Gary Brooks*
INTRODUCTION
Physical therapists are often called on to treat patients/clients with one or more chronic medical conditions that are inherent causes of impairments, dysfunction, and disability and/or increase the risk of other pathologic conditions. Consider, for example, diabetes and coronary artery disease (CAD). Diabetes is, itself, a cause of considerable dysfunction and disability, and it is also a risk factor for CAD, which is the number one killer in the United States.1 Both diabetes and CAD and other cardiopulmonary diseases are highly prevalent and may be present in medically complex patients/clients who are seen by physical therapists in a wide range of practice settings. CAD is also associated with other medical conditions (hypertension, hyperlipidemia, and obesity) and behaviors (cigarette smoking and physical inactivity) that are considered to be risk factors. These risk factors, too, are often encountered by physical therapists in clinical practice. Physical therapy (PT) interventions can help to prevent cardiopulmonary diseases from developing, even among individuals with risk factors. This process is called primary prevention, and an individual referred to physical therapists for risk-factor management may be best referred to as a client. Physical therapists can also intervene in the presence of known, overt cardiopulmonary disease. These interventions are aimed at reducing symptoms and/or slowing the progression of the disease. This process is termed secondary intervention and these people are usually referred to as patients. Regardless of whether clients or patients seek physical therapy services, these individuals may be restricted in their activities due to deconditioning. Some have chronic medical conditions, including cardiopulmonary disease, and may restrict their activities because of symptoms, illness, or hospitalization. This deconditioning causes an impairment due to reduced aerobic capacity, which can lead to disability and dependency.
Both clients with risk factors and patients who are deconditioned may be treated in a variety of practice settings. They may be in hospital, recovering from surgery; they may be outpatients who visit the hospital several days a week for exercises and patient education, or they may receive services in the home. They may also be found in wellness centers for weight-reduction programs and dietary counseling. Cardiopulmonary Practice Patterns A and B are intended to address both prevention of cardiopulmonary disease and the management of the deconditioning that often accompanies cardiopulmonary and other medical conditions.
Patterns A and B may be positioned on different points of the lifespan continuum. Pattern A is seen earlier, where the potential for cardiopulmonary disease is present, but not manifest. Pattern B represents progression such that cardiopulmonary disease may have occurred and has begun to affect not only physiology but also function. Many conditions that are “risk factors” for cardiopulmonary disease in Pattern A may also be present in pattern B. Moreover, Patterns A and B share common primary PT interventions—physical activity patient education—for which there is ample evidence of its effectiveness.
This chapter reviews the pathophysiology related to conditions and behaviors that underlie cardiopulmonary disease. We examine atherosclerosis, the fundamental disease process that leads not only to CAD but also to stroke, peripheral vascular disease, and kidney disease. The acute pathological processes associated with cigarette smoking, including how tobacco smoke damages the lungs, are also discussed. A case study of a prototypical high-risk individual, Joe Sixpack, will help us to understand the similarities and differences between Patterns A and B. The case study will serve as a springboard for a review of the medical conditions, behaviors, and traits that are risk factors for cardiovascular disease (CVD), including hypercholesterolemia (high blood cholesterol), hypertension, diabetes, obesity, cigarette smoking, physical inactivity, gender, family history, and psychosocial characteristics. To understand the rationale for intervention, the physiology of deconditioning and the benefits of physical activity and exercise are also discussed. We also describe appropriate PT examinations and interventions, highlighting the evidence for their effectiveness and considering extra- and intraindividual factors as described in the Disablement Model articulated by Verbrugge and Jette2 (see Chapter 2).
RISK FACTORS: ATHEROSCLEROSIS AND SMOKING
A basic understanding of cardiopulmonary disease prevention requires knowledge of the underlying pathological process leading to cardiopulmonary disease. These topics have been the subject of extensive investigation in recent decades, resulting in voluminous literature. This chapter builds on material provided in earlier chapters—atherosclerosis (Chapter 6) and smoking (Chapter 7).
Atherosclerosis
Atherosclerosis, which is widespread in Western societies, is a major contributing factor to coronary heart disease, including angina pectoris and myocardial infarction. It is a complex disease process that evolves over a period of many years, in most cases decades, before clinical symptoms are apparent. The process is thought to begin with injury to the endothelium, the cells forming the inner layer of arteries, resulting in endothelial dysfunction. Sources of injury may be mechanical, as from high blood pressure (BP); or biochemical, because of lipid accumulation, bacterial toxins, or viruses.3
The endothelium, rather than being merely a passive lining of the arterial lumen, is actually considered to be an organ with an active role in controlling vessel diameter, blood clotting (thrombogenesis), lipid metabolism, and blood vessel growth and repair.4 Injury to endothelial cells initiates a cascading chain of events that eventually leads to formation of atherosclerotic plaque, causing obstruction of the lumen of the artery. These events are described in Chapter 6 (Figs. 6-1 and 6-2), which details the steps leading to plaque development.
Early in the progression, an inflammatory process attracts immune-related cells, including macrophages and T lymphocytes, which begin to undermine the endothelium. Macrophages engulf accumulated lipid molecules and become large, fatty foam cells. Smooth muscle cells, which comprise the layers of the arterial wall adjacent to the endothelium, migrate toward the developing lesion, further undermining the endothelium. Together with the foam cells and T lymphocytes, these cells form what is termed as the fatty streak, which is the earliest pathologically identifiable lesion in the atherosclerotic process.3 These lesions have been found in children and adolescents5,6 attesting to the early age at which this process begins.
The endothelium becomes disrupted and distorted and projects into the arterial lumen. Gaps develop between endothelial cells, attracting even more immune-related cells as well as platelets. Blood flow becomes turbulent, causing eddy currents with relatively static blood flow. All of these events set the stage for thrombus (blood clot) formation. Sites of arterial bifurcation are particularly vulnerable to this process. Lipids continue to accumulate within the lesion that becomes more fibrotic and often hardened by calcium deposits. Keep in mind that these events are ongoing and dynamic and result in space-occupying atheromas that progressively obstruct the arterial lumen over time. The good news is that there is a growing body of scientific evidence that indicates that the process is reversible through changes in lifestyle, including drugs.3,7–12
Cigarette Smoking
In addition to increasing CVD risk, cigarette smoking substantially increases the risk for other diseases, notably chronic obstructive pulmonary disease (COPD) and lung cancer. One out of every five deaths in the United States can be attributed to cigarette smoking. The death rate from COPD has been rising, in contrast to death rates from other major killers, including CVD and CAD, that have recently been falling. Lung cancer death rates rose dramatically throughout the previous century and are only now beginning to level off. Lung cancer is, for both men and women, the deadliest type of cancer.13
Nicotine, the primary ingredient in tobacco smoke, is a highly addictive compound, and cigarettes may be considered to be nicotine delivery devices. Most smokers say they would like to quit smoking, yet those who try to quit typically resume smoking. Physicians and other health care providers, including physical therapists, should discuss cigarette smoking and smoking cessation with their patients/clients, yet many health care providers miss the opportunities to do so. Recent data indicate that only approximately one-fifth of smokers’ visits to physicians included any counseling on smoking cessation.14
In addition to nicotine, tobacco smoke also contains as many as 60 compounds that are or may be carcinogenic. A substance that is carcinogenic is one that damages cells, promoting rapid cell division leading to tumor growth. In addition to the airways of the lungs, many other tissues are exposed to tobacco-related carcinogens during the smoking of a cigarette, including the oral cavity, pharynx, and larynx. This explains why cancers of these tissues are also associated with tobacco use. Metabolites of tobacco smoke are also found in urine, which may explain the increased risk of bladder cancer among cigarette smokers.
Cigarette smoke and other toxic gases in inspired air injure cells within the lungs. This injury causes an inflammatory reaction in large and small airways and in the lung parenchyma that leads to the pathological changes in structure and function that are characteristic of COPD. This inflammatory reaction is part of a repair process that attempts to restore normal tissue where the injury has occurred. This process is illustrated in Fig. 15-1. Initially, toxic gases injure healthy epithelium, creating a wound. A provisional matrix is laid down over the wound that, along with chemoattractant signals from remaining cells within the wound, attracts epithelial cells and other agents involved in the inflammatory process. Epithelial cells adjacent to the wound become less differentiated and they begin to migrate in from the wound edges. These cells proliferate and eventually cover the wound and over the course of days to weeks, resume their normal structure and function.15
FIGURE 15-1 Injury and repair to airway epithelium. (A) Normal epithelium. (B) Wounding from toxic gases in cigarette smoke occurs. Provisional matrix is laid down. (C) Cells remaining in wound attract inflammatory agents. Epithelial cells begin to migrate in from wound edges. (D) Epithelial cells within wound proliferate. (E) Normal epithelium is restored. (Modified with permission from Rennard SI. Inflammation and repair processes in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999;160:S12.)
Unfortunately, because smoking tends to be an ongoing behavior, the inflammation typically becomes chronic and the damage irreversible. Bacteria that are ever present are drawn to the site, which presents an opportunity for colonization. This may be one reason that respiratory infections are commonly seen in smokers. Immune-related cells, including macrophages and neutrophils, are also attracted to the region. In the course of their efforts to clean up and repair the injury, these cells release enzymes that destroy healthy lung tissue. This ongoing injury, inflammation, and repair triggered by chronic cigarette smoking cause scarring and narrowing of small airways and disintegration of the lung parenchyma. The resulting obstruction of airflow and loss of elasticity are some of the hallmarks of COPD.15,16
CARDIOPULMONARY PRACTICE PATTERNS A AND B
Inclusion Criteria
A primary consideration in the decision to place a patient/client in a preferred practice pattern involves an assessment of the medical diagnostic groups—the includes and excludes—for each pattern. For cardiopulmonary Practice Pattern A, Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders, these include the risk factors for cardiopulmonary disease that were reviewed in the introduction. Because this is a primary prevention pattern, patients/clients with a current diagnosis of cardiopulmonary disease are excluded from Pattern A. Risk factors specifically listed for Practice Pattern A in the 2nd edition of the Guide include diabetes, family history of heart disease, hypercholesterolemia, hypertension, obesity, sedentary lifestyle, and a history of smoking.17 This list is not meant to be inclusive and other risk factors may also be considered.
One particular risk factor that has immediate relevance to physical therapists is sedentary lifestyle or a decrease in physical activity. This type of lifestyle will lead to a decrease in maximum aerobic capacity, which is listed as a functional limitation for Pattern A. Physical inactivity is an important risk factor for CVD because it leads to a host of pathological consequences, and it is a behavior that is a prime target for PT intervention.
Practice Pattern B, Impaired Aerobic Capacity/Endurance Associated with Deconditioning, has broad applications in diverse PT practice settings. Patients falling into this pattern may be seen in acute care, rehabilitation (including subacute rehabilitation), long-term care or home care, and other practice settings. Inclusion criteria for this pattern consist of a very wide range of medical conditions, including acquired immune deficiency syndrome (AIDS); cancer; chronic system failure, as well as cardiovascular, neuromuscular, and musculoskeletal disorders17 (see p. S475 of the Guide). Impaired aerobic capacity and endurance resulting from deconditioning distinguish patients in this pattern. According to the Guide, aerobic capacity and endurance are impaired if dependency in activities of daily living (ADL) and/or instrumental activities of daily living (IADL) is present, or if the individual is symptomatic during activity, or unable to perform endurance conditioning. Typically, there is a period of substantially restricted activity or inactivity, such as bed rest, that precedes the diagnosis, which is caused by illness or medical treatment. This activity restriction frequently results from a systemic disorder, which then leads to deconditioning, rather than cardiovascular or respiratory pump dysfunction/failure, which would place the patient in a different practice pattern.
Similarities and Differences Between Practice Patterns A and B
Cardiopulmonary Practice Patterns A and B may be conceptually linked by physiologic, epidemiologic, and clinical elements. A given patient/client may qualify for one or the other of these patterns at different points within the lifespan. Pattern A applies when a sedentary individual, who is at risk for cardiopulmonary disease, is not yet impaired by deconditioning; that is, he or she does not have signs or symptoms during daily activities that are typical of deconditioning. Pattern B applies after the individual has developed impairment related to deconditioning as a result of either pathology or medical treatment, particularly if it involves prolonged bed rest. In contrast to Pattern A, impairment in Pattern B may be a result of diagnosed cardiopulmonary disease.
For both Patterns A and B, PT management should include interventions designed to increase physical activity. This may include physical activity counseling, exercise prescription, and/or training in ADL or IADL. The outcomes of PT intervention may differ, however, between Patterns A and B. For clients in Pattern A, the distinguishing outcome involves an understanding of the risk of continued physical inactivity and increasing their level of physical activity to appropriate levels. For patients in Pattern B, the outcomes are directed more toward improvement in the level of conditioning. Specific interventions as well as measurable outcomes for both Patterns A and B, and the evidence supporting them, are discussed later in this chapter.
Choosing Practice Pattern A or Pattern B
Figure 15-2 illustrates a decision algorithm for Patterns A and B that uses information from the PT examination and evaluation to arrive at a decision regarding the practice pattern to be applied to a patient/client. Determining a practice pattern is, in effect, the equivalent of establishing a PT diagnosis. At the apex of the algorithm is the determination of the individual’s level of physical activity. Patients/clients who are physically active and who have no pathology, impairments, or disabilities, which are amenable to PT intervention, should not be treated. Patients who are physically active, but who may benefit from PT for reasons unrelated to physical activity, will be placed into other practice patterns. The decision to assign patients/clients, who are not physically active, to Pattern A or B or to another cardiopulmonary pattern is determined by the presence or absence of impaired aerobic capacity and endurance. Those who are physically inactive without aerobic impairment, which may be defined by the appearance of signs or symptoms of deconditioning during ADL or IADL, may be assigned to Pattern A. Those with aerobic impairment, who are symptomatic as a result of deconditioning, may be assigned to Pattern B, with the exception of those patients/clients who have cardiovascular pump dysfunction or failure or ventilatory pump failure who, therefore, belong in other cardiopulmonary patterns.
FIGURE 15-2 An algorithm for cardiopulmonary Practice Patterns A and B.
CASE EXAMPLE: MEET JOE SIXPACK
Joe Sixpack will show up in your clinic at some point, perhaps many times during your career (Fig. 15-3). He may be referred for any number of reasons, maybe not related to his cardiovascular risk status. You may encounter Joe in an outpatient clinic, where he wants you to cure his back pain. Perhaps you will meet him in a community setting, at a health fair, fitness clinic, or community exercise program. He saw on TV that he should have his BP checked or he wants to run in the 5-km race next month. When Joe gets sick or needs surgery or has an accident, you will encounter him in the bed at the acute hospital or rehabilitation facility. Joe is everywhere.
FIGURE 15-3 Meet Joe Sixpack.
Joe is the embodiment of the CVD risk factors. He has hypertension, hypercholesterolemia, and for good measure, diabetes. He is also overweight, he smokes, and he is, of course, a “couch potato.” We encounter Joe at two different times in his life. The first time that we meet him he qualifies for Pattern A, the primary prevention pattern. What can you offer Joe that will help him to avoid, or postpone, the heart attack that seems inevitable? What are the clinical signs and symptoms and the physiologic responses that you need to monitor to safely help him to adopt a healthier lifestyle? These are the issues.
