Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
533 Cards in this Set
- Front
- Back
Annual incidence and lifetime prevalence of low back pain in the US
|
- annual incidence: 5-10%
- lifetime prevalence 60-90% |
|
General guidelines for the clinical course of low back pain
|
50% resolve by 1-2 weeks
90% resolve by 6-12 weeks but 85% recur within 1-2 years |
|
Percentage of patients with low back pain that continue with residual complaints
|
10%
|
|
Back pain with gait ataxia and upper motor neuron changes is a red flag for
|
Myelopathy
|
|
Back pain with bowel, bladder and sexual dysfunction is a red flag for
|
Cauda equina syndrome
|
|
Back pain with night pain and weight loss is a red flag for
|
Tumor
|
|
Back pain with fevers/chills is a red flag for
|
Infection
|
|
Top 2 causes of work absenteeism
|
- colds
- low back pain |
|
Describe the general expectations for return to work for patients with low back pain based on how many months they're been off work
|
- 6 months: 50% return
- 12 months: 25% return - 24 months: 0 return |
|
What is the Joint of Luschka
|
degenerative changes in the cervical spine that lead to an uncovertebral joint
|
|
What do you call the changes in the cervical spine that lead to an uncovertebral joint?
|
Joint of Luschka
|
|
What is unique about the vertebral bodies of C3-C7
|
They have uncinate processes projective superiorly from the lateral aspect of the vertebral body
|
|
Which cervical vertebrae have a bifid spinous process
|
C2, C3, C4, C5, C6
|
|
What is the shape of the spinous process of C3, C4, C5, C6
|
Bifid
|
|
What is the shape of the C7 spinous process
|
nonbifid
|
|
Name 2 important anatomical features of the atlas (c1)
|
- ring shaped bone with 2 lateral masses
- no vertebral body or spinous process |
|
Name 2 important anatomical features of the axis (C2)
|
- vertebral body has odontoid process
- bifid spinous process |
|
The posterior border of the dens foramen is the
|
transverse ligament
|
|
2 important anatomical features of the thoracic vertebrae
|
- facets for the head of the rib
- long spinous process |
|
Define lumbar sacralization
|
An anomalous fusion of the 5th lumbar vertebrae with the sacrum
|
|
What is the incidence of lumbar sacralization?
|
- 1% complete
- 6% incomplete |
|
What are the 3 joints that form the motion segment in the lumbar spine?
|
1- disc
2- zygapophyseal joint 3- zygapophyseal joint |
|
What are the foramina like in the sacrum?
|
There are 4 PAIRS of foramina (anterior and posterior)
|
|
How many fused vertebrae are in the sacrum?
|
5
|
|
Define sacral lumbarization
|
An anomalous partial or complete nonunion of the 1st and 2nd segments of the sacrum
|
|
Incidence of sacral lumbarization
|
4%
|
|
5 major components of the zygapophyseal joint
|
- superior articular process
- inferior articular process - joint capsule - articular cartilage - meniscus |
|
Which vertebral joints do not participate in true zygaophyseal joints?
|
Atlantoaxial
Atlanooccipital |
|
General orientation of the facets joints as you progress throught the spine
|
cervical: coronal
thoracic: coronal lumbar: starts sagital, progresses to coronal by L5/S1 |
|
Orientation of cervical z-joints
|
coronal
|
|
Orientation of thoracic z-joints
|
coronal
|
|
Orientation of lumbar z-joints
|
start sagital, then progresses to coronal by L5/S1
|
|
Weight bearing on the facet joint is increased in which position?
|
extension
|
|
Major function of the z-joints
|
Direct vertebral motion including resisting shearing and rotation forces
|
|
The intervertebral disc is made of these 2 parts
|
- nucleus pulposus
- surrounding annulus fibrosus |
|
Major molecular components of the nucleus pulposus
|
- water
- proteoglycans - network of type II collagen |
|
The annulus fibrosus is made of mainly
|
Type I collagen fibers
|
|
General arrangement of collagen fibers in the annulus fibrosus
|
obliquely running lamellae
|
|
Where does the annulus fibrosus attach?
|
At the vertebral endplates
|
|
What forces is the annulus fibrosus good and bad at resisting
|
- Good: distraction, bending
- Bad: torsion |
|
What makes up the top and bottom of the intervertebral disc?
|
The vertebral endplate
|
|
What is the vertebral endplate?
|
cartilaginous covering of the vertebral boy apophysis
|
|
What is the vascular supply of the intervertebral disc?
|
Essentially avascular by adulthood
|
|
What are the 2 major functions of the intervertebral disc?
|
- allows for vertebral body motion
- weight bearing |
|
What happens to the nuclear water content of the intervertebral disc with age?
|
decreases
|
|
What happens to the ratio of chondroitin:keratin of the intervertebral disc with age?
|
decreases
|
|
What happens to proteoglycan molecular weight of the intervertebral disc with age?
|
decreases
|
|
What happens to the fibrous tissue of the intervertebral disc with age?
|
increases
|
|
What happens to the cartilage cells of the intervertebral disc with age?
|
increases
|
|
What happens to the amorphous tissue of the intervertebral disc with age?
|
increases
|
|
What general part of the nerve gives contributions to the trunk musculature and the lumbosacral plexus?
|
the ventral primary rami
|
|
In general, the lateral branch of the dorsal primary ramus innervates
|
- iliocostalis
- skin |
|
In general, the intermediate branch of the dorsal primary ramus innervates
|
- longissimus
|
|
In general, the medial branch of the dorsal primary ramus innervates
|
- multifidus
- spine rotators - interspinalis - intertransversei - posterior spinal ligaments - z-joints |
|
What innervates the iliocostalis?
|
lateral branch of the dorsal primary ramus
|
|
What innervates truncal skin?
|
lateral branch of the dorsal primary ramus
|
|
What innervates the longissimus?
|
intermediate branch of the dorsal primary ramus
|
|
What innervates the multifidus?
|
medial branch of the dorsal primary ramus
|
|
What innervates the spinal rotators?
|
medial branch of the dorsal primary ramus
|
|
What innervates the interspinalis?
|
medial branch of the dorsal primary ramus
|
|
What innervates with intertrnsversei
|
medial branch of the dorsal primary ramus
|
|
What innervates with posterior spinal ligaments?
|
medial branch of the dorsal primary ramus
|
|
What innervates the z-joints?
|
medial branch of the dorsal primary ramus
|
|
What does the sinuvertebral nerve innervate?
|
- posterior longitudinal ligament
- posterior disc - anterior dura - vertebral body - anterior-lateral disc |
|
What innervates the posterior longitudinal ligament?
|
the sinuvertebral nerve
|
|
What innervates the posterior disc?
|
the sinuvertebral nerve
|
|
What innervates the anterior dura?
|
the sinuvertebral nerve
|
|
What innervates the vertebral body?
|
the sinuvertebral nerve
|
|
What innervates the anterior-lateral disc
|
the sinuvertebral nerve
|
|
Define axial cervical pain
|
pain occurring in all or part of a corridor extending from the inferior occiput inferiorly to the the superior interscapular region, localizing to the midline or just paramidline
|
|
Define cervical radicular pain
|
pain involving the shoulder girdle and distally
|
|
Incidence of neck pain
|
30%
|
|
Prevalence of neck pain
|
9-18%
|
|
Percentage of those with traumatic neck pain that becomes chronic
|
40% (10% severe)
|
|
Incidence of cervical radiculopathy
|
83.2/100,000
|
|
Peak age from cervical radiculopathy
|
50s
|
|
Orientation of the cervical z-joints
|
45 deg sagital inclination
|
|
C1-2 allows what % of cervical rotation
|
about 50%
|
|
In cervical spine, lateral flexion is coupled with ____
|
rotation in the same direction
|
|
Cervical spine segments at C2-3 and above move primarily in what directions?
