (advanced cardiac life support) trained individuals with appropriate ‘equipment to handle abnormal responses. (a) Age predicted maximum heart rate. ‘© 220 ~ age: high degree of error associated with it, especially in younger and older adults #208 - 0.7 x age: less error associated with this across different populations. (b)Heart-rate range (Karvonen's formula): 660%-80% (HR max - resting HR) + resting HRs target HR, (2) Submaximal ETT: symptom-limited or termi- nated at 85% of age predicted heart rate max; safe in all settings, used to evaluate the early recovery of patients after MI, coronary bypass, or coronary angioplasty. 4, Continuous ETT: workload is steadily progressed. (1) Step test: workload increases every 2-3 min- utes, allowing the patient to reach steady state. (2) Ramp test: workload increased every minute so patient is not permitted to reach steady state,| | | | | | €. Discontinuous (interval) EIT: allows rest in between workloads/stages, used fox patients with more pronounced CAD. f. Positive ETT: indicates myocardial oxygen sup- ply is inadequate to meet the myocardial oxygen demand; positive for ischemia, 8, Negative ETT: indicates that at every tested phy: logical workload there is a halanced oxygen sup- ply and demand. hi. False-positive ETT: testis interpreted as positive but the patient does not have ischemia i, False-negative ETT: test is interpreted as negative but the patient has ischemia, j, Functional 6-Minute Walk Test (6MWT): patients ‘walk as fa as they can in 6 minutes, taking as many rests as needed. Highly correlated to other ETT, sub: max and maximal VO, Monitoring during exercise and recovery. a. Patient appearance, signs and symptoms of exces- sive effort and exertional intolerance; examine for: (1) Persistent dyspnea, (2) Dizziness or confusion. (3) Anginal pain. (4) Severe leg claudication. (5) Excessive fatigue. (6) Pallor, cold sweat. (2) Ataxia, incoordination. (8) Pulmonary rales b, Changes in HR: HI increases linearly as a function of increasing workload and oxygen uptake (VO,), plateaus just before maximal oxygen uptake (VO, max) «Changes in BP: systolic BP should rise with increas- ing workloads and VO,; diastolic BP should remain about the same. 4. Rate pressure product (RPP): the product of systolic BP and HR (the last two digits of a 5-digit number are dropped) is often used as an index of myocar- dial oxygen consumption (MVO,), (2) Increased MVO, is the result of increased coro- nary blood flow. (2) Angina is usually precipitated at a given RPP. «. Ratings of perceived exertion (RPE): developed by Gunnar Borg, Allows subjective rating of feelings during exercise and impending fatigue. Important to use standanclized instiuctions to reduce misinter- pretation (1) RPE increases linearly with increasing exercise intensity and correlates closely with exercise heart rates and work rates. (2) RPE has intra-user relial inter-user reliability: Ratings can be influcnced by psychological factors, mood states, environ- ‘mental conditions, exercise modes, and age. (3) RPE is an important measure for individu- als who do not exhibit the typical rise in HR Cardiac Rehabilitation 225 with exercise (eg, patients on medications that depress HR, such a8 beta blockers). (4) Category scale (original Borg scale): rates exer- cise intensity using numbers from 6 to 20, with descriptors from very, very light (7) to some what hard (13) to very, very hard (19). (5) Category-ratio scale (Borg): rates exercise inten- sity using numbers ftom 1 to 10 with descriptors from 0 (nothing at all) to very weak (1) to mod- erate (3) to strong (5) to extremely strong (10). £ Pulse oximetty: measure arterial oxygen saturation levels (Sa0,) before, during, and after exercise & ECG changes with exercise: healthy individual. (1) Tachycardia: heart rate inerease is directly pre Portional to exercise intensity and myocardial work. (2) Rate-related shortening of QI interval 3) ST segment depression, upsloping, less than 1mm. (4) Recluced R wave, increased Q wave. (5) Exertional arrhythmias: rare, single PVCs. h.ECG changes with exercise: an individual with myocardial ischemia and CAD. (2) Significant tachycardia: occurs at lower intensi- ties of exercise or with deconditioned individu. als without ischer (2) Excitional aulytunias: incieased frequency of ventricular archythmias during exercise and/or recovery. (3) STsegment depression; horizontal or downslop. ing depression, greater than 1 mm below base line is indicative of myocardial ischemia, i. Delayed, abnormal responses to exercise, can occur hours later. (1) Prolonged fatigue. (2) Insomnia. (3) Sudden weight gain due to fluid retention. (4) Hypotension, especially in patients with heart failure. 3. Ambulatory monitoring (telemetry), a. Continuous 24-hour ECG monitoring, b.Allows documentation of arthythmias and of ST segment depression or elevation, silent ischemia (if, assessing via 12 leads only) 4, Transtelephonic ECG monitoring, a, Used {0 monitor patients as they exercise at home. 5. Activity levels: MEIS (metabolic equivalents) @. MET: the amount of oxygen consumed at rest (sit- ting); equal to 3.5 ml/kg per minute. b. MET levels (multiples of resting VO, ) can be directly determined during ETT: using collection and analy- sig of expired air; not routinely dun © MEF levels can be estimated during ETT during steady state exercise; the max VO, achieved on ETT. is divided by resting VO.; highly predictable with standardized testing modes.