The next time you meet Joe he has been flat on his back for a while and you are going to help him get back on his feet—Pattern B applies here. You have treated lots of patients with his primary diagnosis, but Joe’s medical history makes you a little nervous, and rightly so. He has a lot of hard work ahead of him and that is what worries you. What can you do to see him through his rehabilitation safely? The use of Joe as an example is going to show us how we can use cardiopulmonary Practice Patterns A and B. First, however, it is important to examine and understand the CVD risk factors he exhibits.
RISK FACTORS
Pattern A: Cardiovascular Risk Factors
Basis of Risk Determination
Before discussing specific conditions that are considered CVD risk factors, it may be helpful to review some of the concepts and the derivation of these risk factors that we so commonly associate with CVD. Health care professionals, as well as the concerned public, often wish an answer to the question: “What is the risk of developing a disease?” This concept of risk as it is applied to disease has been defined by studies of human populations. For any particular disease, there are typically numerous attributes that contribute, to varying degrees, to the pathogenesis of the disease. Some of these attributes are themselves diseases that may lead to, that is, increase the risk of the disease in question. An example of this in the context of CVD is diabetes. Other attributes are behaviors such as cigarette smoking, which may contribute to the disease. Still other attributes, BP, for example, are related to aspects of our anatomy and physiology over which we may or may not have any control. Measurement of some risk factors, such as gender, may be relatively straightforward—the characteristic is either present or absent. Other risk factors, for example, cholesterol, are measured on a continuous scale and are best understood by establishing a cutoff, above or below which risk status is established.
For any given disease, then, risk can be defined as the mathematical likelihood that an individual or group with a particular constellation of attributes—or risk factors—will develop the disease compared with those without those same attributes. In this sense, risk is relative, in that for a given individual or group, it is based on a comparison with others. The probability that CVD, for example, will occur in individuals or groups with high BP, diabetes, and obesity is quantifiable only by examining those with and without these characteristics. Calculation of relative risk must also consider those with and without the disease. Our understanding of the major chronic diseases, of which CVD and COPD are two examples, is limited by incomplete knowledge of causation. Some individuals with no apparent risk factors develop disease, whereas other individuals at “high risk” do not. Identification and understanding of disease-related risk factors require carefully designed and implemented research efforts to optimize validity and reliability and to minimize bias in the ascertainment of physiologic, behavioral, and environmental characteristics of human populations.
One of the earliest and most important of the studies that established the basic risk factors for CVD is the Framingham study. Begun in 1948, the Framingham study has examined and reexamined over 5,000 residents of the town of Framingham, Massachusetts, and their offspring, looking for physiologic, psychosocial, and behavioral characteristics that may lead to CVD. This still-ongoing investigation has contributed enormously to the understanding of heart disease and stroke and has identified the chief risk factors for CVD.18 Among the many benefits of this study, one that is applicable to cardiopulmonary Practice Pattern A includes a method for estimating cardiovascular risk, given the presence or absence of specific risk factors. This method makes use of tables derived from Framingham data that enable a clinician to calculate the approximate age- and gender-specific relative risk of heart disease in patients/clients without a documented history of CAD. Interested readers may study this method available at http://circ.ahajournals.org/cgi/content/full/100/13/1481.19 This method is also used in this chapter to highlight the magnitude of risk for the individual risk factors identified by the Framingham study.
Cholesterol
Cholesterol is an essential compound that is used by the body for many important functions, including cell membrane structure and enzymatic activity. Its role as a risk factor for CVD stems from its function as a transporter of fatty acids or lipids. Various forms of lipid-containing molecules (lipoproteins) are linked to cholesterol, forming complexes that circulate within the bloodstream and tissues. Most circulating cholesterol occurs as low-density lipoprotein cholesterol (LDL-C), which delivers lipids to tissues, and high-density lipoprotein cholesterol (HDL-C), which delivers lipids from the tissues to the liver—the primary site of lipid elimination. It is the LDL-C that is primarily responsible for the deposition of lipids within developing atherosclerotic lesions in arteries throughout the body, attracting the macrophages that eventually become foam cells.3,20 For this reason, LDL-C is regarded as the “bad” form of cholesterol. In contrast, HDL-C is thought to be a scavenger of lipids transporting them away from atherosclerotic lesions. Thus, HDL-C is considered to be the “good” form of cholesterol (see Chapter 3).
Serum cholesterol, a common clinical laboratory measure, is strongly related to CVD in epidemiological and clinical studies. It is estimated that 19% of adult Americans have elevated serum cholesterol levels.1 African American males tend to have lower cholesterol levels than do African American females, whites, or Mexican Americans, whereas white females tend to have the highest cholesterol levels. High cholesterol was one of the earliest cardiovascular risk factors identified by the Framingham study,18 creating the basis for current clinical recommendations regarding cholesterol. These recommendations address total cholesterol (TC) as well as subfractions of cholesterol, particularly HDL-C and LDL-C. With regard to the risk of developing CAD, a total serum cholesterol level of <200 mg/dL is considered desirable, whereas serum cholesterol levels of 200 to 239 mg/dL and ≥240 mg/dL are considered to be borderline and high, respectively. A level of LDL-C <130 mg/dL is also considered desirable as is a level of HDL-C ≥45 mg/dL for men or ≥55 mg/dL for women.19 Estimation of relative risk using Framingham risk tables19 will give the reader a better sense of what is meant by the various risk levels. For example, a 40-year-old man with a TC of 250 (high) and a HDL-C level of 30 (also high) is approximately 2.5 times more likely to develop CAD than a 40-year-old man with desirable levels of TC and HDL-C. A 65-year-old woman with similar TC and HDL-C levels also has approximately 2.5 times the risk of CAD as does her counterpart with desirable levels. Men and women with very low TC (<160 mg/dL) and/or very high HDL-C (>60 mg/dL) actually have a lower CAD risk compared with those with merely “desirable” levels.
Blood Pressure and Hypertension
Blood pressure is the force exerted by blood on the arterial wall as it is pumped through the circulatory system. High BP causes mechanical damage to vascular endothelium resulting in areas that are stripped of normal endothelial cells. This facilitates the atherogenic processes discussed earlier, leading to increased thrombus and plaque formation. Furthermore, high BP also leads to intracerebral aneurisms and hemorrhage as well as left ventricular hypertrophy, a marker for severe CAD. Hypertension, defined as a systolic BP (SBP) of ≥140 mm Hg and/or a diastolic BP (DBP) ≥90 mm Hg,21 is particularly insidious because, by itself, hypertension causes no symptoms, yet it can lead to a number of potentially fatal conditions.
Approximately 23% of adult Americans have hypertension. The prevalence of hypertension is higher among African Americans and among older Americans. A large majority of adults older than 65 years have hypertension.1Both SBP and DBP are positively related to atherosclerosis and CVD, that is, as resting BP rises so does the risk not only of CAD but also of stroke and all-cause mortality. Although persons with hypertension are particularly at risk, those with higher than optimal BP (≥120/80 mm Hg) also face increasing risk.19 According to Framingham tables, the risk of CAD for men is approximately 60% to 70% greater at a resting SBP of 140 to 150 mm Hg and 100% to 130% greater at ≥160 mm Hg. Women’s risk is lower than that of men with regard to hypertension, yet they too have a 40% to 50% increased risk at a resting SBP of 160 mm Hg or more.19 Systolic hypertension, without concomitant diastolic hypertension, is also an important risk factor. It has been estimated that a population-wide reduction of SBP of as little as 2 mm Hg would reduce CAD incidence by 6% and strokes by 13%.22
Cigarette Smoking
Unlike the other major CVD risk factors, cigarette smoking appears not to promote atherogenesis. Instead, the use of cigarettes enhances thrombus formation and affects vasomotor responses, interfering with coronary vasodilation. Keep in mind that cigarette use often coexists with other CVD risk factors, so these acute changes occur in the setting of atherosclerosis, further intensifying the danger of myocardial ischemia or infarction. In addition, cigarette use stimulates catecholamine release leading to hemodynamic responses that may be dangerous in the presence of CAD. Both heart rate (HR) and BP increase during cigarette smoking, causing elevated myocardial oxygen demand, which may induce ischemia if coronary circulation is inadequate to meet the increased demand. The acute nature of these physiologic alterations explains why cardiovascular risk associated with smoking is immediately reduced after quitting.23
Cigarette smoking is the nation’s leading cause of mortality, responsible for approximately 430,000 deaths each year. Cigarette smoking is associated not only with CAD but also with stroke, COPD, and lung and other cancers. Women who smoke during pregnancy also have higher rates of low birth weight and subsequent illnesses in their children, including sudden infant death syndrome. Smokers also harm those around them through exposure to environmental tobacco smoke, which has been linked to CVD, lung cancer, and pediatric respiratory diseases in nonsmokers.24
Slightly less than one-fourth of adults in the United States are current smokers. The good news is that prevalence of smoking has declined since the 1960s, when over half of men and one-third of women smoked.1 The bad news is that smoking rates are higher—more than one-third—among persons younger than 18 years, and they are rising.24 On the basis of Framingham risk tables, cigarette smoking alone is responsible for a 50% to 70% increase in CAD risk for men and a 30% to 50% increase for women. These calculations are based on average consumption of one pack per day. Individuals who smoke more than this face dramatically greater risk.19
Diabetes
Diabetes mellitus is a disorder in which the body is unable to utilize glucose because of a disorder of insulin metabolism. The type of diabetes present in an individual determines the nature of this inability to metabolize glucose. Broadly, two types of diabetes are commonly seen in clinical practice: type 1 diabetes and type 2 diabetes, which is much more common. Type 1 diabetes includes persons who produce little or no insulin, typically because of autoimmune destruction of the pancreatic cells that secrete insulin. Onset of type 1 diabetes commonly occurs in childhood, though some adults develop the condition, and those with the disease generally require exogenous insulin administration for survival. Type 2 diabetes is characterized by insulin resistance, or the inability of target organs, particularly skeletal muscle to take in and utilize or store glucose. Adult onset of type 2 diabetes is common, and exogenous insulin dependency is uncommon. Obesity, especially central, or abdominal obesity is strongly associated with type 2 diabetes because it causes or exacerbates insulin resistance.25
Regardless of etiology, one of the central pathophysiologic features of untreated or inadequately managed diabetes is hyperglycemia—elevation of plasma glucose. This is a clinical laboratory value that is the most commonly used diagnostic measure for diabetes. A value of ≥126 mg/dL, drawn after an overnight fast, is the current criterion. Chronic hyperglycemia is associated with a number of microvascular (small-vessel) complications including retinopathy, a common cause of blindness in persons with diabetes, and with peripheral and autonomic neuropathy. The relationship of hyperglycemia with macrovascular (large-vessel) complications, such as accelerated atherosclerosis, in type 2 diabetes is less clear. It is now believed that type 2 diabetes is characterized by insulin resistance with compensatory hyperinsulinemia (elevated plasma insulin levels), which is etiologically related to atherosclerosis. Other powerful CVD risk factors such as dyslipidemia (high LDL-C and low HDL-C), hypertension, and as mentioned, obesity are also associated with this syndrome. This complex mix of physiologic abnormalities accelerates the development of atherosclerosis and leads to many of the cardiovascular complications seen in diabetes.26
Diabetes is highly prevalent in the United States, with type 2 diabetes being roughly 10 times more common than type 1 diabetes. Overall, approximately 5% of adults have diabetes; however, the prevalence rises to nearly 20% in adults older than 65 years. Many of those with diabetes—up to one-third of the total number of cases in older Americans—are unaware that they have the condition. Like many of the other CVD risk factors, diabetes prevalence varies by race and gender, with higher rates in women as well as in African Americans and Mexican Americans.27 According to Framingham risk tables for men, diabetes confers an increased risk of CAD equal to that of cigarette smoking. However, women with diabetes lose the protective effect of their gender, so their CAD risk is essentially equal to that of men at any age.19 Persons with diabetes often have asymptomatic CAD and tend to have more severe involvement at the time of diagnosis. They are also more likely to develop congestive heart failure due to cardiomyopathy.28 Autonomic neuropathy, a common complication in diabetes, may cause abnormal physiologic changes during activity, such as postural hypotension or maladaptive HR and BP responses to exercise.25 For this reason it is particularly important to monitor vital signs during PT examination and intervention.
Obesity
The role of obesity as an independent CVD risk factor is somewhat controversial because many of its effects appear to be mediated through other risk factors. Obesity, diabetes, and hypertension are often clustered together in what is known as the metabolic syndrome. Insulin resistance and dyslipidemia, characterized by low HDL-C and increased LDL-C, also appear as part of the metabolic syndrome, which greatly increases the risk of CVD.26 It is hypothesized that abdominal obesity—fat deposition around the trunk rather than around the hips—is etiologically related to the abnormalities seen in the metabolic syndrome, contributing to insulin resistance and to the atherogenic lipid profile.29Cardiac abnormalities such as left ventricular hypertrophy and conduction disturbances are also more common in persons with obesity.29
There has been much recent concern about obesity in the United States. Approximately one-third of American adults may be considered overweight, a proportion that has increased from one-fourth since 1980. Higher rates of overweight are seen in African Americans and Mexican Americans, particularly among women in those ethnic groups. Among children, the proportion of those overweight has nearly doubled in the same time period, rising to more than 13% and 11% in children aged 6 to 11 years and 12 to 17 years, respectively.1 See chapter 16.
Physical Inactivity
Among all the CVD risk factors, physical inactivity is perhaps the risk factor most relevant to PT because it is most clearly within our domain of practice. Physical therapists work to achieve desirable health outcomes by counseling patients/clients to become more physically active or by prescribing exercise to improve fitness. As a CVD risk factor, physical inactivity like obesity may exert much of its influence through other risk factors.30 Indeed, physical activity has been shown to improve lipid profile, improve insulin sensitivity and blood glucose control, and to reduce BP.31 On the other hand, there is evidence that physical fitness is independently predictive of all-cause and CVD mortality.32,33 Readers interested in a more comprehensive discussion of the risk-factor status of physical inactivity are invited to review the Surgeon General’s Report on Physical Activity.34 This seminal document is available at http://www.cdc.gov/nccdphp/sgr/sgr.htm.
Regardless of the “independence” of physical inactivity as a CVD risk factor, numerous public health and medical associations have identified physical inactivity as a significant risk factor for cardiovascular and other diseases.30–32 The U.S. Surgeon General has determined that a majority of American adults do not participate in physical activity that is sufficient to achieve health or fitness benefits and that approximately one-fourth are completely inactive. Almost half of the nation’s children are not active enough to ensure healthy futures.34 Physical activity need not be vigorous to be beneficial. Men who are active enough to maintain a moderate level of physical fitness have substantially reduced mortality compared with men with low fitness.33 Walking, a form of moderate physical activity, is associated with lower mortality and improved health outcomes in older men and women.35,36These, and many similar research findings, have led to the recommendation that all Americans should participate in at least 30 minutes of some form of moderate physical activity, such as brisk walking, on most if not all days in the week.37–39 Exercise, which is a structured form of physical activity that is performed specifically to improve some aspect(s) of fitness and/or health,40 is one way to achieve the desired outcomes. However, other “lifestyle” forms of activity, such as gardening, walking, or bicycling as transportation and occupational forms of physical activity, are also beneficial (see Chapter 3).