|
rotation
|
|
Cervical spine segments below C2-3 move primarily in what directions?
|
flexion, extension and lateral bending
|
|
The z-joints are generally innervated by the
|
medial branches of the cervical dorsal rami
|
|
The C0-1 joint is also innervated by
|
C1 ventral ramus
|
|
The C1-2 joint in also innervated by
|
C2 ventral ramus laterally and the sinuvertebral nerves of C1-3 medially
|
|
The greatest amount of flexion in the cervical spine occurs at what level?
|
C4-5 and C5-6
|
|
The greatest amount of lateral bending in the cervical spine occurs at what level?
|
C3-4 and C4-5
|
|
Which vertebrae have joints of Luschka?
|
C3-7
|
|
Normally the dorsal root ganglia/radicular complex takes up what % of space in the neural foramen?
|
25%
|
|
What besides nerve tissue is in the neural foramen
|
- adipose tissue
- Hoffman's ligaments - radicular artery - numerouss venous conduits (encircle nerve root) |
|
Innervation of the annulus fibrosis
|
posterolaterally by the sinuvertebral nerve, anteriorly by the vertebral nerve
|
|
How do discs contribute to the normal cervical lordosis?
|
They are thicker anteriorly
|
|
The mechanism of somatically referred pain involves ______
|
convergence
|
|
Describe convergenge is referred pain
|
afferents from spine and distal limb converge on second-order neurons within the spinal cord
|
|
Does cervical disc pain tend to be unilateral or bilateral?
|
30-50% in bilateral
|
|
The structures that threaten nerves in the intervertebral foramina
|
- zygapophyseal joints
- uncovertebral joints - intervertebral disk |
|
Ddx causes of cervical radiculopathy
|
- arthritis
- tumor - trauma - sarcoidosis - arteritis - cerebral palsy |
|
2 general categories of cervical intervertebral disk injury
|
- internal disruption
- herniation |
|
Subcategories of intervertebral disk herniation
|
- protrusion
- extrusion - sequestration |
|
Define cervical strain
|
musculotendinous injury produced by an overload injury due to excessive forces imposed on the cervical spine.
|
|
Define cervical sprain
|
overstretchning or tearing injuries of spinal ligaments
|
|
Do cervical muscles have tendons?
|
Many just have direct insertions with myfascial tissue
|
|
% of patients in a MVC that develop neck pain within 24 hours
|
30%
|
|
Cervical sprain and strain injuries account for what % of neck pain in the US
|
85%
|
|
Describe the movement of the c-spine during MVC acceleration-decceleration injury
|
90ms: posterior neck muscles activate
100ms: s-shaped curve 200ms: neck maximally extends to 45deg and then starts forward flexion; neck extensors eccentrically contract |
|
What is the boundary like between the anterior longitudinal ligament and the intervertebral disk?
|
merges imperceptibly
|
|
Muscles most commonly involved in gaurding during neck pain
|
upper trapezius, SCM
|
|
When is imaging indicated in soft tissue neck injury?
|
- neuro or motor abnormalities
- significant pain in the limbs |
|
Progression of ordering imaging in neck pain
|
- plain radiographs for fracture/bony malalignment; +/- flex/ext to eval for instability
|
|
Non-specific loss of cervical lordosis after neck soft tissue injury is thought to be due to
|
muscle splinting
|
|
General 3 step approach to treating soft tissue neck injuries
|
- controlling pain/inflammation (NSAIDs/acetaminophen)
- mitigate deconditioning - functional restoration program |
|
Soft cervical collars used as part of treatment for neck soft tissue injuries should be d/c'd at _____
|
72 hours
|
|
4 major s/s in cervical radicular pain
|
- myotomal weakness
- paresthesias - sensory disturbances - stretch reflex changes |
|
What's the difference between cervical radicular pain and cervical radiculopathy?
|
radiculopathy implies pathological changes at the nerve root
|
|
Most commonly involved levels of cervical radiculopathy (most to least)
|
- C7
- C6 - C8 - C5 |
|
Estimated incidence of cervical radiculopathy
|
83/100,000
|
|
Decade when cervical radiculopathy appears most common
|
50s
|
|
#1 and 2 causes for cervical radiculopathy
|
-1-cervical intervertebral disk herniation
- cervical spondylitic changes |
|
4 major changes considered part of spondylosis
|
- ligamentous hypertrophy
- hyperostosis - disk dengeneration - zygapophyseal joint arthropathy |
|
2 major (general) ways that herniated disk causes radicular pain/radiculopathy
|
- mechanical compression
- biochemical irritation |
|
Radicular pain referred to the medial scapular edge is usually from what level(s)?
|
C5-7
|
|
Radicular pain referred to the superior trapezius is usually from what level(s)?
|
C5-6
|
|
Radicular pain referred to the precordium is usually from what level(s)?
|
C5-6
|
|
Radicular pain referred to the deltoid/lateral arm is usually from what level(s)?
|
C5-6
|
|
Radicular pain referred to the posteromedial arm is usually from what level(s)?
|
C7-T1
|
|
What is the shoulder abduction relief sign?
|
Relief of radicular symptoms by elevating tHe ipsilateral humerus.
|
|
What is the classic position in patients with new intervertebral disk herniation?
|
patients clinically tilt toward the side of the disk herniation.
|
|
Where do you look for muscle wasting in C5-6 radiculopathy?
|
suprascapular fossae, infrascapular fossae, deltoid
|
|
Where do you look for muscle wasting in C7 radiculopathy?
|
tricpes
|
|
Where do you look for muscle wasting in C8 radiculopathy?
|
thenar eminence
|
|
Where do you look for muscle wasting in T1 radiculopathy?
|
first dorsal interossei
|
|
Is severe muscle weakness consistent with single level radiculopathy?
|
Not so much; ddx should then include:
- multilevel radiculopathy - alpha motor neuron disease - plexopathy - focal peripheral neuropathy |
|
3 major reasons for a positive L'hermitte's sign
|
- tumor cervical cord involvement
- spondylosis - multiple sclerosis |
|
Progression of imaging in cervical radiculopathy
|
- plain x-rays (add views if trauma, arthritis, etc)
- CT if concerned about bone * MRI is modality of choice |
|
Imaging gold standard for degenerative cervical spine conditions
|
CT myelography
|
|
Imaging test of choice for disk pathology in patients who cannot undergo MRI
|
contrast enhanced CT
|
|
General electrodiagnostic guidelines for radiculopathy
|
abnormalities in two or more muscles innervated by the same root but different peripheral nerves, provided that normal findings are observed in muscles innervated by adjacent nerve roots; need one motor and sensory nerve conduction study in affected limb to rule out plexus or peripheral process; look at corresponding muscles in contralateral limb
|
|
For screening upper limb radiculopathy 6 upper limb muscles + paraspinals gives ____ sensitivity
|
94-99%
|
|
How can you use EMG/NCS to predict motor recovery in radiculopathy?