Gender
Although male gender has traditionally been listed as a CVD risk factor, this is a misleading characterization of the differences in risk between men and women. In fact, CAD is the number one killer of women, surpassing all forms of cancer, including breast cancer, combined. There are important differences, however, in CAD risk for women compared to men. There is, for example, an age differential, such that the risk of dying from CAD is roughly equal for a woman as compared to a man 10 years younger. Women also present somewhat more of a diagnostic challenge with regard to CAD. This is because women are more likely to exhibit atypical symptoms, particularly variation or absence of chest pain, and because for women, the accuracy of many commonly used diagnostic tools is reduced. In addition, the prognosis following myocardial infarction is worse in women, with higher death rates compared to men. This may be due to women’s older age, more severe disease, and higher comorbidity rate at the time of the diagnosis. However, less aggressive treatment may also play a role. Differences in CAD occurrence are also seen among women in different ethnic groups. For example, CAD death rates among African American women are higher than those for white women, a difference that is considerably greater than the corresponding difference in mortality between African American and white men.41
At the onset of menopause, women’s CAD risk begins to approach that of men. The hormone estrogen appears to have several physiologic effects that tend to protect women from CAD. Estrogen promotes fat deposition peripherally in thighs and buttocks, which is a more favorable pattern of fat deposition with regard to CAD. Estrogen increases HDL-C (“good cholesterol”) levels and improves vasomotor reactivity, which promotes vasodilation and improved tissue perfusion. Estrogen and progestin, another female sex hormone, may also reduce the tendency to form clots, which may cause both strokes and heart attacks. The protective effect of estrogen via hormone replacement therapy has become a common recommendation for some women who are past menopause to reduce the risk of CAD. The protection against CAD conferred by estrogen is not universal. Obese women, especially those with abdominal adiposity, and women with diabetes lose the benefits conferred by their female status.
Family History
The Framingham study established family history of CAD as an important risk factor, one that is not subject to modification. Family history is considered positive if myocardial infarction or sudden cardiac death occurred in a primary male relative, aged 55 years or less, or in a primary female relative, aged 65 years or less. Because of family behavior patterns such as dietary and physical activity habits, the independence of family history as a risk factor is unclear. Recent investigations, however, have demonstrated that family history remains predictive for CAD even when other risk factors are accounted for.42,43 Familial genetic characteristics appear to influence lipoprotein metabolism, providing a possible mechanism for the effect on atherosclerosis and CAD occurrence. Although family history is not, strictly speaking, a modifiable risk factor—one that an individual can do anything about—realization that many behaviors are culturally and therefore, familially derived can help to identify ways to effectively target those behaviors for CVD risk reduction efforts.
Psychosocial Factors
Researchers have long suspected that certain personality traits are associated with CAD. The term type A personality was coined to describe the driven, workaholic individual, usually male, who was more likely to succumb to heart disease because of chronic stress. It now appears that responses to stress that are characterized by hostility and impatience increase CAD risk. Other psychosocial factors have been linked to CAD. These include depression, social isolation, and yes, chronic stress, particularly the type of job-related stress that an individual feels unable to control. In addition, low socioeconomic status is related to CAD so that lower status predicts higher rates of disease. To be sure, psychosocial traits have a complex relationship with behaviors, such as smoking, and poor dietary habits that increase the risk of CAD, but there are plausible biologic mechanisms that explain why these characteristics may independently contribute to CAD. Many of the psychosocial traits linked to CAD are associated with arousal of the autonomic nervous system such that sympathetic stimulation is increased. This, in turn, results in higher HR and BP levels both at rest and in response to stressful events. These responses not only increase myocardial work but also promote endothelial dysfunction and atherosclerosis. Furthermore, some characteristics also enhance blood clotting by way of increasing platelet activation.44
Co-occurrence of CVD Risk Factors and Clinical Implications
Most individuals at risk for CVD exhibit multiple risk factors, which accumulate to increase risk dramatically. For example, on the basis of the Framingham risk tables,19 a 65-year-old man with high TC, say above 240, and a low HDL-C, below 35, faces 2.5 times the risk of CAD compared with a man of the same age with desirable TC and HDL-C levels. Add hypertension, for example, SBP >160 and the risk increases to 4.5 times. Add smoking and the risk is greater than 5.5 times that of a nonsmoking, normotensive man with desirable cholesterol levels. Risk continues to rise as additional risk factors are added. Risk factors may cluster, as is seen in the metabolic syndrome, in which obesity, especially central or abdominal obesity, diabetes, hypertension, and dyslipidemia coexist, often complicated by physical inactivity.
Clustering of risk factors has important clinical implications for the physical therapist treating patients like Joe Sixpack, particularly as a primary care provider. Clinicians must be aware of patient/client risk-factor status, especially in the absence of a documented history of CAD. Lack of a diagnosis of heart disease does not necessarily rule out the presence of the condition. It may be wise to refer back to the physician in cases where there is a suspicion of CAD and potential PT interventions will involve physical activity counseling or exercise prescription. A method for determining whether or not physician referral is indicated is presented later in this chapter. Box 15-1summarizes the risk factors for Pattern A.
BOX 15-1
Risk Factors Associated with Cardiopulmonary Practice Pattern A
Hypercholesterolemia
Hypertension
Cigarette smoking
Diabetes
Obesity
Physical inactivity
Family history
Hostile response to stress
Pattern B: Deconditioning
The primary risk factor associated with Pattern B is deconditioning, a complex process that leads to significant changes in physiology, some of the consequences of which will be briefly summarized, particularly as they relate to clinical practice. Deconditioning may best be characterized by a decrease in maximal oxygen uptake (
O2max), which occurs relatively quickly, within several days of the onset of maintained bed rest. The rate of decrease in O2maxis greatest in the first week of bedrest. There is a dose–response relationship between the duration of bedrest and the degree of deconditioning, meaning that the longer the bedrest continues, the greater will be the loss of O2max. It is important to remember that deconditioning occurs even in the absence of concurrent disease processes.45
Following bedrest or inactivity, loss of O2max uptake results from central and peripheral changes in physiology. Central changes appear to have the greatest effect on reduction in O2max and are primarily a result of a decrease in stroke volume during activity. This loss of stroke volume is due to a loss of plasma volume, and consequently of venous return, that occurs as a result of bedrest and/or inactivity, thus altering the Frank–Starling mechanism. To maintain cardiac output with the loss of stroke volume in the deconditioned state, there is an increased HR response, both at rest and during activity. This deconditioning-related physiologic change in HR is an important clinical indicator that is readily assessed during the PT examination and intervention.
CLINICAL CORRELATE
The clinician should be alert for higher-than-normal HR at rest and during activity and should consider the consequence of this response in regard to myocardial work.
Peripheral changes in physiology associated with bedrest or inactivity, which are characterized by reduced skeletal muscle blood flow and capillarization, also influence hemodynamic responses to activity.45
Clinically, these physiologic changes may become manifest as orthostatic intolerance, resulting from a tendency for venous pooling to occur when the individual assumes an upright posture and leg fatigue during activity. Furthermore, skeletal muscle mass and strength decreases and bone demineralization occurs.45 Fortunately, the effects of deconditioning are readily reversed following bedrest. In one study, V.O2max returned to pre–bedrest levels within 30 days in subjects who participated in a post–bedrest reconditioning exercise program and subjects who merely resumed normal activities. The reconditioning exercise group, however, had a lower submaximal HR during a constant workload, an important potential benefit for subjects with CAD.46 It should be kept in mind that the research on the physiologic effects of deconditioning has primarily involved healthy male subjects, necessitating caution in the generalization of the findings to patient populations. There are few studies that examine the effects of bedrest in patient populations. However, the consequences of physical inactivity on health in various patient populations may be inferred from results of epidemiologic studies.
Box 15-2 summarizes the effects of deconditioning.
BOX 15-2
Physiologic and Clinical Effects of Deconditioning
Decreased maximal oxygen uptake because of
loss of plasma volume
decreased venous return
decreased stroke volume
alteration in Frank–Starling mechanism
Orthostatic intolerance
Decreased skeletal muscle mass and strength
Bone demineralization
EXAMINATION TECHNIQUES
Use of the Guide and the Hypothesis Testing Process
The Guide characterizes the initial examination, which is performed when seeing the patient/client for the first time, as an “investigation”17 (see p. S34) or a careful, systematic inquiry designed to provide data needed to formulate an appropriate plan of care.
CLINICAL CORRELATE
The examination, and subsequent evaluation, uses a form of hypothesis testing. In other words, the clinician tests a hypothesis, which may be thought of as an “educated guess,” regarding a practice pattern. One’s initial impression may be that a given patient/client fits a particular practice pattern. This “hypothesis” is then tested by evaluating the data gathered from the examination, and either the hypothesis is confirmed or another practice pattern is suggested. This new hypothesis is tested in light of the examination data and confirmed or refuted, and so on, until clinicians are satisfied that they have identified a tenable practice pattern.
Novice clinicians may be tempted to conclude that once they have completed the initial examination, and progressed to evaluation, diagnosis, prognosis, and intervention, the examination process is over. Certainly, one may foresee the need for a reexamination at some point, but in an important sense the examination process is ongoing. Perhaps we can best characterize this ongoing examination by another term, say assessment or monitoring. Indeed, when working with patients/clients with cardiopulmonary dysfunction, it is this ongoing assessment or monitoring of physiologic responses to activity that brings the full skill of the physical therapists to bear in a clinical encounter. The term skill, as used in the previous sentence, implies not only that the clinician has the technical ability to obtain measurements such as HR and BP during an examination or intervention but also that the clinician has the wisdom to interpret the information derived from clinical measurements to make appropriate decisions regarding continuation, modification, or termination of the procedure (see Chapter 12).
In the current health care environment, in which many clinicians are able to practice independently, without physician referral, the physical therapist may be acting as the primary provider of care. This adds to the responsibility of the clinicians who may be seeing Joe Sixpack in their clinic. It is incumbent on the primary care provider to gather as much information as possible regarding the health status of the patient or client. Referral to other health care provider(s) is indicated when additional information, which may be beyond the skill of the clinician or outside of the scope of PT practice, is needed. Furthermore, physician referral does not guarantee that all medically relevant information has been obtained or is provided or available to the physical therapist. Even in hospital settings, where there is typically an abundance of medical records, charts, and the like, information may be hard to come by. Charts can be misplaced, or in use by someone else, and sometimes they are inaccurate. Physicians and nurses (and yes, other physical therapists) are busy and may have neither the time nor the inclination to share information at a given point in time. The astute clinician in any setting must be prepared to gather information from as many sources as are available including the patient or client, family members and other associates, other health care providers, and the medical record.
Imagine that you are a therapist with a successful private practice who wishes to expand into a new territory by starting a “wellness” clinic. In walks Joe Sixpack. He saw a TV show, an infomercial perhaps, that featured young, slim, attractive men and women bouncing around some beach in the Caribbean doing aerobics in spandex and having lots of fun. Now Joe is no longer young (let’s say he is “middle aged”) nor is he slim and he (as you will soon discover) has lots of medical issues that put him “at risk” for cardiopulmonary disease. But he pictures himself on that beach someday. Fortunately, Joe had the good sense to come to you before embarking on his workout program and you eventually determine that he belongs to cardiopulmonary Practice Pattern A.
Now imagine that you are working in a busy hospital, or in a rehabilitation center, or may be doing home care, or even consulting in a nursing home. You receive a new PT referral—It is Joe. Only this time he is a little older, or maybe a lot older, and he has had ________. You can fill in the blank because his primary diagnosis is not the basis of your decision to place him in cardiopulmonary Practice Pattern B. Joe has been sick in bed for several weeks and he is quite deconditioned. For our purposes, let us say that Joe does not have a condition, like a stroke or a hip fracture or an amputation, that would place him in some other practice pattern. However, even if he did, much of the discussion about PT examination and intervention for Pattern B would still apply. This is because, regardless of his primary diagnosis, he is still deconditioned and he is what can be called a “complex medical patient,” owing to the presence of multiple comorbidities17 (Guide, see p. S475). This illustrates the extraordinary breadth of cardiopulmonary Pattern B. It encompasses a wide range of patients/clients that may include the presence of risk factors—those who have become deconditioned as a result of bed rest or inactivity due to medical illness.
History
The Guide lists a number of categories of data to be obtained when taking a history from the patient/client. All of the elements listed are important, but the clinician may elect to emphasize particular items in a given clinical scenario. This section discusses some of the more crucial factors to be obtained from Joe’s history. A key area of inquiry involves his medical/surgical history. Whether one queries Joe himself, his family, or friends, or obtains the information from the medical record, the physical therapist will want to establish the presence or absence of medical comorbidities, particularly those that relate to cardiopulmonary disease. These include the Framingham risk factors—diabetes, hyperlipidemia, hypertension, and obesity—as well as other relevant conditions that impact on clinical decisions. The presence and nature of cardiopulmonary disease must be assessed. A positive history of cardiopulmonary disease not only excludes a patient/client from Pattern A but also indicates heightened monitoring during intervention. However, whether or not Joe has a documented history of CAD or other cardiopulmonary condition, the presence of multiple risk factors indicates high-risk status. In this case, the clinician is wise to proceed as though the patient/client does have cardiopulmonary disease and monitor accordingly during intervention.
More information about risk factors can be obtained when assessing Joe’s past and current social habits, particularly with respect to cigarette smoking and physical activity, and his family history. Do not hesitate to discuss smoking with Joe: Ask him how many years he has smoked and how many packs per day he smokes. From this you can calculate his pack-year smoking history, a clinically useful measure of smoking status, simply by multiplying the number of packs per day smoked by the number of years of smoking. In Joe’s case, he smoked two packs per day for approximately 30 years, so he has a 60-pack-year smoking history. If the patient/client is not currently smoking, you will also want to know about past smoking. Joe might tell you he does not smoke, and if you leave it at that you would not find out that he had “quit” smoking this morning. When assessing physical activity level, do not assume that lack of exercise during leisure time means patients/clients are inactive. They may have a physically active occupation, such as a letter carrier or homemaker/parent (think of all the work that goes into cleaning and vacuuming, etc, not to mention child care) or an active hobby like gardening. In Joe’s case, however, we find that he is indeed a couch potato. When discussing family history, ask about primary relatives, parents, and siblings and whether there is a history of a heart attack before 55 years of age, for men, and 65 years, for women.
Also important are the medications that Joe is taking. It is imperative to get an accurate account of all drugs, including dosages and times and routes of administration. Not only will this information be crucial when assessing physiologic responses to activity, it can also provide valuable clues about risk factor and comorbidity status, particularly if the patient’s/client’s account or the medical record is lacking in detail regarding medications. If, for example, Joe is a bit fuzzy about his cholesterol levels, but he is taking medications you know to be drugs that lower cholesterol, it is a good bet that his cholesterol level is, or hopefully was, high. It is also important to assess the patient’s/client’s adherence with medication and, in some cases, the response to medication. Joe may well be taking antihypertensive medication; but if his resting BP is consistently high, say over 160/90 mm Hg, there is good reason to question him regarding adherence to his medication regime and if he is adherent, to discuss your concerns about the drug’s effectiveness with his physician.
Laboratory and diagnostic tests provide important information regarding CVD risk factors, information that determines the course of medical therapy for individuals such as Joe. Joe’s risk-factor history suggests that he may be classified as having the “metabolic syndrome,” a common clustering of CVD risk factors that include diabetes, obesity, hypertension, and dyslipidemia. The physical therapist can learn much from laboratory test results for these conditions. For example, a lipid profile, from serum cholesterol measurement, provides information on TC, HDL-C, and LDL-C, which are all important indicators of CVD risk.
For diabetes, there are several useful, and sometimes necessary, laboratory tests including blood glucose, the amount of glucose within the plasma, and glycosylated hemoglobin (GHb), the fraction of hemoglobin bound with glucose. We have seen that hyperglycemia, or excessive blood glucose, is the primary diagnostic feature of diabetes, and it is a condition that has to be avoided to reduce the likelihood of the occurrence of diabetic complications. Fasting blood glucose (FBG), measured in blood drawn after at least 8 hours since eating, is used as a diagnostic indicator of diabetes. A FBG level of $126 mg/dL is considered to be diagnostic for diabetes. Blood glucose levels should also be monitored prior to, and sometimes during, exercise or sustained physical activity.
CLINICAL CORRELATE
If FBG is >250 mg/dL, exercise should be avoided until blood glucose levels are brought under better control. Exercise should also be avoided or stopped and a carbohydrate snack should be given, if blood glucose levels are <100 mg/dL at any time.25
Many individuals with diabetes, and many facilities that care for persons with diabetes, have blood glucose–monitoring kits available. These involve blood sampling by finger stick, rather than by venipuncture, and can be readily used for rapid determinations of blood glucose levels that are the basis for clinical decision making. Measurement of GHb is an indicator of overall blood glucose levels during the previous 2 to 3 months and as such, provides information on long-term diabetes control. As blood glucose levels rise, so do values of GHb. GHb values of 4% to 6% are considered normal, and values >8% are indicators of ongoing hyperglycemia and inadequate control. GHb is a particularly useful outcome measure for interventions designed to improve glycemic control and reduce diabetic complications.
Discussing the history of the current condition and health status presents an opportunity to learn why Joe has come to you, what his perceptions and concerns are about his health, and what his level of understanding is of his condition. A patient who when asked, “Why did you come here today?” answers with “… I dunno, the doctor told me I had to come here” has a very different understanding of his or her condition than one who answers with a 5-minute rendition of medical history, including details about drugs or surgery or other medical treatments. You want to know about functional status and activity level, paying particular attention to a recent decline in ADL and IADL. Recent decline could be a key influence on the decision to place a patient/client in Pattern B rather than in Pattern A.
Here you can get an idea of Joe’s willingness to change behavior. Has he thought about his physical inactivity? Does he want to be more active? Has he tried to become more active in the past? Does he have a plan to increase his activity level by exercising or by some other activity? The answers to these questions help the clinician to design the most appropriate intervention, perhaps incorporating a behavior change theory such as the Transtheoretical Model.47
The Transtheoretical Model of behavior change provides a means to assess the patient’s/client’s willingness to change a behavior like physical activity. Using this approach, clinicians may tailor their intervention to optimize the chance of success in motivating the individual to progress to a higher stage toward behavior change. The model is based on a progression of stages of change that are listed in Table 15-1. For Pattern A, Joe is in the preparation stage, ready for action; he came to a physical therapist, looking for advice on how to become more physically active. Knowing this, the clinician can reasonably implement an exercise prescription or a specific plan to increase lifestyle physical activity. Had Joe been in an earlier stage, say precontemplation or contemplation, a specific action plan would be less likely to succeed. Provision of information about cardiovascular risk factors, or exposure to media campaigns, would be appropriate to help Joe progress toward the preparation or action stage. Once Joe adopts the desired behavior—he participates in regular exercise or lifestyle physical activity—the clinician may suggest strategies to encourage him to continue. These may include use of exercise groups for support or reviewing contingency plans to exercise in different seasons or environments (indoors vs outdoors).
TABLE 15-1 Five Stages of Change in the Transtheoretical Model of Behavior Change
Systems Review
The systems review is where a scan of functions relating to the four primary domains of PT—musculoskeletal, neuromuscular, cardiopulmonary, and integumentary—is performed. In Joe’s case, many of the assessments that fall under the cardiopulmonary domain will be emphasized as tests and measures during your examination. You will want, however, to quickly assess functional strength, range of motion, sensation, coordination, balance and equilibrium, and skin condition. A deficit in any of these areas indicates a need to assess the impairment in greater detail and will likely be a consideration in the type of physical activity you recommend or exercise you prescribe.
Tests and Measures
Placement of a patient/client in a particular practice pattern may require all the information that is gathered during the examination process before a final decision can be made. This can be said of many of the cardiopulmonary practice patterns, but for some patterns the decision is more apparent at the beginning of the episode of care. Pattern A may be one pattern in which the clinician senses at the outset that primary prevention is of interest. This determination needs to be confirmed by the examination, particularly by ruling out documented cardiopulmonary disease. If cardiopulmonary disease is present, Pattern A is excluded; however, the presence of one or more CVD risk factors should be established by reviewing the patient’s/client’s history. These risk factors are listed in the Guide under the Patient/Client Diagnostic Classification.17 Note that many of the Framingham risk factors are listed.
Clinicians may wish to use structured screening tools that facilitate the assessment of CVD risk factors, such as that shown in the cardiac examination chapter and provide guidance regarding further referral and/or intervention. Formal cardiovascular risk screening procedures are desirable in settings where the clinician may be practicing without physician referral, or where the patient/client is referred for primary musculoskeletal or neuromuscular dysfunction and the physical therapist identifies physical activity or aerobic exercise as an appropriate intervention. Formal screening tools, like the Physical Activity Readiness Questionnaire (PAR-Q) or the American Heart Association/American College of Sports Medicine Health/Fitness Facility Preparticipation Screening Questionnaire are available at http://circ.ahajournals.org/cgi/content/full/97/22/2283.48 However, the goal of screening is to identify patients who need additional medical assessment. In the absence of physician referral or evidence that the referring physician has sufficiently assessed CVD risk, additional consultation should be considered. Typically, this involves referral to a physician to rule out coronary or other heart disease, often by exercise testing, for patients/clients with multiple risk factors and/or symptoms. Some physical therapists may be qualified to conduct such assessments. Attributes that indicate the need for further medical evaluation include age (males >45 years and females >55 years) and/or the presence of two or more CVD risk factors.48
Utility of the Decision Algorithm
The decision algorithm (Fig. 15-2) is meant to facilitate the clinical decision process when considering the cardiopulmonary practice patterns, particularly Patterns A and B. According to the algorithm, once it has been established that the patients/clients are not physically active, the next step involves determining if they have aerobic impairment resulting from deconditioning. In some cases, this determination is fairly obvious. Most of us would have little difficulty choosing between Patterns A and B for a client who walks up to you at a health and fitness clinic in a shopping mall and for a patient who has been sick in an intensive care unit bed for several weeks. Clinical decisions are rarely that straightforward, however, and it is useful to consider the tests and measures that will help us to distinguish between Patterns A and B.
Impaired aerobic capacity, which is characteristic of Pattern B, is suggested by the impairments, functional limitations, and disabilities listed under the Patient/Client Diagnostic Classification. What are some of the tests and measures that correspond to these features? Table 15-2 lists impairments, functional limitations, or disabilities with some corresponding tests and measures. Ability to perform functional activities, including gait and locomotion, self-care, and other occupational activities, and to gain access to home, work, and community environments may be severely compromised by impaired aerobic capacity resulting from deconditioning. Unusual or abnormal responses, such as a high resting HR and an exaggerated HR response during activity or exercise, are hallmarks of deconditioning. In addition, ADL or IADL scales, which are available in some clinical databases (eg, the Minimum Data Sets (MDS) or Outcome and Assessment Information Set (OASIS)), are useful in that they provide valid and reliable quantitative measures of functional status. From a cardiovascular and pulmonary standpoint, safety during activity is measured by assessing physiologic responses to activity, including vital signs such as HR, BP, and RR, along with associated signs and symptoms. The Borg Perceived Exertion Scales are widely used and are valid and reliable measures of subjective responses to activity.49
TABLE 15-2 Impairments, Functional Limitations, or Disabilities Associated with Impaired Aerobic Capacity in Pattern B with Corresponding Tests and Measures
Beyond assisting with practice pattern determination, the tests and measures performed during a PT examination also help to identify patient/client impairments that must be considered to provide the most appropriate intervention. Furthermore, the tests and measures performed during an examination enable the clinician to assess the safety and effectiveness of interventions. Selection of specific tests and measures by a clinician will depend not only on the practice pattern chosen but also on both the practice setting and the skill and experience of the therapist. We next review some tests and measures that might be used to assess Joe Sixpack for both Patterns A and B.
Tests and Measures for Pattern A
We first encounter Joe when he asks the physical therapist to advise him about physical activity. He realizes that his sedentary habits are not healthy and wants to change them. During the examination process, the clinician has determined that Joe has multiple CVD risk factors including diabetes, obesity, hypertension, and hyperlipidemia. Joe has discussed this with his primary care physician who has examined him and ruled out CAD. During the PT examination, the clinician collects information that suggests that Joe belongs to Practice Pattern A and that will help the physical therapist to provide a safe and effective intervention.
To assess Joe’s aerobic capacity and endurance, the physical therapist performs a submaximal exercise test, using an established exercise protocol, to ascertain his physiologic responses to activity and to establish a safe level of activity. The protocol chosen is the modified Bruce protocol, which begins at a relatively low intensity. Because this was a submaximal exercise test, the clinician predetermined an endpoint based on HR, using 85% of Joe’s age-related maximum HR as the primary termination criteria. Since Joe is 50 years old that endpoint is approximately 173 beats per minute (bpm), using the revised formula:
ARMHR = 208 ∇ 0.7 × age.50
The stress test protocol and results are displayed in Table 15-3. Note that Joe’s vital sign responses to the test were relatively normal, with the exception of elevated BP at rest with a hypertensive response to activity. Joe reached stage 2, where he just exceeded the termination criteria leading to cessation of the test. After 5 minutes of recovery, he had not attained resting values of HR and BP. At the highest metabolic equivalent (MET) level achieved on this test (7) Joe’s perceived exertion level corresponded to “heavy.” These findings indicate decreased aerobic capacity, an inclusion criterion for Practice Pattern A.
TABLE 15-3 Results of Submaximal Stress Test Using the Modified Bruce Protocol
Measurement of height, weight, and girth will enable calculation of body mass index (BMI) and waist circumference, which are used to determine relative weight and body fat distribution (see Chapter 3). To calculate BMI using English measurements, divide the weight in pounds by the square of the height in inches and multiply the quotient by 703:
BMI = [body weight (lb)/height (in.)2] × 703.
In Joe’s case, his weight is 240 lb and his height is 71 in. (5 ft 11 in.), yielding a BMI of 33.5 ([240/(71)2] × 703 = 33.47) that is well within the obese range (BMI ≥ 30 kg/m2) according to National Institutes of Health criteria.51Joe’s waist circumference is 43 in., which places him at “high risk” (>40 in.) for conditions associated with obesity.51 Readers interested in online calculation of BMI and other information related to overweight and obesity may visit the National Heart, Lung, and Blood Institute Web site at http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm.
For Pattern A, other tests and measures that are helpful to provide a safe and effective intervention may include performance of pulse oximetry and assessments of pulmonary function test results, ability to clear his airway, chest wall mobility, and cough assessment, particularly if there is a history of pulmonary disease or dysfunction. Questions about Joe’s self-care and home management abilities, as well as work and leisure activities, will provide important information on ADL and IADL functioning. To assess potential neuromuscular or musculoskeletal impairments that may necessitate modification of physical activity and/or exercise analysis of functional muscle strength, resting posture, and range of motion are useful. In Joe’s case, no gross pulmonary, neuromuscular, or musculoskeletal abnormalities, other than generalized muscle tightness, are seen. To obtain more information about function and quality of life outcomes, a health-related quality-of-life instrument, the SF-12 (see Fig. 15-4), is administered.
FIGURE 15-4 SF-12(r) completed by Joe pre-PT. (Reprinted with permission from Ware JE Jr, Kosinski M, Turner-Bowker DM, et al. User’s Manual for the SF-12® Health Survey with a Supplement Documenting SF-12® Health Survey. Lincoln, RI: QualityMetric Incorporated, 2002.)
Tests and Measures for Pattern B
The Pattern B scenario is quite different. This time we meet Joe when he is approximately 60 years old and has been hospitalized after surgery, resulting in a prolonged recovery period that required much bed rest. His primary medical comorbidities—hypertension, diabetes, and obesity—continue to be important clinical issues. Joe’s level of conditioning, which was low to begin with, is now very poor. Just moving in bed causes him to be short of breath, and he feels woozy the first time you ask him to sit up at the side of the bed. He is barely able to perform active range-of-motion exercises and complains of excessive fatigue when asked to do so. Clearly, he meets the criteria for Pattern B.
Table 15-2 lists the tests and measures that can be used to qualify a patient/client for Pattern B. We now examine some other tests and measures that would assist the clinician in providing a safe and effective intervention. One of the more important categories of tests and measures, and one that relates directly to the primary impairment that characterizes this pattern, is appraisal of aerobic capacity and endurance. Assessment of performance during established exercise protocols can provide information that may be used to determine an appropriate intervention and to evaluate the effectiveness of the intervention. A good choice in this setting is the timed walk (6- or 12-minute walk). The procedure for this test is detailed in Chapter 9. The validity and reliability of this procedure have been established for patients/clients with COPD and other conditions,52 and the test may be used as an outcome measure for patients/clients with chronic diseases. Joe’s test results are presented in Table 15-4. Following a practice test, designed to wash out a learning effect, Joe is able to cover 385 ft in 6 minutes, stopping twice to rest during the procedure. During the procedure, Joe experienced shortness of breath and an elevated respiratory rate and rated his perceived exertion as 15 on the Borg scale.49 Physiologic responses are mildly hypertensive but otherwise acceptable.