|
If CMAP amplitude is at least 50% of nomral side then functional recovery can be expected with conservative care
|
|
4 major goals of rehab for cervical radiculopathy
|
- resolution of pain
- improve myotomal weakness - avoid spinal cord complications - prevent recurrence |
|
Definitive indication for surgery for cervical radiculopathy
|
progressive neurologic deficit
|
|
General precautions in cervical radiculopathy
|
- no heavy lifting
- avoid extension, axial rotation and ipsilateral flexion |
|
General guidelines for superficial heat and cold in cervical radiculopathy
|
- heat: 30 min tid
- cold: 15-30 min qid |
|
Should US be used in cervical radiculopathy?
|
No, increase metabolic response/inflammation can aggravate nerve root injury
|
|
Soft cervical collar limit flexion and extension by about ____%
|
26%
|
|
The neck should generally be maintained in a _______ position at rest
|
neutral or slightly flexed (position thin part of soft collar anteriorly)
|
|
Typical force needed in cervical traction
|
25 pounds, at 24 degrees of pull for 25 minutes (this will distract midcervical segments)
|
|
Contraindications to cervical traction
|
- myelopathy
- L'hermitte's sign - rheumatoid arthritis - atlantoaxial subluxation |
|
Medications useful in cervical radiculopathy from herniated disk
|
* NSAIDs
- muscle relaxants for sleep - TCAs for sleep - antiepileptics for persistant pain (start qhs and titrate up) - short acting narcotics for severe pain disrupting sleep |
|
Key components of stabilization program in cervical radiculopathy
|
- spinal flexibility
- postural reeducation - conditioning (cervical strengthening) |
|
Key muscles to have strong in cervical radiculopathy
|
- trapezius
- serratus anterior - rhomboids - rotator cuff |
|
When might a fluoroscopically guided diagnostic selective nerve root block be helpful for considering the diagnosis of cervical radiculopathy?
|
when the exam and EMG/NCS are equivocal in the setting of abnormal MRI
|
|
Sensitivity and specificity of diagnostic selective nerve root blocks for cervical radiculopathy
|
100% sensitive
87+% specific |
|
Natural history of cervical radiculopathy from herniated disk
|
~60% have a gradual resolution of symptoms
|
|
In general, surgical outcomes studies for cervical radiculopathy indicate a good or excelelnt result in ____% of patients
|
80-96%
|
|
In general, how do outcomes from surgery and conservative care for cervical radiculopathy compare?
|
surgery provides faster pain relief but they are about the same at a year
|
|
Estimated prevalence of chronic traumatic cervical zygapophyseal joint-mediated neck pain
|
~60%
|
|
Painful cervical zygapophyseal joints most commonly occur in association with a ________
|
symptomatic intervertebral disk at the same level
|
|
% of patients with chornic zygaophyseal cervical joint pain that also complain of headache
|
60+%
|
|
% of patient with posterior headaches after whiplash injyury who have C2-3 z-joint pain
|
50%
|
|
Traumatic lower cervical pain from z-joints is usually at what level?
|
C5-6
|
|
Atraumatic z-join pain is often from ____
|
- spondylosis
- improper biomechanics (usually effects just one joint) |
|
Are there any clear physical exam findings for z-joint pain?
|
no
|
|
What do you often find on exam with painful C1-2 joint?
|
focal suboccipital pain that occurs/exacerbated with 45 deg cervical flexion and then axial rotation
|
|
General guidelines for imaging in z-joint pathology of the cervical spine
|
Unclear usefulness
- x-ray or CT if fracture/malalignment suspected - NM scan does not clearly reflect symptomatic findings |
|
% of diagnostic z-joint blocks that are false positives
|
30%
|
|
Define cervical internal disk disruption
|
intervertebral disk has lost its normal internal architecture but maintains a preserved external contour in the absence of nerve root compression
|
|
% of patients with traumatic chronic neck pain with an element of cervical internal disk disruption
|
60%
- 20% with CIDD - 20% with CIDD and facet problem |
|
What's better for cervical internal disk disruption, non-operative or operative intervention?
|
they are about the same in non-litigation cases
|
|
11 elements often part of the symptom complex of cervical internal disk disruption
|
- posterior neck pain
- occipital/suboccipital pain - upper trap pain - inter- and periscapular pain - non-radicular arm pain - vertigo - tinnitus - ocular dysfunction - dysphagia - facial pain - anterior chest wall pain |
|
Typical exacerbating factors for cervical internal disk disruption
|
- prolonged sitting
- coughing - sneezing - lifting |
|
Typical alleviating factors for cervical internal disk disruption
|
- lying supine
- resting recumbent with head supported |
|
Markers of disk degeneration on MRI
|
- disk desiccation
- loss of disk height - annular fissure - osteophytosis - reactive end plate changes - decreased T2 signal |
|
Is MRI helpful in detecting symptomatic cervical disks
|
no
|
|
Preferred imaging for painful cervical disks
|
functional imaging such as provocative diskography
|
|
Treatment of cervical internal disk disruption
|
- NSAIDs
- Adjunct meds for sleep - modalities to modulate pain - cervical traction - functional restoration program |
|
Guidelines for checking renal function while patients are on NSAIDs (American College of Rheumatology)
|
If otherwise healthy, check renal function at 6 weeks, if normal check again at 12 months
|
|
Where do cervical internal disk disruptions and facet pathology overlap in referred symptoms?
|
head and face pain
|
|
What levels are transforaminal epidural steroid injections typical performed at for cervical internal disk disruptions?
|
- C7 if pain at the base of the neck
- C5/C6 if pain in upper neck/head |
|
What is the surgical option for pain from cervical degenerative disk disease?
|
fusion
|
|
Most common cervical cord lesion after middle age
|
cervical spondylitis myelopathy
|
|
Typical age of onset of cervical myelopathy
|
over 50
|
|
Is cervical myelopathy more common in men or women?
|
men
|
|
8 causes to consider for cervical myelopathy
|
- spondylosis
- multiple sclerosis - motor neuron disease - vasculitis - neurosyphilis - subacute combined degeneration - syringomyelia - spinal tumors |
|
% of patients with cervical myelopathy NOT due to simple degeneration
|
17%
|
|
Proportion of patients with cervical myelopathy with bladder/bowel symptoms
|
about 1/3
|
|
What is the typical mechanism for intrinsic hand wasting in cervical myelopathy?
|
compression of anterior horn cells
|
|
% of middle aged patients with cervical myelopathy that have ossification of posterior longitudinal ligament on imaging
|
27%
|
|
What cervical spine central canal diameter in a symptomatic patient supports a diagnosis of myelopathy?
|
less than 10mm
|
|
% of patients under the age of 64 with asymptomatic central cervical spine stenosis
|
16%
|
|
Minimum % reduction in cross-sectional area of the cervical spine canal to cause symptoms
|
30%
|
|
Imaging finding for cervical myelopathy that best predicts surgical outcome
|
transverse area of the cord
|
|
% of patients with cervical myelopathy who have improvement in motor or sensory symptoms with conservative care
|
30-50%
|
|
Indications for surgery in cervical myelopathy
|
- progressive symptoms
- severe symptoms - failure of conservative therapy |
|
General approach to anterior vs. posterior decompression for cervical myelopathy
|
- if 3 or fewer levels -> anterior
- 3 or more levels with lordosis preserved -> laminoplasty - 3 or more levels with loss of lordosis -> laminectomy and posterior fusion |
|
% of patients with cervical myelopathy who get pain relief with anterior decompression
|
~90%
|
|
Definition of cervicogenic headache
|
constellation of symptoms that represent the common referral patterns of cervical spinal structures.
|
|
Are women or men more commonly affected by cervicogenic headaches?
|
women
|
|
Mean age for cervicogenic headache
|
43years
|
|
How are cervicogenic headaches possible?