TABLE 15-4 Six-Minute Walk Performance
Other tests and measures appropriate here include assessments of orientation to time, place, person, and situation and screening for level of cognition. These assessments provide important information about Joe’s safety awareness and his ability to follow your instructions. Joe has developed dependency in ADL such that the therapist elects to use assistive and/or adaptive devices during examination and intervention. A wheeled walker is less energy costly than a standard walker and is the assistive device of choice for this deconditioned patient. Accordingly, the therapist should assess gait and locomotion during functional activities with or without the use of assistive, adaptive, orthotic, protective, supportive, or prosthetic devices and equipment17 (see p. S479 of the Guide). These analyses should indicate whether Joe is able to ambulate with fewer symptoms, less assistance, and reduced danger of falling when using the device. During the analysis of the wheeled walker, the therapist is also analyzing gait, locomotion and balance, and self-care and home management activities, specifically ambulation. Other functional tests and measures include ability to gain access to home environments and safety in self-care and home management activities17 (see p. S479 of the Guide). These tests measure how well Joe is able to move about his hospital room and about the hospital floor and perform important ADL activities like using the toilet, washing up, and getting dressed. Analysis of muscle strength, power, and endurance; functional range of motion; and postural alignment and position17 (see p. S479 of the Guide) provide evidence of other impairments that will need to be considered during intervention.
Among the most important function-related tests and measures are assessments of autonomic responses to position changes and of physiologic responses during self-care and home management activities, including, of course, transfers and ambulation. The significance of these assessments cannot be emphasized too strongly, for they are key elements of PT practice for patients such as Joe.
CLINICAL CORRELATE
All too often, the assessment of physiologic responses, such as HR and BP, during activity is ignored by practicing physical therapists. Not only is important information neglected—information that alerts the clinician to potentially unsafe responses—but also the therapist misses an opportunity to contribute in a meaningful way to the overall management of the patient.
Indeed, it is this type of assessment, performed during examinations and interventions, that many consider to be routine and mundane, which demonstrate the skill of the therapist. In the current health care environment, characterized by cost-efficiency and competition, our profession must take every opportunity to demonstrate that the services we provide are unique and necessary and that we are the ones with the best skills to provide them. In most settings there may be other health care professionals, for example, nurses, who take vital signs; but it is the physical therapist who can and should monitor these responses before, during, and after activity.
A distinction may be made here between assessment of physiologic responses to activity as part of the PT examination and physiologic monitoring during intervention. During the examination, the therapist should perform an assessment of physiologic responses to activity for any patient/client who may qualify for Practice Patterns A or B as well as for any patient with two or more CVD risk factors or a documented history or CVD. Medical clearance may also be indicated in primary care settings. The choice to continue to monitor physiologic responses, including vital sign assessment, during intervention-related physical activities is based on the cardiovascular status and medical history of the individual. A proposed decision model for physiologic monitoring based on American Heart Association (AHA) risk stratification criteria is presented in Table 15-5.48,52 This model is based on age, CVD risk factors, and known heart disease and includes patients/clients who may qualify for Pattern A or B. Although the AHA recommends a diagnostic exercise test performed by a physician, this information is typically not available in inpatient settings. A reasonable substitute for an exercise test, particularly when the primary PT intervention involves training in ADL (bed mobility, transfers, ambulation, etc) or aerobic exercise, is to assess physiologic responses during the examination.
TABLE 15-5 Criteria for Ongoing Physiologic Monitoring and Recommended Activity Intensity48,52
CLINICAL CORRELATE
The decision to continue monitoring during intervention depends on the responses during examination as well as on the medical status of the patient.
This model proposes minimal criteria for physiologic monitoring and clinicians may, at their discretion, decide that physiologic monitoring is needed even though it may not be indicated here.
Monitoring for patients/clients with comorbid pulmonary disease (eg, COPD) should also include performance of pulse oximetry to assess oxygen saturation and assessment of dyspnea. Patients/clients with diabetes deserve special consideration when it comes to monitoring physiologic responses. Persons with diabetes may have unusual vital sign responses to activity, including changes in position. This is particularly important to remember when mobilizing someone like Joe out of bed after a prolonged period of bed rest. Assessment of orthostatic tolerance by monitoring vital signs and symptoms is essential (see Chapter 10).
INTERVENTION TECHNIQUES
The health care interventions for individuals like Joe Sixpack—individuals with multiple risk factors for cardiopulmonary disease—can be broadly classified into pharmacologic and lifestyle interventions. This section provides an overview of both categories of interventions that pertain to diabetes, hyperlipidemia, and hypertension—conditions we see in our case study. The key components of the health care management of all these are weight loss in those who are overweight or obese and adequate physical activity and/or exercise. Accordingly, this section also reviews health care interventions for patients/clients who are overweight and obese. Interventions for physical activity, a component of health care management that physical therapists are ideally suited to provide, are discussed separately. PT interventions emphasizing physical activity and/or exercise, as they pertain to Patterns A and B, are highlighted.
Interventions for Diabetes
The primary goal in management of both type 1 and type 2 diabetes is to achieve and maintain normal levels of blood glucose. Maintenance of euglycemia (normal blood glucose levels) will prevent the acute and chronic complications of diabetes. Among the most serious acute complications of diabetes are diabetic ketoacidosis, which occurs primarily in persons with type 1 diabetes, and hyperosmolar hyperglycemic nonketotic syndrome, which is seen mostly in those with type 2 diabetes. Both conditions represent acute decompensation due to inadequate levels of insulin and/or uncontrolled hyperglycemia. These conditions, if untreated, may lead to coma and death. Hypoglycemia, which is also known as an insulin reaction, is an acute state characterized by an abnormally low level of blood glucose. This condition, which causes symptoms ranging from confusion, weakness, and irritability to unconsciousness, requires immediate intervention, typically in the form of rapidly absorbed carbohydrates. Chronic complications of diabetes become manifest in numerous ways ranging from accelerated CVD and its attendant pathologies to retinopathy and blindness to peripheral and autonomic neuropathies, which impair sensorimotor function and cardiovascular responses to activity.
Achievement of euglycemia involves both medical intervention, including pharmacologic intervention, and self-care on the part of persons with diabetes. Pharmacologic management differs according to whether or not endogenous insulin is present. In type 1 diabetes, little or no insulin is available and individuals must rely on exogenous insulin that is injected or supplied by an insulin pump. Ideally, the patient self-monitors blood glucose levels several times daily and adjusts insulin and food intake, as well as physical activity, accordingly. For those with type 2 diabetes, the problem typically is not inadequate insulin. In fact, hyperinsulinemia (too much insulin in the blood) is common; rather, the problem is resistance to insulin leading to poor glucose uptake by cells such as skeletal muscle cells. Pharmacologic management of type 2 diabetes often involves the use of oral medications (sulfonylureas) to lower blood glucose. In some cases, persons with type 2 diabetes require insulin, although typically an insulin schedule that is less complex is recommended in type 1 diabetes. On the basis of evidence that regular exercise or physical activity contributes to glycemic control in type 2 diabetes, and prevention of CVD in all persons with diabetes, the American Diabetes Association recommends regular exercise as an important component of diabetes management.25
Self-care in diabetes has taken on increased importance as the benefits of glycemic control have become evident. Self-care places more responsibility on the patient/client, but it enables the individual to maintain blood glucose within a much narrower range, potentially avoiding prolonged episodes of hypoglycemia or hyperglycemia. Cornerstones of self-care include monitoring of blood glucose and recognition of signs and symptoms associated with acute and chronic complications of diabetes as well as modifying diet and physical activity.
Home glucose monitoring kits are commonly used for self-monitoring of blood glucose. A drop of blood is obtained from a finger stick and tested in a small device that gives an immediate reading of blood glucose level. The results enable rapid adjustment of insulin and/or diet, if necessary, to normalize blood glucose. Patient/client use of home or ambulatory monitoring systems can be very helpful to the physical therapist in planning or adjusting physical activity and/or exercise, particularly if the patient/client is symptomatic or is known to have difficulty with glycemic control. The same types of devices may be used in inpatient settings for convenient blood glucose monitoring, avoiding costly and time-consuming laboratory work.
Patients are taught to recognize the signs and symptoms of acute decompensation and to monitor changes related to chronic complications. Foot care is particularly important for the person with diabetes because of the problems associated with sensory neuropathy, which affects distal extremities early in its course. Wearing well-fitting shoes that avoid friction or cramping, inspecting the feet daily for early signs of skin breakdown or infection, and taking care not to injure the feet during ADL are all important aspects of foot care. Many older people with diabetes have their toenails trimmed by a health care professional to avoid infection. Early skin problems can be quickly treated before they become catastrophes like amputation.
Dietary self-management is important for persons with both type 1 and type 2 diabetes. In type 1 diabetes, food intake should correspond with insulin administration to avoid hypoglycemia, which can result from inadequate food intake following insulin injection, and hyperglycemia, which may occur if food is eaten without exogenous insulin administration. In addition, persons with type 1 and type 2 diabetes are urged to maintain a healthy, balanced diet that is low in saturated fats and contains the recommended components from all food groups. Individuals with type 2 diabetes, most of whom are overweight or obese, should receive education in strategies to help them maintain a healthy weight. For sedentary individuals, increasing physical activity is a vital element in weight-loss efforts—one for which physical therapist referral may be indicated.
Interventions for High Blood Cholesterol
The health care management of hyperlipidemia is based on overall CVD risk as well as on cholesterol levels of the patient/client. For individuals with high blood cholesterol, the focus of management is on reducing LDL-C, a high level of which is recognized as a distinct CAD risk factor. The National Cholesterol Education Program (NCEP) recommends that persons with established CAD be treated more aggressively than those who are merely “at risk” due to other CAD risk factors as well as those who are otherwise at relatively low risk.53 This risk stratification is reflected in the clinical management of different patient populations. For patients/clients with diagnosed CAD, nonpharmacologic intervention is initiated if LDL-C is >100 mg/dL, whereas pharmacologic intervention should be considered if LDL-C is >130 mg/dL. In the absence of CHD, but when multiple risk factors are present (the clinical scenario for Practice Pattern A), LDL-C values of ≥160 and ≥130 mg/dL are threshold levels for initiation of nonpharmacologic therapy and consideration of pharmacologic intervention, respectively.
Nonpharmacologic intervention for cholesterol management consists of lifestyle changes in diet and physical activity. Dietary modification follows a two-step plan based on progressively reducing intake of fats and cholesterol and on reducing weight in those who are overweight or obese. A recommendation for the step I diet is to limit fat intake to 30% of the total nutrients consumed, of which 8% to 10% should come from saturated fats. Consumption of less than 300 mg of cholesterol and of sufficient calories to maintain healthy weight are also components of the step I diet. For the step II diet, saturated fats should comprise less than 7% of total fat intake and less than 200 mg of cholesterol should be consumed. For those who are overweight or obese, adjustment of calorie intake to achieve weight loss is recommended.54
Pharmacologic intervention is reserved for those who are unable to lower LDL-C to desirable levels—desirability being based on risk-stratification thresholds—with dietary modification and physical activity. Several classes of drugs are currently used for their LDL-C–lowering characteristics, including bile acid sequestrants, “statins,” and fibric acids. For postmenopausal women, estrogen replacement may be considered to help raise HDL-C levels and lower LDL-C levels.
Interventions for Hypertension
Risk stratification is also used to determine the medical treatment course for patients/clients with high BP. Risk is based not only on the magnitude of BP elevation but also on the presence or absence of other CVD risk factors and evidence of CVD. Diabetes is a particularly strong factor in clinical decisions, as is evidence of organ-related pathology, such as left ventricular hypertrophy or renal insufficiency. Patients with BP in the high-normal range (130–140 mm Hg systolic and 80–85 mm Hg diastolic) or who are hypertensive, with SBP ranging between 140 and 160 mm Hg and DBP ranging between 90 and 99 mm Hg, are urged to adopt lifestyle modification unless diabetes, CVD, or organ damage is present. Pharmacologic intervention is the recommended treatment for all individuals with BP higher than 160 mm Hg systolic or 100 mm Hg diastolic or who have elevated BP with diabetes, clinical CVD, or organ-related pathology.21
Recommended lifestyle modifications include dietary modification by reducing sodium and maintaining sufficient intake of potassium, calcium, and magnesium and limiting alcohol intake to no more than 1 oz of ethanol, which is roughly equal to 24 oz of beer, 10 oz of wine, or 2 oz of 100-proof liquor. Allowable amounts of alcohol are lower for women and other persons of smaller stature. Where appropriate, weight loss is strongly recommended, as is increasing physical activity. Other lifestyle modifications designed to reduce CVD, such as smoking cessation and limiting intake of saturated fats and cholesterol, are also recommended. Relaxation and biofeedback have been used as interventions for high BP; however, the benefit of these therapies is difficult to distinguish from that conferred by providing support or education. Clinical trials examining the efficacy of relaxation therapy and/or biofeedback have yielded mixed results.21
Pharmacologic management of hypertension is undertaken in a stepwise fashion. Initially, low-dose consumption of a drug that should be taken only once a day is tried. Dosages are increased, or other medications are added, if target BP ranges are not met. Many antihypertensive medications produce undesirable side effects, an important consideration in patient/client adherence. Dosages and combinations of medications are adjusted until sufficient reduction in BP is achieved with minimal side effects. Various classes of drugs are used in the management of hypertension, including diuretics, adrenergic inhibitors such as β-blockers, calcium antagonists, direct vasodialators, and ACE inhibitors. Combination medications are becoming more available.21 Specifics regarding the classes of antihypertensive drugs are discussed in more detail in Chapter 8.
Interventions for Overweight and Obesity
Determination of treatment for the overweight and obese is based on several factors, including BMI, waist circumference, and other CVD risk factors. For adults who are obese (BMI ≥30 kg/m2), intervention is recommended. Intervention is also recommended for adults who are overweight (BMI 25–29.9 kg/m2) or who have increased waist circumference (males ≥40 in. and females ≥35 in.) if two or more CVD risk factors are present. Interventions that are effective for weight management include dietary modification, increased physical activity, drug therapy, and in some cases, surgery. The goals of intervention are highly dependent on the patient’s/client’s motivation to control weight. For some, an initial goal simply may be to prevent further weight gain. For more motivated individuals, weight loss is the goal and once weight loss has been achieved, maintenance of healthier weight becomes a long-term goal.51
Dietary modification involves reduction in the amount of calories as well as in the percentage of fats and saturated fats consumed. Calorie reduction between 500 and 1,000 kcal/day from the patient’s regular consumption is recommended. Crash diets are generally not effective in reducing and maintaining weight. Successful dietary modification programs consider individual food preferences as well as ethnic and cultural attitudes toward food and weight. Gradual weight loss, approximately 1 to 2 lb/wk, is preferred over more rapid, but difficult to maintain, weight-loss programs.51
Other interventions for weight loss and weight control include behavior therapy incorporating self-monitoring, stimulus management (recognizing and controlling the triggers that lead to overeating), stress reduction and management, and cognitive retraining. Consideration of pharmacotherapy is usually reserved for those in the obese range of BMI or for those who are overweight and who have multiple CVD risk factors. Drugs that have been used for weight loss are appetite suppressants, of which there are few available choices due to lack of the Food and Drug Administration approval and a history of abuse and addiction. One such drug, which combined phentermine and fenfluramine (phen/fen), was withdrawn from the market in the early 1990s after an unacceptably high number of patients taking this medication developed valvular heart disease. A new anorexiant, called sibutramine, has recently been approved. Another medication, orlistat, reduces weight by decreasing fat absorption and has also recently received approval. Patients/clients who are extremely obese (BMI ≥40 kg/m2) may be offered surgical therapy, including gastric restriction by stapling or banding or gastric bypass.51
Finally, physical activity is considered to be an integral aspect of weight reduction and maintenance. See Chapter 16.