|
convergence
|
|
Primary structres thought to be the source of cervicogenic headaches
|
- C2-3 z-joint
- C2-3 intervertebral disk - C3-4 intervertebral disk - C4-5 intervertebral disk - C5-6 intervertebral disk |
|
Typical history for cervicogenic headaches
|
trauma
|
|
Sequence of injections often tried for cervicogenic headaches
|
intrarticular injections at:
C2-3 C3-4 C1-2 |
|
3 components of "whiplash"
|
- whiplash event (biomechanics)
- whiplash injury (injured structure) - whiplash syndrome (symptoms) |
|
Common symptoms with whiplash
|
- neck pain
- headaches - shoulder girdle pain - upper limb paresthesias - weakness |
|
Less common symptoms with whiplash
|
- dizziness
- visual changes - tinnitus |
|
General recovery after whiplash
|
- most recover in 2-3 months
- after 2 years 80% are symptom free |
|
Function of the anterior longitudinal ligament
|
- limits hyperextension
- limits anterior translation |
|
Course of the anterior longitudinal ligament
|
attaches to all vertebral bodies anteriorly
|
|
Course of the posterior longitudinal ligament
|
Posterior rim of the vertebral bodies and disc from occiput (tectorial membrane), C2 to sacrum
|
|
Function of the posterior longitudinal ligament
|
limits hyperflexion
|
|
Course of the ligamentum nuchae
|
continuation of the supraspinaous ligament
|
|
Function of the ligamentum nuchae
|
boundary of the deep muscles in the cervical region
|
|
What's the boundary of the deep muscles in the cervical region
|
ligamentum nuchae
|
|
Course of the ligamentum flavum
|
attaches laminae to laminae
|
|
Function of ligamentum flavum
|
maintains constant disk tension and assists in straightening the spinal column after flexion
|
|
Supraspinous ligament runs from
|
C7-L3
|
|
Function of the interspinous ligament and supraspinous ligament
|
resists spinal separation and flexion (weak)
|
|
Course of intertransverse ligament
|
transverse process to transverse process
|
|
Function of intertransverse ligament
|
resists lateral bending of the trunk
|
|
Anterior landmark of C2
|
transverse process at the angle of the mandible
|
|
Anterior landmark of C3
|
hyoid bone
|
|
Anterior landmark for C4/C5
|
thyroid cartilage
|
|
Anterior landmark for C6
|
- first cricoid ring
- carotid tubercle |
|
Posterior landmark for C2
|
- first palpable midline spinous process
- 2 fingerbreadths below the occiput |
|
Posterior landmark for C7
|
vertebral prominens
|
|
Posterior landmark for T3
|
spine of the scapula
|
|
Posterior landmark for T8
|
inferior angle of the scapula
|
|
Posterior landmark for T12
|
lowest rib
|
|
Landmark for L4
|
iliac crests
|
|
Landmark for S2
|
Posterior superior iliac spine
|
|
What are the extrinsic back muscles?
|
Superficial
- trapezius - latissimus dorsi Intermediate - serratus posterior |
|
What are the superficial intrinsic back muscles?
|
- splenius capitis
- splenius cervices |
|
What are the intermediate intrinsic back muscles?
|
Erector spinae...
- Iliocostalis: lumborum, thoracis, cetrvices - Longissiumus: Thoracis, cervicis, capitis - Spinalsi: thoracis, cervicis, capitis |
|
What are the deep intrinsic back muscles?
|
* Transversospinal muscles:
- semispinalis: thoracis, cervicis, capitis - multifidus - rotators * interspinalis, intertransversarii |
|
What back muscle are normally active in erect posture?
|
Mild activity in the erector spinae muscles
|
|
What muscles are active (in sequence) as you flex the trunk forward?
|
- initial: increased erector spinae activity
- mid flexion: increased gluteus maximus activity - Late flexion: increased hamstring activity - terminal flexion: electrical silence |
|
50% of the flexion of the cervical spine occurs at the ____ joint
|
occipitoatlantal
|
|
50% of the extension of the entire cervical spine occurs at the ____ joint
|
occipitoatlantal
|
|
50% of the rotation oft eh entire cervical spine occurs at the ____ joint
|
atlantoaxial
|
|
3 phases of the Kirkaldy-Willis function degenerative classification
|
1) dysfunction
2) instability 3) stability |
|
Enzyme released from herniated nucleus pulposus thought to be involved in starting the inflammatory cascade
|
phospholipase A2
|
|
Inflammatory mediators thought to be involved in pain from herniated nucleus pulposus
|
- leukotrienes
- prostaglandins - platelet activating factors - bradykinins - cytokines |
|
Typical age for herniated nucleus pulposus
|
30-40
|
|
3 most common spine levels for herniated nucleus pulposus
|
L4-5
L5-S1 C5-6 |
|
Natural clinical course in herniated nucleus pulposus
|
3/4 will resolve with conservative care in 6-12 months
|
|
Central herniated nucleus pulposus is typically made worse by what movement?
|
forward flexion
|
|
posterior-lateral herniated nucleus pulposus is typically made worse by what movement?
|
forward flexion
|
|
lateral herniated nucleus pulposus is typically made worse by what movement?
|
extension
|
|
Reflex abnormality at L2
|
Cremaster
|
|
What is Lasegue's test?
|
dorsiflexion of the ankle with straight leg raise neural tension test
|
|
What is Bowstring test (Cram test)?
|
with positive straight leg raise, then bend the knee about 20 degrees and apply pressure to the nerve behind the popliteal fossa
|
|
Indications for cervical traction
|
radicular pain
muscle spasm |
|
Contraindications for cervical traction
|
- ligamentous instability
- radiculopathy of unclear origin - acute injury - rhematoid arthritis - vertebrobasilar arteriosclerotic disease - spinal infections |
|
Epidural steroid injections can exacerbate these underlying medical conditions
|
- DM
- CHF - HTN |
|
Chymopapain injections are used to treat what?
|
herniated nucleus pulposus
|
|
Mechanism of action of chymopapain injection
|
dissolve subligamentous herniations contained by the posterior longitudinal ligament (poor efficacy)
|
|
5 major causes of cauda equina syndrome
|
- large central disk herniation
- epidural tumors - hematomas - abscesses - trauma |
|
Internal disk disruption is association with
|
- annular fissures
- nuclear tissue disorganization |
|
Grading of internal disk disruptions
|
grade 0 = no annular disruption
grade 1 = inner 1/3 annular disruption grade 2 = inner 2/3 annular disruption grade 3 = outer 1/3 annular disruption +/- circumferential spreading |
|
Etiology of internal disc disruption
|
endplate fractures from excessive loads
|
|
Internal disc disruption pain is usually worse with what position?
|
sitting
|
|
Best imaging for radial fissures of the disk?