Intervention for Smoking Cessation
Every clinical interaction with a patient who smokes should include a discussion of smoking status and an offer of treatment for smoking cessation. This is the advice from the Agency for Health Care Research and Quality for primary care physicians, nurses, and respiratory therapists, and there is no reason why this advice should not pertain to physical therapists as well. Discussion and documentation of smoking status with patients is associated with higher rates of quitting.55 As many readers may know from personal or family experience, quitting smoking is no easy matter. There are powerful environmental, social, and behavioral inducements to smoke, not to mention the highly addictive nature of nicotine. For example, fear of, or actually, gaining weight after quitting may reduce cessation prevalence. Cultural attitudes toward smoking and beliefs regarding the efficacy of personal behavior in disease prevention also affect quit rates.
An effective pharmacologic approach, particularly for heavy smokers, involves nicotine replacement, either with nicotine gum or with a nicotine skin patch. Programs using these interventions generally do not exceed 8 weeks in length. Relative precautions regarding the use of nicotine replacement include pregnancy and diagnosed CVD. For persons with these conditions, the risks of continued smoking may outweigh the risks of nicotine replacement. Individuals who find quitting especially difficult may benefit from specialized, intensive smoking cessation intervention. These interventions may include counseling and behavior therapy. Problem-solving skills and encouraging social support are two effective approaches.55 Physical therapists can assist with smoking cessation efforts by avoiding cigarette smoking, themselves, by discussing smoking cessation with patients/clients and being knowledgeable about available smoking cessation programs in their communities.
Intervention to Promote Physical Activity
There is abundant evidence that increased physical activity and/or physical fitness confers substantial health benefits, including lower all-cause mortality and mortality from CHD.32–34 Furthermore, regular physical activity is also associated with improvements in nearly all of the modifiable cardiovascular risk factors discussed in this chapter. For example, habitual physical activity helps to prevent hypertension, type 2 diabetes, and obesity.34 Physical activity also contributes to an improvement in lipid profile, through an increase in HDL-C20,34,56; helps to lower BP34; and to improve glycemic control in type 2 diabetes.25,34,57
Virtually, all of the health care interventions for the conditions seen in Joe Sixpack include efforts to increase the individual’s level of physical activity. Because increasing physical activity is a fundamental consideration in the management of CHD and its attendant risk factors, physical therapists have an outstanding opportunity to contribute to prevention of morbidity and mortality from the nation’s number one killer. The remainder of this section is devoted to interventions designed to increase physical activity for individuals and for communities. Public health intervention strategies for physical activity promotion are briefly reviewed. A substantial portion of this section is also devoted to specific PT interventions as they relate to cardiopulmonary Practice Patterns A and B.
Public Health Approaches to Physical Activity Intervention
From the perspective of individual behavior change, there has been substantial interest in behavioral models of physical activity promotion. Many theories of behavior change, such as the Transtheoretical Model, described earlier in this chapter have been applied to physical activity intervention. Common strategies include education in the benefits of, and instruction in, physical activity, goal-setting, and self-monitoring; providing inducements and rewards; contests within and between groups; and development of skills to avoid resumption of inactivity. Mass-marketing strategies have also been used. Behavioral intervention trials have occurred in homes, schools, places of work and worship, as well as in whole communities or regions. Of primary importance to physical therapists, however, are potential interventions that may be applied in clinical settings.
Although physical therapists are primarily concerned with the level of physical fitness of their patients and clients, they may also have an interest in promoting physical activity within their communities as a public service to encourage wellness. Ecological approaches to physical activity promotion encompass community-based considerations and interventions. For example, the design of many of our communities, in which one must drive somewhere to shop, learn, or worship, actually discourages physical activity. Pedestrian and bicyclist safety is an issue in communities without sidewalks or bike paths or pedestrian traffic signals. Concerns about crime also prevent many individuals from walking outdoors. All of these factors increase dependence on automobile transportation and decrease community physical activity. Our lifestyles, too, have become impediments to physical activity. Human labor used to have a substantial physical component that is lacking in today’s office-oriented environment. The ubiquity of television encourages physically inactive behavior, especially among youth.
Community- and worksite-based approaches to physical activity promotion involve a wide range of disciplines, including health care professionals who are knowledgeable about the benefits of physical activity and physical fitness. Advocates for physical activity can lobby for installation of sidewalks or pedestrian crossings and signals at intersections. By constructing bicycle paths, we can encourage bicycling to the workplace and to other locations. Communities can also preserve open spaces for recreation rather than industrial development. Playgrounds that are safe and pleasant places for children to play, with shade from the sun and water for drinking, can be built and/or maintained. Progressive physical education in our schools develops lifetime physical activity skills that are inclusive of all students, not just of those that are athletically inclined. Children, youths, and adults—all benefit from community athletic leagues and clubs such as soccer teams or Little League. Community institutions that install secure bicycle storage areas promote bicycle transportation to and from these locations. Workplaces can encourage physical activity by installing fitness facilities and encouraging their use through workplace policies. Shopping malls and schools can be opened during off-hours and used for indoor physical activity. These indoor facilities are especially important when very hot or cold weather, or air pollution, prohibits outdoor activities. Venues for physical activity should be accessible to persons with disabilities to encourage physical activity in this population.
Physical Therapy Interventions for Physical Activity
Physical therapists are ideally suited to play a vital role in disease and disability prevention, as well as wellness, through counseling in physical activity and exercise prescription—activities that are principal interventions for cardiopulmonary Practice Patterns A and B. Just as Patterns A and B may be distinguished by the presence or absence of pathology-related deconditioning so is the focus of intervention determined by the intent to reverse deconditioning or prevent pathology.
For Pattern A, the focus is on prevention of disease in the presence of multiple risk factors. We have seen what health care interventions may be applied to risk factors other than physical activity, and we have glimpsed some community- and individual-based strategies. The task of the physical therapist is to safely increase the client’s level of physical activity and to optimize the potential that the gains in physical activity will be maintained. To accomplish this, physical therapists may wish to familiarize themselves with a model of behavior change, such as the Transtheoretical Model,47 that can help to focus the intervention in the most effective manner.
Pattern A may apply in primary care settings or in situations where CVD risk is not identified by the referring physician. Because of this, risk stratification can assist the physical therapist in determining the need for further referral and the level at which physical activity or exercise may be safely undertaken by the patient/client. Earlier in this chapter, a risk stratification model to identify individuals needing monitoring of physiologic responses during activity was proposed (see Table 15-5). The attributes identified in this table may also be used to determine safe intensity of physical activity or exercise. According to AHA guidelines,48 all persons without diagnosed heart disease, including apparently healthy younger, older, and at-risk (two or more CVD risk factors) individuals, may participate in moderate physical activity or exercise without first having an exercise test or physician examination. Before participating in vigorous activity, however, apparently healthy older and at-risk individuals should have a physician examination. Individuals with stable heart disease should undergo a physician examination and diagnostic exercise test before participating in either moderate or vigorous activity.
Parameters that can be used to distinguish between moderate and vigorous activity include HR and RPE during activity, and the level of METs at which an individual is working during activity. Please refer to Chapter 3 for discussion of metabolic equivalents. Table 15-6 lists the approximate parameters that define activity or exercise intensity. For HR, the revised percentage of age-related maximum HR may be used. The RPE scale used is the 6- to 20-point Borg scale.49
TABLE 15-6 Clinical Indicators of Activity/Exercise Intensity52
Primary Prevention for Joe Sixpack
For Joe Sixpack in Pattern A, CHD has been ruled out by physician examination and he has undergone a submaximal exercise test to assess physiologic responses to activity. This type of exercise test should not be confused with a diagnostic exercise test performed by a physician or other qualified health care professional. Such a test would include 12-lead electrocardiogram monitoring to detect myocardial ischemia during the procedure. Theoretically, he would be allowed to engage in vigorous activity; however, the therapist may choose to be more cautious given his risk-factor profile and in light of the evidence that substantial health benefits accrue from physical activity and exercise done at moderate intensities. In addition, a moderate exercise program is likely to result in better adherence than a vigorous program.
Specific Interventions: Physical Activity Prescription
Specific interventions from the Guide that will improve Joe’s CVD risk status include aerobic endurance activities and conditioning and active strengthening exercises. Other intervention components that would promote overall health and fitness might include body mechanics education, breathing exercises, posture education, and stretching. A PT intervention program for Joe in Pattern A will include an aerobic exercise prescription. Joe states that walking is an activity that he might enjoy and that is feasible for him. In keeping with recommendations regarding frequency of physical activity, Joe should walk 4 to 5 d/wk, or more often if he is able to do so. His walking intensity is based on HR and RPE parameters, so Joe will also be instructed in self-monitoring of HR and RPE using the 6- to 20-point Borg scale. Because Joe is 50 years old, his target HR range during activity may be as low as 87 and as high as 121, which is approximately between 50% and 70% of his age-related maximum HR. RPE should be around 11 to 12 out of 20. There is certainly some “wiggle room” at the upper end of his target HR and RPE range, given that vigorous activity is not contraindicated in his case, and he could be allowed to achieve a higher HR, say 133, during exercise. Keep in mind, however, that physical activity should be enjoyable and that Joe may not perceive his exercise as such at higher intensities where perceived exertion is higher and symptoms such as shortness of breath may occur. Because Joe is sedentary, he has the most to gain simply from advancing to a moderate level of fitness,33which can be accomplished at moderate intensities of activity. Duration of activity should be at least 30 minutes daily; however, at least initially, this need not occur all at once. The 30 minutes of daily activity may be accumulated throughout the day. Sedentary individuals beginning a physical activity or exercise program may use shorter, but more frequent daily bouts of activity, for instance, 10 minutes, three times per day, to achieve the recommended dose of physical activity. Table 15-7 summarizes Joe’s physical activity prescription.
TABLE 15-7 Joe Sixpack’s Physical Activity Prescription for Pattern A
Joe’s program should include warm-up and cool-down periods before and after his walking. Three to 5 minutes of slower walking can suffice as warm-up and cool-down activities. Gentle stretching of major muscle groups will increase flexibility, whereas low-intensity, high-repetition resistance training will improve lean muscle mass. Depending on Joe’s level of motivation, the therapist may wish to observe caution in recommending too complex a regime. The main goal is to get Joe off the couch and get him to be more physically active on most days of the week. Of course, Joe can substitute other activities for walking such as bicycling or gardening. He should also be advised that incorporating activities into daily life, by walking to the corner store to pick up the newspaper or taking the stairs instead of the elevator at work, is a good way to increase overall physical activity.
As clinicians we might be tempted to treat Joe at our clinic 2 to 3 d/wk for as long as it takes for an improvement in conditioning to occur. This is neither feasible in the current health care environment nor necessary or desirable. In reality, we may have one shot to convince Joe of the necessity of becoming more physically active and to teach him what he needs to know to accomplish this safely. The upper limit of visits for Pattern A is six visits,17(pS469) so let us assume that we have several more visits. Following the examination, Joe receives an initial instruction session, covering the mode of activity, in his case walking; the frequency duration; and intensity. Because Joe seems to be fairly well motivated and ready to change his behavior, we also provide instruction in stretching and strengthening activities. Additional instruction in HR and RPE monitoring as well as symptom awareness is provided.
How should the remaining sessions be utilized? Joe may return once per week for the next week or two to check on his adherence, answer questions, and perhaps, assess his responses to an increase in intensity (ie, speed and/or grade on the treadmill). Following this, he may return once per month or every other month for an additional two to three visits to monitor adherence and progress and to troubleshoot. Joe will find, and the therapist will recommend, that he can walk a bit faster as he progresses, as long as he remains within his target HR and RPE levels. If he wishes, Joe may increase the intensity even further, into the vigorous range, but only if he does not exhibit any symptoms during activity that might suggest heart disease. If he began his program by accumulating shorter bouts of daily activity, he can try to exercise for longer periods, less frequently during the day. During the last session, the submaximal stress test should be repeated and we can assess his overall adherence with the recommendations. The goals of this intervention are to improve aerobic capacity, physical function, health status, and the physiologic response to activity. In addition, Joe should achieve a better understanding of personal and environmental factors that affect his health and adoption of health prevention strategies. Specifically, he becomes more physically active.
Joe Sixpack in the Hospital
When we encounter Joe in Pattern B, the clinical picture is very different. Now Joe is in the hospital and deconditioned; that is, he is short of breath during ADL such as moving in bed, transferring, and ambulating (Fig. 15-5). The focus of intervention will be to restore Joe to his previous level of function or at least to a functional level at which he is able to perform ADL and IADL without dyspnea. Interventions from the Guide that have the potential to remediate the primary impairment, deconditioning, include therapeutic exercise and functional training in self-care.
FIGURE 15-5 Joe Sixpack in the hospital.
Specific Interventions: Physical Activity Prescription
Table 15-8 summarizes the physical activity prescription for Joe’s PT intervention. The initial interventions will involve ADL training, including training in bed mobility, transfers, gait, and locomotion. These activities—moving in and arising from bed, sitting down in our favorite chair, and getting up and getting a cold drink from the kitchen—are activities that we tend to take for granted, and we no more think about the energy we expend doing these things than about breathing. For Joe, and many others like him who are recovering from or living with illness and are severely deconditioned, these tasks seem monumental. Simple daily activities represent a significant challenge to their cardiopulmonary system, causing them to work very hard indeed. The clinician must remember that performance of ADL in this setting may provide a more-than-adequate stimulus to reverse deconditioning and may be considered as vigorous activity. Because of the energy requirement associated with ADL and because of Joe’s complex medical history, careful monitoring of physiologic responses to activity is indicated. As was discussed previously in this chapter, this includes vital sign monitoring before, during, and after activity and assessment of subjective responses including RPE, dyspnea, and other signs and symptoms.
TABLE 15-8 Joe Sixpack’s Physical Activity Prescription for Pattern B
As Joe improves—and with ADL training he improves quite quickly—aerobic conditioning and strengthening are added to his program. A stationary bicycle, which is often well tolerated by individuals who are deconditioned, is used for aerobic conditioning. Joe progresses from initially performing short bouts of 2 to 3 minutes, interspersed with 1- to 2-minute rest periods, to 15 to 20 minutes of continuous cycling. He also progresses from freewheeling, with no added resistance to cycling at 25 W. Other exercise modes are used as well, including hallway walking, which is part of an activity program that is carried out by nursing aides periodically during the day. Joe is also instructed in strengthening exercises using elastic resistance bands that are graded by resistance. Resistance is increased for each strengthening exercise pattern when Joe is able to perform 10 repetitions of a pattern without fatigue. An assistive device (wheeled walker) is prescribed, initially, to enhance his ambulatory safety. Over the course of time, as Joe’s functional status improves he will be able to be weaned from this device.