|
postdiscogram CT
|
|
Most common levels of spinal stenosis
|
L3 and L4
|
|
Normal spinal canal size
|
17mm
|
|
The spinal cord is typically ____ in diameter
|
10mm
|
|
3 sub-areas of lateral spinal stenosis
|
- lateral recess
- mid zone - intervertebral foramen |
|
Stenosis at the lateral recess is typically caused by
|
hypertrophic facet joints
|
|
Stenosis at the pars region (midzone) is typically caused by
|
osteophytes under the pars
|
|
Stenosis at the intervertebral foramen is typically caused by
|
hypertrophic facet joints
|
|
The root level affected by lateral recess stenosis is
|
the same level as the vertebrae
|
|
The root level affected by midzone stenosis is
|
the same level as the vertebrae
|
|
The root level affected by intervertebral foramen is
|
one level up from the vertebrae
|
|
Pain in neurogenic claudication is typically described as
|
numbness, aches
|
|
Pain in vascular claudication is typically described as
|
cramping, tightness
|
|
Location of pain in neurogenic claudication is typically described as
|
thigh and calf
|
|
Location of pain in vascular claudication is typically described as
|
calf
|
|
Neurogenic claudication is often exacerbated by
|
standing
walking lying flat |
|
Vascular claudication is often exacerbated by
|
walking/cycling
|
|
In neurogenic claudication the bicyle test is
|
painless
|
|
In vascular claudication the bicyle test is
|
painful
|
|
In neurogenic claudication walking downhill is
|
painful
|
|
In vascular claudication walking downhill is
|
painless
|
|
In neurogenic claudication walking uphill is
|
painless
|
|
In vascular claudication walking uphill is
|
painful
|
|
Neurogenic claudication is alleviated by
|
- flexed position
- bending - sitting |
|
Vascular claudication is alleviated by
|
- standing
- resting - lying flat |
|
Associated factors in neurogenic claudication
|
- back pain
- decreased spine motion - atrophy - weakness - normal pulses |
|
Associated factors in vascular claudication
|
- rare back pain
- normal spine motion - rare atrophy/weakness - abnl pulses - shiny skin - loss of hair |
|
Average length of stay on acute care post-MI and post cardiac surgery
|
post-MI: 3-5 days
post surgery: 5-7 days |
|
Leading cause of morbidity and mortality in the USA in both men and women
|
cardiovascular disease
|
|
% of people between the ages of 55-64 with cardiovascular disease
|
- men 51%
- women 48% |
|
% of people over the age of 75 with cardiovascular disease
|
- men 71%
- women 79% |
|
% mortality 1 year and 8 years after MI
|
- 1 year men: 25%
- 1 year women: 38% - 8 years: 50% |
|
Globally, heart disease contributes to what % of deaths each year
|
33%
|
|
% of adults in the US that participate in regular physical activity
|
40%
|
|
Risk factors for generally being less physically active
|
- single women
- elderly - less educated - less affluent - African American - Hispanic |
|
American College of Sports Medicine general recommendations for exercise
|
30 min of moderate activity on most days of the week (aprox 600-1200 kcal)
|
|
How does exercise best relate to modifying cardiovascular risk factors
|
Total energy expenditure is more important that intensity or duration of activity
|
|
Risk of cardiac event from exercise in patient with CV disease
|
1/400,000-1/800,000 hours of exercise; lower in regular exercisers
(that's once in 545 years of exercising for 30 min every day) |
|
SBP or DBP parameters for normal BP
|
SBP <120
DBP <80 |
|
SBP or DBP parameters for prehypertension
|
SBP 120-139
DBP 80-89 |
|
SBP or DBP parameters for stage 1 hypertension
|
SBP 140-159
DBP 90-99 |
|
SBP or DBP parameters for stage 2 hypertension
|
SBP >160
DBP >100 |
|
Most significant risk for death worldwide
|
HTN
|
|
Risk for MI and death from HTN increases above what BP level?
|
115/75
|
|
A 5mmHg decrease in blood pressure provides what % reduction in mortality from CAD?
|
9%
|
|
Expected effects of lifestyle modification on BP
|
lower SBP about 4mmHg
|
|
How long of a trial of lifestyle modification do you get for HTN before you're started on medications?
|
- 12 months for stage 1 HTN with no other CAD risk factors
- 6 months for stage 1 HTN with other risk factors - Done with meds for stage 2 HTN |
|
Number of people in the USA who start smoking every day
|
4,000
|
|
% of men and women in the US who smoke
|
- men 25%
- women 20% |
|
Leading cause of preventable illness and death in the US
|
cigarette smoking
|
|
Someone who quits smoking can expect what reduction in CAD risk after 1 year
|
50%
|
|
% of people who quit smoking after CABG who relapse within 1 year
|
70%
|
|
What is the best program for smoking cessation (and its success rate)
|
20% success with:
behavioral support, nicotine replacement, and sustained release bupoprion |
|
General categories now used for classification of dyslipidemia
|
- optimal
- near optimal - borderline high - high - very high (but not all used for each subset of lipds) |
|
Classification of total cholestrol in dyslipidemia
|
- Optimal <200
- Borderline high 200-239 - High >240 |
|
Classification of LDL in dyslipidemia
|
- Optimal <100
- Near optimal 100-129 - Borderline high 130-159 - High 160-189 - Very high >190 |
|
Classification of triglycerides in dyslipidemia
|
- Optimal <150
- Borderline high 150-199 - High 200-299 - Very high >500 |
|
Classification of HDL in dyslipidemia
|
- optimal >60
- higher risk <40 |
|
What % of dyslipidemia can be explained by modifiable factors like weight, activity, smoking and DM?
|
50% (genetics play the other large role)
|
|
Benefits of exercise in dyslipidemia continue how long?
|
as long as exercise is continued
|
|
Definition by BMI of overweight and obese
|
>25 = overweight
>30 = obese |
|
% of American adults that are overweight
|
60%
|
|
% of American adult that are obese
|
- Causasians 30%
- AA men 30% - AA women 50% |
|
Changes in weight that appear to be significant for changing cardiovascular disease risk
|
- gain of 10 pounds
- loss of 10% |
|
General dietary guidelines of lipid management
|
Total fat 30% of cal
Carbs 50% of cal Protein 15% of cal Cholesterol <200mg/day Fiber 20-30 grams/day |
|
Fasting glucose that = diabetes
|
>125
|
|
What's a normal fasting glucose?
|
less than 110
|
|
Impaired fasting glucose is
|
110-125
|
|
Prevalance of DM in USA
|
7% adn increasing
|
|
What characterizes the metabolic syndrome
|
1. abdominal obestiy
2. triglycerides >150 3. HDL <40 in men or <50 in women 4. HTN >130/85 5. Fasting glucose >110 6. proinflammatory state 7. prothrombotic state (3+ of #1-5 must be present) |
|
% of people with metabolic syndrome
|
- 45% of people 60yo+
- 30% of all people who are overweight/obese |
|
4 emerging risk factors for CAD
|
- lipoprotein a
- homocysteine - prothrombotic states - high-sensitivity CRP |
|
3 substrates used in metabolic pathways
|
carbohydrates, fats, proteins
|
|
Carbohydrates are stored as
|
glycogen in liver and muscle
|
|
Fat is stored as
|
triglycerides in adipose tissue
|
|
Protein is stored as
|
muscle
|
|
Carbohydrates for metabolism circulate as
|
glucose
|
|
Fat for metabolism circulates as
|
fatty acids, glycerol
|
|
Protein for metabolism circulates as
|
amino acids
|
|
In exercise, carbohydrates are converted to
|
- pyruvate
- acetyl coenzyme A |
|
In exercise, fat is converted to
|
- acetyl coenzyme A
- glucose |
|
In exercise, protein is converted to
|
- pyruvate
- acetyle coenzyme A |
|
Metabolic pathway for carbohydrates in exercise
|
citric acid cycle in mitochondria
|
|
Metabolic pathway for fats in exercise
|
beta-oxidation, citric acid cycle
|
|
Metabolic pathway for proteins in exercise
|
deamination
|
|
Stored ATP in muscle is suffecient for what duration of intense muscle activity?
|
10 seconds
|
|
Is production of pyruvate aerobic or anaerobic?
|
anaerobic
|
|
Is use of stored ATP and phosphcreatine in muscle consider aerobic or anaerobic?
|
anaerobic
|
|
Effects of lactic acid production during anaerobic exercise
|
- imapired cellular metabolism
- muscle soreness - fatigue - respiratory stimulation - forced decrement of exercise |
|
2 main ways of degrading lactic acid
|
- Cori cycle (liver)
- buffering systems |
|
How can you identify the transition from aerobic to anaerobic exercise?
|
- when rate VO2 exceed oxygen consumption
- spike in CO2 production |
|
What is the anaerobic threshold?
|
when the rate VO2 exceeds oxygen consumption
|
|
When is the anaerobic threshold important in cardiac rehab?
|
Patients with heart disease don't feel well above the threshold and program should be designed to keep them below the threshold
|
|
At rest, what is the average rate of oxygen consuptiom of a 70kg man?
|
3.5cc of O2/min/kg
|
|
Define 1 MET
|
the unit of oxygen consuption at rest (basal metabolic rate)
|
|
What is aerobic capacity?
|
maximum rate of O2 consumption
|
|
List MET equivalents for different level of exercise intensity
|
Light = 1-3 METS
Light to mod = 3-4 METS Mod = 4-5 METS Heavy = 5=7 METS Very Heavy = >7 METS |
|
Example of self-care activity that's 1-3 METS
|
- sponge bathing
- shaving - dressing/undressing |
|
Example of self-care activity that's 3-4 METS
|
- showering
- climbing stairs - driving |
|
Having sex is how many METS?
|
4-5
|
|
Example of household activity that's 1-3 METS
|
- light meal prep
- setting the table - dusting |
|
Example of household activity that's 3-4 METS
|
- light gardening
- ironing - vacuuming - grocery shopping |
|
Example of household activity that's 4-5 METS
|
- heavy gardening
- cleaning floors - moving furniture - raking - washing car |
|
Example of household activity that's 5-7 METS
|
- splitting wood
- shoveling snow - climbing ladder |
|
Example of household activity that's >7 METS
|
- moving heavy furniture
- pushing or pulling hard |
|
Example of recreational activity that's 1-3 METS
|
- walking 2mph
- writing - reading - playing piano |
|
Example of recreational activity that's 3-4 METS
|
- walking 3mph
- slow bicycling - golfing with cart |
|
Example of recreational activity that's 4-5 METS
|
- walking 3.5mph
- doubles tennis - slow dancing - easy swimming - bicyling 8 mph |
|
Example of recreational activity that's 5-7 METS
|
- walking 4-5 mph
- tennis - mod cross country skiing - gymnastics |
|
Example of recreational activity that's >7 METS
|
- Jogging at 5 mph
- soccer - basketball - horseback riding |
|
Example of job activity that's 1-3 METS
|
- typing
- light machine work - lifting <10 pounds - sewing |
|
Example of job activity that's 3-4 METS
|
- light carpentry
- assembly line - lifting 20 pounds - bricklaying |
|
Example of jobactivity that's 4-5 METS
|
- light shoveling
- mixing cement - light farming - lifting 50 pounds |
|
Example of job activity that's 5-7 METS
|
- heavy farming
- heavy industry - lifting 50-100 pounds |
|
Example of job activity that's >7 METS
|
- Heavy construction
- lifting 100 pounds |
|
Effecient oxygen transportion during activity is dependent on what 3 major systems?
|
lungs, CV, muscle
|
|
What is the Fick equation
|
(oxygen consumption) = (cardiac output) x (AV O2 difference)
|
|
Describe the mechanisms for increased cardiac output as activity intensity increases
|
- initally from increased stroke volume
- then becomes dependent on HR as diastolic filling time become more limited |
|
What is the general relationship between exercise intensity and cardiac output
|
linear
|
|
What is the general relationship between exercise intensity and HR
|
linear
|
|
Maximal HR estimation in a healthy person
|
220-age
|
|
Is aerobic training muscle group specific?
|
Yes; a treadmill conditioning program will NOT increase conditioning for bicycling in the same way
|
|
Signifcant adaptions are noted with aerobic training withing what time frame?
|
- 6-10 weeks grossly
- 10 days at biochemical level |
|
Benefits of aerobic conditioning are lost ____ weeks after stopping training
|
2-3 weeks
|
|
Why is an exaggerated HR response common after MI?
|
- decreased vagal tone
- increase sympathetic tone from circulating catecholamines |
|
True or false: Av O2 difference rapidly declines with bed rest
|
true
|
|
What does AV O2 difference represent?
|
the body's ability to extract O2 for metabolic use
|
|
General muscle changes seen with CHF
|
- altered cellular structure
- depletion of phosphocreatine - depletion of oxidative capacity - muscle fiber atrophy - increased vasoconstriction - impaired arterial dilatation |
|
Why is there resting tachycardia after heart transplant?
|
loss of vagal tone to the sinoartrial node
|
|
Why is rate of HR increase and cardiac output response to exercise blunted after cardiac transplant?
|
heart is dependent on circulating catecholeamines to increase these parameters
|
|
Peak HR and rate of oxygen consumption in a patient s/p heart tranplant compared to controls
|
- HR 25% lower
- rate V02 33% of predicted |
|
Aerobic training influences what determinant of the Fick equation?
|
all of them
|
|
Why is heart rate at rest and submaximal work intensities decreased after aerobic training?
|
increased vagal tone
|
|
Adaptations allowing increased AV O2 difference following aerobic training
|
- increased Hb O2 sat
- increased RBC [Hb] - Increased artery size to muscle - increased capillary density - increased size of type 1 muscle fibers - increased muscle fiber myoglobin concentration - increased mitochondrial size and concentration - increased aerobic enzymes concentration - enhanced minute ventilation |
|
Major determinant of myocardial blood flow
|
diameter of the coronary arteries
|
|
How is cardiac ischemia noted on EKG, echo and nuclear perfusion
|
- EKG: ST depression
- echo: wall motion abnormalities - perfusion: reversible perfusion deficits |
|
What causes more myocardial oxygen consumption, exercise with the upper limbs or lower limbs?
|
upper limbs
|
|
What causes more myocardial oxygen consumption, exercise with upright or supine?
|
upright
|
|
How does myocardial oxygen consumption at rest change after aerobic conditioning and why does this matter for cardiac rehab?
|
O2 consumption lower at rest and submax exercise. Important because patient able to do more activity before they become ischemic
|
|
Which has more myocardial oxygen demand, exercise with or without a significant isometric component?
|
more demand with isometric component
|
|
Future exercise should be performed at a HR of _____ below the ischemic point in patients with CAD
|
10 bpm
|
|
Does exercise training influence the ischemic threshold in CAD?
|
no
|
|
typical ischemic cardiac pain is mediated by the ______ nervous system
|
autonomic
|
|
Sputum in cough associated with heart disease usually has what characteristics
|
clear or pink; frothy
|
|
What variant of Parkinson's disease often has orthostatic hypotension?
|
Shy-Drager
|
|
Common medication for heart disease that causes fatigue
|
b-blockers
|
|
Patients with significant vascular disease may have very different BP readings between arms because of
|
subclavian stenosis
|
|
What BP is a contraindication to exercise?