For Pattern B, the course of treatment requires a longer period comprising a greater number of sessions that may span more than one practice setting. This particular episode of care begins in the acute hospital and culminates in an inpatient rehabilitation setting. In the acute hospital, the physical therapist sees Joe daily for four visits until he is transferred to the subacute rehabilitation unit. He resides there for 12 days where he is seen twice daily (once a day during the intervening weekend) and is discharged home. Before going home, Joe is instructed in a home walking program including self-monitoring of HR, RPE, and symptoms. A total of 26 PT treatment sessions were provided across two practice settings during this episode of care.
The goals for the interventions are to improve in performance of, and achieve independence in, ADL and IADL; to increase aerobic capacity and the ability to perform tasks related to self-care; and to improve the physiologic response to increased oxygen demand. Joe is able to perform ADL and IADL without the symptoms associated with deconditioning. The key outcomes associated with the course of treatment pertain to functional limitation and disability. Joe has returned to his former role function in his home environment where he safely and independently performs ADL and IADL. The risk of disability associated with acute and chronic illness is also prevented.
THRESHOLDS FOR INTERVENTION
This section summarizes the threshold parameters for health care interventions for the CVD risk factors seen in Joe Sixpack. Recall that a threshold behavior is one that triggers the inception of an intervention and identifies a minimum intensity, or higher, to realize the desired benefit (see Chapter 2). Tables 15-9 and 15-10 detail the thresholds, interventions, and potential benefits of treatment, according to risk-factor status, for obesity, hypertension, and high blood cholesterol. Health care interventions for these conditions are based on complex risk-stratification decisions that are somewhat simplified in this presentation. For high blood cholesterol, initial screening is based on TC, which, if elevated, triggers further laboratory analysis of the full lipid profile. Subsequent intervention decisions are based primarily on LDL-C. For high blood cholesterol, high BP/hypertension, and overweight/obesity, risk status is based on the presence and number of other CVD risk factors. For high BP/hypertension, an additional risk consideration is based on clinical evidence of organ damage such as renal insufficiency or left ventricular hypertrophy. Notice also that increased waist circumference qualifies as overweight status.49,53,58
TABLE 15-9 Practice Pattern A: Threshold Values and Behaviors, Interventions, and Potential Improvement for Overweight and Obesity51
TABLE 15-10 Practice Pattern A: Threshold Values and Behaviors, Interventions, and Potential Improvement for High Blood Cholesterol and High Blood Pressure21,54
Table 15-11 summarizes the clinical thresholds, interventions, and potential benefits for diabetes, stratified by type of diabetes. Regardless of type of diabetes, the clinical threshold for elevated blood glucose is 126 mg/dL, and the desired clinical response to intervention is a lowering of blood glucose to <120 mg/dL and of GHb to <7%. Interventions vary for type of diabetes based principally on use of exogenous insulin. Although some individuals with type 2 diabetes benefit from use of exogenous insulin, the decision to use insulin in type 2 diabetes usually occurs late in the course of the disease. Insulin use in type 1 diabetes is a fundamental component of management at the onset of the disease. Common elements of management in both type 1 and type 2 diabetes include dietary modification and physical activity. Because a high proportion of individuals with type 2 diabetes are also overweight or obese, weight loss is typically an additional consideration.25
TABLE 15-11 Practice Pattern A: Threshold Values and Behaviors, Interventions, and Potential Improvement for Diabetes25
Table 15-12 presents the thresholds that identify individuals as physically inactive, the desirable level of activity, and the potential benefits34,35,38 of physical activity with regard to selected CVD risk factors and physiologic parameters measured during exercise. The benefits of increased physical activity and exercise extend to a wide range of conditions including CVD risk factors and physiologic parameters. A benefit of physical activity that may be especially important to individuals with CHD is the reduced resting and submaximal HR and rate pressure product (RPP), which is seen following training. Lowering of these parameters reduces myocardial oxygen demand—the workload of the heart—at rest and during usual daily activities. Not listed in Table 15-12 is the potential benefit of increased physical activity and exercise with respect to weight loss and reduced incidence of CHD, hypertension, diabetes, osteoporosis, some types of cancer, all-cause mortality, and overall physical functioning.33,34
TABLE 15-12 Threshold Parameters, Physical Activity (PA) Objectives and Benefits34,37,38
It should be said that characterizing the benefits of physical activity and exercise is not a straightforward process. The issue is clouded by variation in measurement of physical activity and physical fitness, which are very different attributes. Further confusion results from studies in different populations, for example, healthy young subjects versus older patients with CAD or other pathology. The evidence that has accumulated regarding the benefits of physical activity and exercise is derived from various types of investigations, including epidemiologic studies and studies using an interventional approach. Therefore, the benefits of physical activity listed in Table 15-12 must be interpreted with caution. Just because an epidemiologic study shows that a particular parameter changes by x amount in a population does not necessarily mean that the same parameter will change by x amount in Joe Sixpack, the individual. Activity that fails to increase aerobic fitness may nevertheless result in improved health and decreased risk for disease. Taken as a whole, the evidence for the beneficial effects of an active lifestyle on disease incidence, risk factors, and physiologic parameters is strong and undeniable.
Intervention thresholds for Practice Pattern B are less clear in terms of measurable clinical and physiologic parameters. A decision method for physiologic monitoring based on age and the presence of CVD risk factors or CAD is proposed in Table 15-5. A maximal exercise capacity of 6 METs or less is considered to be a threshold for symptomatic deconditioning, which is the hallmark of Pattern B.52 Maximal exercise capacity of 6 METs has also been associated with increased CAD and all-cause mortality.33 Unfortunately, maximal exercise testing is not feasible in the typical clinical setting in which Pattern B is operative, so we are left with a more subjective assessment. The presence of any symptoms including dyspnea, dizziness, fatigue, or diaphoresis during ADL may be a reasonable threshold indicator for intervention in Pattern B. An additional threshold for consideration of immediate treatment modification or termination is a fall in SBP below resting value, particularly if the decrease is 20 mm Hg or more.
GOALS AND OUTCOMES
The Guide to Physical Therapist Practice was developed using the Disablement Model developed by Nagi and articulated by Verbrugge and Jette2 to conceptualize the results of PT intervention. This model is discussed in Chapter 2. Briefly, goals and outcomes may be classified within the Disablement Model based on their impact on disability, functional limitation, and impairment and indirectly, on pathology pertaining to risk factors. Using the Disablement Model, Tables 15-13 and 15-14 summarize the results (ie, goals and outcomes) of PT intervention for Patterns A and B, respectively. Goals of PT intervention address impairments and at least one risk factor, physical inactivity, whereas outcomes of PT intervention address functional limitations and disabilities.
TABLE 15-13 Goals and Outcomes for Pattern B17 (p S471) According to the Disablement Model
TABLE 15-14 Goals and Outcomes for Pattern B17 (p S483) According to the Disablement Model
For Pattern A (Table 15-13) the episode of care spanned six visits over a 6-month period. Joe states that he now walks 4 to 5 d/wk, usually outdoors, but he uses the local shopping mall when weather prohibits outdoor activity. Performance on the repeat submaximal exercise test 6 months later improved by one stage to the 10-MET level. At this stage, peak HR was 146, BP was 184/90, and RPE was reported at 15—values that are essentially unchanged from his pretest performance. This indicates that his aerobic capacity has improved because he is able to achieve a higher workload without additional physiologic stress. Subjectively, Joe reports that ADL and IADL require less effort at home. The score on the SF-12 has improved, primarily because of increase in score in the physical functioning domain. Prior to PT intervention, Joe’s SF-12 physical domain score was 42.00, which is below the national mean for the instrument. Following PT intervention, Joe achieved a physical domain score of 56.61, which is above the national mean (see Figs. 15-4 and 15-6). Joe now rates his overall health as “very good,” is no longer “limited in the kind of work or other activities” he does, and now has “a lot of energy, most of the time.” Finally, Joe relates how, in addition to acquiring the habit of walking on most days of the week, he has quit smoking and is eating a healthier diet, though he admits that he relies on snacks to help cope with cravings for cigarettes. Consequently, Joe has not lost as much weight as he had hoped—he has lost from 240 to 228 lb—although he appears trimmer, perhaps due to weight redistribution, and his waist circumference has decreased by 1.5 in.
FIGURE 15-6 SF-12(r) completed by Joe post-PT. (Reprinted with permission Ware JE Jr, Kosinski M, Turner-Bowker DM, et al. User’s Manual for the SF-12™ Health Survey with a Supplement Documenting SF-12® Health Survey. Lincoln, RI: QualityMetric Incorporated, 2002.)
Joe received a total of 26 visits from a physical therapist, 4 in the acute care setting and 22 in subacute inpatient rehabilitation. Table 15-14 presents the results of PT intervention for Pattern B. On admission to rehabilitation, the functional independence measure (FIM) and 6-minute walk were administered. Total score on the FIM also improved. End of program 6-minute walk distance was 625 ft, which is an improvement of 240 ft. Other changes noted during the exit test were a lower peak HR of 124 and a lower RR of 20, indicating an improvement in physiologic response to increased oxygen demand. On the stationary bicycle, Joe began his program by freewheeling—pedaling with no resistance—for several 2- to 3-minute bouts, with 1- to 2-minute rest periods each session. He has progressed to cycling with resistance and revolutions per minute (rpm) set at 25 W for a total of 20 minutes. In his strengthening program, he progressed in grade of resistance bands by two grades throughout the episode of care. When Joe is discharged home he is independent in bed mobility and transfers and ambulates within and around his home. He understands the importance of maintaining his physical activity level and plans to continue with a walking program of moderate intensity. He is accurate in monitoring his own HR and uses HR and the RPE scale to maintain a safe level of independent activity while in the rehabilitation unit (Fig. 15-7).
FIGURE 15-7 The new Joe Sixpack.
LIMITS OF KNOWLEDGE
The scientific evidence supporting the health care interventions discussed in this chapter is based on extensive clinical and epidemiologic research, which forms a large body of literature. However, much of the research that has informed us about the risk factors of CHD is based on studies of populations with relatively high socioeconomic status that has included few members of African American or Asian ethnic groups and many studies included only men. The generalizability of this research is limited by these considerations. There has been heightened interest, recently, in investigating CVD risk in women and in non-white ethnic groups, but the full impact of this research on clinical practice is yet to be seen. Research on the effects of deconditioning has similar limitations in that most of these studies, too, used young, healthy, predominantly male volunteers. Very little work has been done to investigate the effects of deconditioning on patient populations.
Other considerations regarding the literature on CVD risk factors are worth discussing. Risk factors, such as cholesterol, BP, BMI, and blood glucose, that are associated with CVD and related conditions are measured on continuous, numeric scales. For example, an SBP of 140 is 1 unit higher than an SBP of 139, 2 units higher than an SBP of 138, and 10 units higher than an SBP of 130, and so on. The epidemiologic research identifying these risk factors indicates that risk factors are associated with various disease outcomes, including CHD and mortality, in a continuous fashion. In other words, the risk of a developing CHD or of dying increases incrementally as, say, SBP increases. The risk for someone with an SBP of 130 is slightly higher than that for someone with an SBP of 120 or even 128, and it is higher still than that for someone with an SBP of 96. Yet, an SBP of 140 or higher is generally regarded as the point at which we decide that someone is hypertensive because of increased risk of undesirable outcomes such as CHD, stroke, or death. Indeed, virtually all clinical risk stratification guidelines identify risk-factor cut-points, above or below which the risk of disease is said to increase or decrease. Defining thresholds in this manner helps to translate scientific knowledge in ways that the public may better understand and use in personal decisions. Thresholds are also useful for clinical decision making, as is apparent in this chapter and textbook and in other works devoted to developing evidence-based clinical practice. Students, as well as practitioners at all levels of expertise, are wise to remember, however, that thresholds may not capture the true relationship between risk factor and disease occurrence or between clinical indicator and clinical outcome.
Another caveat regarding the setting of thresholds is that we may set them too high or too low. In so doing, we may misclassify individuals as being at high risk when they really are not or as being at low risk when they truly are at high risk. The former type of misclassification may needlessly stigmatize individuals and/or expose them to unnecessary diagnostic procedures or treatment interventions, with their inherent risks. The latter type of misclassification leads to withholding of potentially beneficial diagnostic procedures or interventions.
The recently updated BMI cut-points that define overweight and obesity, endorsed by the National Heart, Lung, and Blood Institute (NHLBI), provide an example of a controversial threshold. As Strawbridge and colleagues57point out in the American Journal of Public Health, the NHLBI threshold assigns a “disease” status to 55% of American adults. They argue that the evidence for increased risk of morbidity and mortality for those in the overweight range (BMI 25–29 kg/m2) is weak and may not be equally valid for elders, women, and members of non-white ethnic groups. Furthermore, lowering the threshold for overweight and obesity may have the unintended consequence of promoting eating disorders such as anorexia and bulimia as people, particularly young women, strive to achieve an “acceptable” weight. The increased emphasis on overweight and obesity also tends to overlook the risk of underweight status (BMI < 18 kg/m2), which is significantly related to mortality in women.57
This chapter emphasizes the interrelations between CHD risk factors and highlights how behaviors such as physical activity and exercise, cigarette smoking, and dietary modification are common elements in many interventions associated with reducing CHD risk. In the current health care environment in the United States, much emphasis is placed on an individual’s behavior and the corresponding impact on health. We urge patients/clients to stop smoking, lose weight, and exercise more, and when they are unsuccessful in their efforts, as many are, we tend to hold the individual accountable and in effect, blame the victim. Individual behavior is subject to many powerful environmental influences from peers, culture, and the larger society. These influences can be very difficult to resist. Advertising, for example, portrays cigarette smoking as sociable, glamorous, and desirable. Tobacco companies have successfully marketed products to specific demographic groups, such as women and African Americans. Remember, too, that nicotine is highly addictive, making it difficult to quit once one has started smoking. Cultural preferences for high-fat foods may be difficult to overcome in prevention efforts. Healthy foods like fresh fruits and vegetables tend to be expensive and may not be available or accessible in low-income neighborhoods. The automobile culture and the design of our communities provide few opportunities for physical activity. The images of physical activity seen in broadcast and print media typically portray young, attractive, spandex-clad athletes engaging in sweaty and often painful appearing “workouts.” Perhaps these images actually discourage physical activity when viewed by habitually sedentary, older individuals like Joe Sixpack. Remember that preventive health care interventions often must try to change the habits of a lifetime.
Heads Up!
This chapter includes a CD-ROM activity.
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CHAPTER 15
An International Perspective: Canada
Elizabeth Dean
INTRODUCTION
As a backdrop to my commentary on the chapter by Dr. Brooks, I provide an overview of the status of contemporary physical therapy practice in Canada based on my observations as a practitioner and a scientist, and then on the practice of cardiovascular/cardiopulmonary physical therapy specifically. With respect to Dr. Brooks’ chapter, in addition to reviewing aspects of the pathophysiology of cardiovascular disease and selected risk factors, Dr. Brooks has provided an overview of the process of decision making related to categorizing a given patient to either Practice Pattern A or B within the cardiovascular/pulmonary specialty. The purpose of my commentary on the chapter is twofold: first, to evaluate the application of practice patterns in the context of primary prevention, risk reduction, and deconditioning with respect to the patient described in the chapter; and second, to comment on the relevance of the model of practice patterns to Eastern cultures.