|
200/110
|
|
Common reason for asymmetrical LE edema after CABG
|
Side with vein harvested for graft will have more edema
|
|
Why is cardiovascular disease in patients with DM often not amenable to intervention
|
often have diffuse artherosclerosis instead of focal plaques
|
|
3 common endpoints for submaximal exercise stress testing
|
- HR 120
- 70% of predicted max HR - 5 METS |
|
What guidelines should you give patients about caffeine and medications prior to an exercise stress test
|
- no caffeine for 3 hours prior
- take meds as scheduled |
|
Normal BP changes during exercise stress testing
|
- SBP increased by 10-30mmHg with peak >140
- DBP stable or decreases |
|
When is exercise stress testing normally terminated?
|
when 85% of age and gender predicted max HR is reached
|
|
Markers of exercise capacity
|
- exercise duration
- MET level - max HR - HRxSBP (direct product) |
|
Why are METs useful to calculate in exercise training?
|
they allow for comparisions across activities
|
|
Arm exercises produces a(n) _______ HR and SBP response compared with similar workload performed by the legs
|
exaggreated
|
|
Compared peak HR with arm vs. leg exercise
|
Peak HR with arm exercise is 70% of with leg
|
|
What's typical force progression of exercise during phase II cardiac rehab?
|
start at 25W and increase in 25W increments every 2 min
|
|
Compare recumbant bicycle ergometry vs. treadmill for cardiac rehab
|
- less likely to reach VO2 max with bike
- less likely to reach peak predicted target HR on bike - likely to have early fatigue of quads on bike - lower anaerobic threshold on bike |
|
Starting point for most common exercise stress test protocol
|
BRUCE
- start at 1.7mph on 10% grade - increases at 3 min intervals |
|
Associated prognostic outcome of post-MI exercise -induced angina during exercise stress testing
|
stable angina within 1 year
|
|
Associated prognostic outcome of achieving <85% of age-predicted max HR during exercise stress testing
|
increased 2-year mortality
|
|
Associated prognostic outcome of delayed HR recovery during exercise stress testing
|
Increased 6-year mortality
|
|
Associated prognostic outcome of delayed fall in SBP during exercise stress testing
|
Increased mortality
|
|
Associated prognostic outcome of post-MI inadequate increase of SBP during exercise stress testing
|
LV dysfunction
|
|
Associated prognostic outcome of post-MI rate-pressure product <21,700 during exercise stress testing
|
increased 6 month mortality
|
|
Associated prognostic outcome of 2mm ischemic ST segment depression during exercise stress testing
|
increased MI with 1% annual increased mortality and multivessel disease on angiography
|
|
Associated prognostic outcome of early 1mm ST segment depression during exercise stress testing
|
increased MI; 5% annual mortality
|
|
Associated prognostic outcome of being unable to tolerate exercise stress test
|
highest adverse cardiac event rate
|
|
Associated prognostic outcome of acheiving <5 METS during exercise stress testing
|
increased mortality
|
|
METS =
|
metabolic equivalents
|
|
_____ are especially prone to false positive studies with exercise stress test
|
Women
|
|
Normal exercise response for ejection fraction
|
increase in EF by at least 5%
|
|
The strongest determinant of cardiac events is
|
coronary plaque burden
|
|
How is electron beam computed tomography used in evaluating cardiovascular disease?
|
creating a coronary artery calcification score correlates well with cardiac events and can be followed over time
|
|
Early mobilization at what MET level helps prevent loss of cardiovascular reflexes associated with prolonged bed rest?
|
2-3 METS
|
|
Risk of cardiac events during exercise training is highest in what groups
|
- poor LV function
- ventricular arrhythmias - non-ST elevation MI - non-compliance with exercise rx - poor compliance with HR restrictions |
|
How is risk assigned prior to starting phase II cardiac rehab
|
assigned to group:
- no risk - low risk - moderate risk - high risk Based on ischemia, arrhythmia and pump failure |
|
When is hypoglycemia after exercise most commonly seen in insulin dependent DM?
|
several hours after exercise
|
|
What should you tell a patient with DM with blood glucose >350 about exercise?
|
postpone exercise as glucose utilization is compromised
|
|
Hold exercise when INR above ___ to avoid hemarthrosis and muscle hematoma
|
5.0
|
|
How is phase II cardiac rehab training HR usually calculated?
|
Karvonen:
training HR = RHR + [(PHR - RHR) xI] where RHR = resting HR from EST PHR = peak HR from EST I = coefficient based on risk stratification |
|
What is the I in the Karvonen equation for training HR for cardiac rehab based on risk stratification?
|
- low: 70-85%
- moderate 55-70% - high 40-55% |
|
Goal HR during cardiac rehab for patients on b-blockers with a blunted HR response
|
10-20 beat above resting
|
|
How do you determine exertional guidelines for cardiac rehab after cardiac transplantation?
|
50-60% of rate VO2 max
|
|
Recommendations for lifelong exercise stress testing after cardiac rehab
|
yearly to update risk stratification and training HR
|
|
Why is a cool down helpful during cardiac rehab
|
minimize post-exercise hypotension that may result in ischemia
|
|
General frequency and duration of outpatient phase II cardiac rehab
|
three times per week for 12 weeks
|
|
To reduce exercise induced angina, when should long-acting nitrates be taken
|
about 3 hours prior o exercise
|
|
Does cardiac rehab for severe angina increase return to work rates?
|
yes
|
|
When is exercise training generally instituted after MI
|
2-6 weeks depending on the size and risk
|
|
Difference in survival rates following MI for those who participate in cardiac rehab vs. those who don't
|
3 year survival
- with CR: 95% survive - without: 64% |
|
When can upper body exercise be started after CABG?
|
at 6 weeks post-operative sternal knitting should be complete
|
|
% of patients that have arrhythmias during inpatient cardiac rehab
|
1/3
|
|
Risk factors for arrhythmias during inpatient cardiac rehab
|
- HTN
- DM - hyperlipidemia - older age - discontinuation of amiodarone - autonomic dysfunction |
|
When do patients seen improvement in exercise tolerance during cardiac rehab for CHF?
|
most improvement at 3 weeks but continues for 6 months
|
|
% of patients with CHF that have conduction abnormalities
|
40%
|
|
Exertional guidelines after cardiac transplant
|
Start with Borg scale of 11-13 and then increase to 13-15 as tolerated
|
|
Exercise guidelines after LVAD placement
|
- ambulation at 7-10 days
- treadmill trainig at 3 weeks - ADLS up to 5 METS at 6 weeks |
|
Is supine or upright exercise more likely to induce ventricular arrhythmias?
|
supine
|
|
Very general recommendations for exercise type in patients with ICDs
|
upright - less likely to induce arrhythmia
|
|
% of patients that experience some cognitive impairment after CABG
|
80%
|
|
cognitive dysfunction in CHF increased mortality ___ times
|
5
|
|
List 5 atherosclerotic diseases
|
- CAD
- PVD - CVD - renal artery stenosis - abdominal aortic aneurysm |
|
Which rehab patients also need cardiac precautions due to increased associated cardiovascular risk
|
- thrombotic strokes
- PVD - dysvascular amputation |
|
The majority of cardiac rehab patients return to work in __ months
|
6 months
~80% if sedentary work ~60% if heavy work |
|
Avoid sexual intercourse after MI for __ weeks
|
2
|
|
Achieving __ METS on exercise stress test indicates low risk for a cardiac event during sex
|
6 (assuming familiar partner and place)
|
|
Most common lung diesease in the USA
|
COPD
|
|
Biggest contributing factor to COPD
|
Smoking
|
|
90% of new smokers are...
|
teenagers and young adults
|
|
Most common childhood chronic disease
|
asthma
|
|
3 major causes of COPD
|
- asthma
- chronic bronchitis - emphysema |
|
COPD is the ___ (rank) leading cause of death worldwide.
|
5th
|
|
Restrictive pulmonary disease is most often caused by
|
neuromuscular and orthopedic disorders
|
|
Incidence of Duchenne muscular dystrophy in the USA
|
21/100,000 births
|
|
6 major modalities used in pulmonary rehabilitation
|
- general medical management
- oxygen therapy - chest PT - exercise training - nutritional support - psychosocial support |
|
How does theophylline help in COPD?
|
- improve respiratory muscle endurance
- central ventillatory stimulation |
|
When is oxygen therapy indicated in COPD?
|
- arterial O2 sat <88%
- arterial O2 sat <89% with evidence of pulm HTN, CHF or polycythemia |
|
When is it safe to mount portable O2 on a electric wheelchair?
|
motor and batteries are sealed and covered by a rigid housing
|
|
Main ways that breathing retraining works in COPD
|
- maintain positive airway pressure during exhalation
- reduce over-inflation |
|
List some to the techniques taught for breathing to people with COPD
|
- general relaxation
- pursed lips - head down/bent forward - slow deep breathing - localized expansion/segmental breathing |
|
Is diaphragmatic breathing helping in COPD?
|
No - it increased the work of breathing compared to the typical baseline breathing pattern in COPD
|
|
Why should coughing be controlled in COPD?
|
coughing can trigger dynamic airway collapse, bronchospasm or syncope
|
|
What is autogenic drainage?
|
Technique of pulmonary secretion clearance that combines variable tidal breathing (at 3 distinct volumes), controlled expiratory airflow and huff coughing
|
|
Mechanical in-exsufflation is contraindicated in
|
- bullous emphysema
- history of PTX - history of pneumomediastinum |
|
In obstructive pulmonary disease, vital capacity is increased or decreased?
|
same or decreased
|
|
In obstructive pulmonary disease, FEV is increased or decreased?
|
decreased
|
|
In obstructive pulmonary disease, midmaximal flow is increased or decreased?
|
decreased
|
|
In obstructive pulmonary disease, maximal voluntary ventilation is increased or decreased?
|
decreased
|
|
In obstructive pulmonary disease, residual volume is increased or decreased?
|
increased
|
|
In obstructive pulmonary disease, functional residual capacity is increased or decreased?
|
increased
|
|
In obstructive pulmonary disease, total lung capacity is increased or decreased?
|
increased
|
|
In restrictive pulmonary disease, vital capacity is increased or decreased?
|
decreased
|
|
In restrictive pulmonary disease, FEV is increased or decreased?
|
same or decreased
|
|
In restrictive pulmonary disease, midmaximal flow is increased or decreased?
|
same or decreased
|
|
In restrictive pulmonary disease, maximal voluntary ventilation is increased or decreased?
|
same or decreased
|
|
In restrictive pulmonary disease, residual volumeis increased or decreased?
|
decreased
|
|
In restrictive pulmonary disease, functional residual capacity is increased or decreased?
|
decreased
|
|
In restrictive pulmonary disease, total lung capacity is is increased or decreased?
|
decreased
|
|
What are the 7 general indications for cardiopulmonary exercise testing per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
|
- eval of exercise tolerance
- unexplained dyspnea - eval of CV disease - eval of respiratory disease - preop evaluation - to creat exercise rx for pulmonary rehab - eval impairment or disability |
|
What are the indications for cardiopulmonary exercise testing for respiratory disease (which diseases?) per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
|
- COPD
- interstitial lung disease - chronic pulmonary vascular disease - cystic fibrosis - exercise induced bronchospasm |
|
What are the indications for cardiopulmonary exercise testing for preop eval (which surgeries) per the American Thoracic Society - American College of Chest Physicians 2001 guidelines?
|
- lung cancer resection
- lung volume reduction surgery - lung transplant - other preop |
|
How long does exercise training take for muscles to develop increased ability to perform aerobic exercise?
|
30min a day for 3-5 days per week for 4-8 weeks
|
|
Describe the classification scheme for COPD severity
|
Stage 0: normal lung function
Stage 1 (mild): FEV1 at least 80% of predicted Stage 2 (moderate): FEV1 50-79% of predicted Stage 3 (severe) FEV1 30-49% of predicted Stage 4 (very severe): FEV1 less than 30% of predicted or presence of respiratory failure or clinical right sided heart failure (only valid if FEV1:FVC less than 70%) |
|
What improvements can be expected from inspiratory muscle training in a patient with moderate COPD?
|
- increased max inspiratory mouth pressure
- increased strength of the diaphragm |
|
What improvements can be expected from general pulmonary rehabilitation in a patient with moderate COPD?
|
- increased max workload
- improved ADL scores - improved anxiety and depression scores - increased 6 and 12 minute walking distance |
|
What improvements can be expected from pulmonary rehabilitation with cycle ergometry at 70W in a patient with moderate COPD?
|
minute volume decreased of 2.5L/min per blood lactate decreased of 1mEq/L
|
|
General effects of aerobic exercise in patients with asthma
|
improves overall fitness and health
|
|
Inheritance of cystic fibrosis
|
autosomal recessive
|
|
When is Dornase alfa (Pulmozyme) prescribed to patients with cystic fibrosis and what does it do?
|
- rx when older than 5years and FVC greater that 40%
- digests extracellular DNA |
|
Pulmonary picture of chronic lung disease in cystic fibrosis
|
combined severe obstructive-restrictive disease
|
|
What's the technical name for "The Vest" for cystic fibrosis chest PT
|
high-frequency chest wall oscillation
|
|
What is the median expected survival age for patients with cystic fibrosis born in the 1990s?
|
over 40 years
|
|
3 major factors that have extended the life span of individuals with cystic fibrosis
|
- airway clearance
- nutritional support - antibiotic therapy |
|
Proportion of adults with cystic fibrosis that have multiple-resistance gram negative organisms
|
1/3
|
|
Why shouldn't patients with cystic fibrosis exercise within close proximity of each other?
|
- possibility of transmitting Burkhoderia cepacia
|
|
Survival in cystic fibrosis is correlated with _____ ____ ____
|
maximal oxygen uptake
|
|
6 components of the chest wall
|
- rib cage
- spine - diaphragm - abdomen - shoulder girdle - neck |
|
In pulmonary rehab useful in patients with Parkinsons?
|
yes
|
|
Define paradoxical vocal cord dysfunction
|
vocal cords adduct during inspiration
|
|
The diagnosis of paradoxical vocal cord dysfunction is based on
|
patient history and laryngoscopy
|
|
Treatment of acute exacerbations of paradoxical vocal cord dysfunction
|
Heliox (79:30)
|
|
What is the total daily expenditure in patients with COPD compared to normals?
|
the same, regardless of weight
|
|
Major cause of malnutrition in patients with COPD
|
insufficient food intake
|
|
The energy cost of the exercise associated with a pulmonary rehabilitation program is estimated at __ kcal/day
|
191
|
|
3 major indications for phrenic nerve pacing
|
- congenital central hypoventilation syndrome
- acquired central hypoventilation syndrome - high SCI |
|
Congenital central hypoventilation syndrome is also known as
|
Ondine's curse
|
|
When is lung volume reduction surgery generally used?
|
patients with advanced emphysema
|
|
What is usually removed in lung volume reduction surgery
|
one or both apices
|
|
Children with SCI over the age of ____ can usually learn glosspharyngeal breathing
|
over the age of 3 years
|