PHYSICAL THERAPY PRACTICE AND CARDIOVASCULAR/CARDIOPULMONARY PHYSICAL THERAPY IN CANADA
In my view, physical therapy practice in Canada, comparable to that in the United States, has advanced markedly in some notable domains over the past three decades, yet has remained relatively unchanged in others. With respect to areas of change, the majority of physical therapists in Canada can now practice without a physician referral. The trend with respect to scope of practice is away from doctor- and hospital-based care and toward community, home, and self-care. Despite this trend, as yet, there is less prominence of rehabilitation aides and assistants in Canada compared with the United States. I attribute this to a prevailing belief that assessment and treatment go hand in hand and that a physical therapist needs to perform ongoing assessment. In Canada, I anticipate that within the decade, physical therapy will be an outsourced service in the hospital sector, supporting the growing trend toward consultation services. This change has been paralleled by greater promotion of interdisciplinary team care in which patients are increasingly empowered to be active participants in preserving their health, self-healing, and long-term remediation of health problems. There has been exponential growth of not only scientific activity in the profession reflected by the growing number of doctoral qualified academic faculty members and numbers of graduate programs and students in the country but also recognition of the need to ensure scientific rigor and translate scientific findings into evidence-based practice. A growing number of studies are being published on the cost-effectiveness of treatments, which reflects demands on the profession to be increasingly accountable to the public and those paying the bills. These advances have all been very positive. But, I query whether these advances could be too much too late.
With respect to areas of relative stagnation within the profession in Canada and in the United States, in my view these include an inexplicable lag in physical therapists embracing their role foremost as clinical exercise physiologists and educators as integral components of their professional identity. Exercise is the hallmark of physical therapy and the physical therapist’s principal “drug.” We were strategically positioned to have been leaders in the clinical exercise physiology movement beginning in the 1970s; I believe this was a missed opportunity that has altered the course of the evolution of our profession. Exercise testing and training became integrated into “cardiac rehabilitation” and then “pulmonary rehabilitation” in the 1970s and 1980s. For many years it appeared that exercise testing and training were viewed by physical therapists as being unique to “cardiac and pulmonary rehabilitation” rather than principles and practices that were applicable across specialties. Only relatively recently have formal exercise testing and training become terms used in orthopedics and neurology, and even so this does not appear to be a consistent practice.
The cardiovascular/cardiopulmonary systems subserve every other system; therefore, physical therapists across specialties require assessment and treatment skills in this specialty. Conditions of these systems will invariably constitute comorbidities in patients being treated for orthopedic and neurologic conditions. Despite this, I have observed a deficiency in basic hemodynamic monitoring of patients with these conditions. Given the powerful combination of exercise and education tailored to both the needs and the wants of the patient, treatments require time. Appropriate treatment time is not reflected in most billing schedules. I would not find it surprising that physical therapy continues to be underfunded due to the lack of advocates supporting the need for the appropriate treatment frequency and course. PT will be shown to be ineffective because, like antibiotics, if the course of treatment is insufficient, so will the treatment be shown to be ineffective. The current structure and distribution of physical therapists across specialties (detailed further in reference to the cardiovascular/pulmonary specialty, in particular, later) have failed to expand and contract in the face of changing demographics. For example, in addition to cardiovascular/pulmonary physical therapy, other virtually invisible specialties are gerontology, oncology, and diabetes.
Despite the fact that patient education, a subspecialty in education, has also been a hallmark of physical therapy, in my view little of the scientific evidence supporting teaching principles is being integrated into contemporary physical therapy practice. This element of the patient–therapist relationship may determine whether a treatment succeeds or fails. Without question, most physical therapists would acknowledge that they advise their patients for prevention and instruct them in carrying out their treatment programs. I contend, however, that with the move toward greater empowerment and active participation in their care, patients require formalized education based on documented education principles including assessments of attitudes, learning style, and as required, readiness to adhere to treatment or change. This is particularly true considering that the leading causes of morbidity and mortality today in the more developed world are largely preventable according to the World Health Organization.
In my view, as a profession we have been slow in responding to the needs of those from other cultures. Immigration within Canada and the United States has enriched our respective societies with different attitudes, values, and beliefs. To maximize patient rapport, hence, treatment effectiveness, it behooves us to understand the values, attitudes, and beliefs of our patients regarding their health, ill health, and means of recovery and to incorporate this knowledge into our treatments. On the basis of my experience and observations in non-Western cultures, physical therapists from these cultures, who have qualified in Western-based programs either in the West or in their countries, are more adept than Western physical therapists treating individuals from non-Western countries, in ensuring that their treatments are culturally relevant and sensitive. Health care practitioners in the West, I believe, have a great deal to learn from our colleagues from other cultures—the success of our treatments depends on it.
The rapid change needed in these professional domains, during this period of shifting sands in the health care reform movement in Canada as well as in the United States, does not appear imminent to me. The slowness of change may give the impression that we are self-serving as a profession, rather than our priority being the public and societal need. In addition, it is clear that multiple other professions are encroaching on areas of practice in which the physical therapist, I believe, is the most qualified health care professional to provide such service.
Many of the areas of relative stagnation that I have identified in Canada as well as in the United States are particularly apparent in the cardiovascular/pulmonary specialty. Despite national and global indicators that the cardiovascular/pulmonary specialty should be one of the largest specialties, the conventional breakdown of specialty dominance is roughly 50% orthopedics, 30% neurology, 15% cardiovascular/pulmonary, and 5% other. As therapists within the profession and within the specialty, we have fallen short in assuming prominent leadership roles in influential political, national, and provincial/state arenas including public health and health care policy. Further, I believe that the profession has failed in large part to update our health care colleagues and the public on changes in our practice. We seem bewildered when our expertise fails to be recognized and promoted by our health care colleagues. The profession needs articulate advocates to establish its rightful place in the health care delivery system as a primarily noninvasive health care service, whose benefits should be promoted as “primary” intervention before invasive care whenever possible and ethical to do so. It is clear that noninvasive care should be exploited primarily to support health ahead of invasive care, given the growth of iatrogenic conditions and their associated economic and societal costs. A prime example of the failure to exploit physical therapy is its diminishing presence in critical care—the most invasive and costly of health care settings; a trend widespread in the United States and increasingly in Canada. There is substantial lack of awareness, both within and outside the profession, of the essential role of physical therapy as a primarily noninvasive practice in this setting. The more high tech this setting becomes, the more noninvasive practices need to be exploited in my view for ethical and cost considerations as well as for minimizing the risk of iatrogenic effects. This area of practice provides an example of the lack of integration of the literature into practice. For several decades the literature has supported unequivocally the potent and direct effects of body positioning and exercise principles on gas exchange and that these potent interventions need prescription to achieve optimal results in critically ill patients. There appears to be an unsubstantiated belief that “routine” nonprescriptive body positioning and mobilizing performed by non–physical therapists achieves an equivalent result. The literature fails to support this view. Rather, body positioning and mobilization can be prescribed to enhance the steps of the oxygen transport pathway selectively, thereby impacting oxygen delivery directly. Considering the indications for a physical therapy presence in intensive care, how is our diminishing visibility explained?
APPLICATION OF PRACTICE PATTERNS IN THE CONTEXT OF PRIMARY PREVENTION, RISK REDUCTION, AND DECONDITIONING
The model of preferred practice patterns has emerged in the United States over the past decade, in response to the demand for physical therapist practice guidelines.1 These guidelines were achieved through consensus. They describe the treatment options for each practice pattern that is recommended to affect an optimal outcome within an optimal number of treatments. Ten preferred practice patterns have been defined to encompass all possible physical therapy diagnoses within the cardiovascular/pulmonary specialty. The focus of this chapter is on primary prevention, risk reduction, and deconditioning; thus, my remarks will be confined to these. As a means of distinguishing the basis for selecting Practice Pattern A (Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders) versus B (Impaired Aerobic Capacity/Endurance Associated with Deconditioning), Dr. Brooks describes two scenarios related to the case of Joe Sixpack.
The Case of Joe Sixpack
Joe’s history included hypertension, hypercholesterolemia, and diabetes. In addition, he was overweight and sedentary, and he smoked. The first time we were introduced to Joe, he was seeking advice regarding preparation for a 5-km race in a month. He was categorized into Practice Pattern A, in that, this opportunity could be used to promote primary prevention and risk reduction related to cardiovascular or pulmonary disorders. At another time, Joe was described as having been “flat on his back for a while,” presumably in an acute or rehabilitation setting following surgery or an accident. In this instance, Joe was categorized into Practice Pattern B, that is, consistent with Impaired Aerobic Capacity/Endurance Associated with Deconditioning.
Strengths and Limitations of Practice Patterns
The case of Joe Sixpack exemplifies the strengths and limitations of a model of practice based on practice patterns. With respect to strengths, practice patterns constitute the lowest common denominator of patient management. Practice patterns can increase the standards of physical therapy practice in situations or settings where practice standards are low. They aim to expand the level and scope of care by crossing specialty boundaries, promote safety standards, identify practice guidelines based on a consensus exercise of those in the specialty, and identify aspects of care that are outside as well as within the boundaries of physical therapist practice.
With respect to their limitations, practice patterns can promote a narrowness of focus in patient care because of the need to have the patient conform to one or more practice patterns within or outside the specialty. This limitation is particularly salient as health care delivery shifts toward holistic, integrative, patient-centered care. Joe Sixpack demonstrates this point.
On the basis of his risk-factor profile, Joe has both nonmodifiable and modifiable risk factors for several “diseases of civilization” including lung disease, hypertension, stroke, cancer, and diabetes as well as atherosclerosis and coronary artery disease. With respect to the “number one killer” in the United States, namely, coronary artery disease, Joe’s nonmodifiable risk factors include his gender and his age. His modifiable risk factors include cholesterol and saturated fat intake, smoking, sedentary lifestyle, and obesity. In the first instance, because he is currently asymptomatic for heart disease, Joe is classified as Practice Pattern A (Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders). Although hypertension, hypercholesterolemia, and diabetes are established risk factors for cardiovascular disease, these conditions are primarily life-threatening conditions that have been well documented to be amenable to diet, exercise, and education.2–9 Joe has clinical signs of these conditions for which he is being medically managed. Noninvasive management in their primary management has yet to be exploited. There is substantial evidence supporting physical therapy intervention for these primary medical diagnoses2–9 in the same way that there is for coronary artery disease10 or for smoking-related pulmonary disease.11 Potent noninvasive interventions need to be instituted as primary interventions for the management of these life-threatening conditions.
Joe Sixpack Falls Between the Practice Pattern Cracks
For optimal and safe management of Joe, he should be viewed as having multiple interrelated life-threatening conditions rather than as an individual with a collection of risk factors, ranging in degree of severity, for cardiovascular disease. He is a candidate for primary physical therapy to address his serious medical problems, namely, hypertension, hypercholesterolemia, and diabetes in addition to weight control, with the goal being to wean him from his medications, avoid surgery, and restore him to good health. Given this perspective, there is no ideal practice pattern for Joe.
On a general note, noninvasive interventions need to be promoted as the “primary” interventions in the absence of pharmacologic agents, coincident with pharmacologic agents until these can be weaned or in conjunction with these agents for a long term. As primarily a noninvasive practitioner, the physical therapist’s principal goal is to eliminate the patient’s need for medication and surgery and to promote lifelong self-responsibility for health and well-being. If medication is needed, then minimizing the potency of the medication and the dose in combination with noninvasive interventions is the priority. If the patient fails to adhere to a noninvasive program, in favor of invasive care only, then reasons for failure need to be addressed. The lack of appropriate practice patterns to identify the primary management of physical therapy for hypertension, hypercholesterolemia, and diabetes not only limits our professional “lens” in terms of our management of patients with these conditions but also conveys to others outside the profession an apparent lack of a primary role of physical therapy in the management of these conditions.
With respect to the second scenario, preferred Practice Pattern B (Impaired Aerobic Capacity/Endurance Associated with Deconditioning) fails to focus on Joe’s more urgent problems. Deconditioning as a result of restricted activity would certainly be demonstrable; however, the severity of his other problems will contribute more significantly to reduced aerobic capacity and endurance. His other problems compound the complicating physiologic effects of recumbency and any further restriction in his physical activity. These factors should be the focus of the practice pattern in the context of his being hospitalized.
Both Practice Patterns A and B focus on functional capacity. This reflects, in part, the move away from the biomedical model to Nagi’s Disablement Model and the levels problem definition, namely, impairment, action, and participation (or formerly impairment, disability, and handicap).12,13 However, in the cardiovascular and pulmonary specialty, patients can have normal functional capacity in the presence of life-threatening impairments such as arrhythmias and conditions such as high blood pressure, hypercholesterolemia, and diabetes. Thus, in this specialty, impairment needs to be considered as a primary focus.
Noninvasive physical therapy practice needs to assume its rightful place in the health care delivery system. In the public’s best interest, it is imperative that we within the profession do not marginalize the priority of physical therapy in the primary management of a range of cardiovascular/pulmonary conditions beyond primary cardiovascular and pulmonary disorders. The exploitation of noninvasive approaches needs to remain a priority and become an increasing and not less of a priority, commensurate with more costly, hi-tech, and invasive medical care that also constitutes greater risk. This is particularly evident in the management of chronic degenerative conditions whose management through traditional invasive care has been considerably less impressive than that through noninvasive management including diet, exercise, and education.
PRACTICE PATTERNS AND THEIR PSYCHOSOCIAL AND SOCIOCULTURAL RELEVANCE AND SENSITIVITY
At the psychosocial level, health care is shifting away from a patriarchal biomedical model to a patient-focused model that is reflected in the preferred practice patterns. Along with this trend has been a greater awareness of patients as individuals worthy of respect and having the opportunity to be active participants in their own care.
With respect to sociocultural considerations, the determinants of health and ill health reflect sociocultural as well as physical influences. At a global level, health care trends and rehabilitation, in particular, reflect Western culture, attitudes, values, and beliefs. Eastern-based medical philosophies have been largely ignored or minimized in importance yet have serviced well a large proportion of the world’s population for several thousand years.14 Even though there has been growing awareness and acceptance of Eastern-based health care practices, the prevailing attitude in the West is still one of these being “alternatives” or “complementary” rather than first-line interventions, implying that Western approaches remain those of choice. This is an interesting observation, given that Western-based medicine is in its infancy compared to ancient Chinese medicine. Clearly, both approaches have strengths and limitations. Health care providers, educators, and researchers need to think beyond practice patterns based on Western values in order to be receptive to the merging of Eastern and Western philosophies to maximize interventions and health care outcomes by combining their strengths and minimizing the limitations of either philosophy individually.
SUMMARY AND CONCLUSION
Dr. Brooks’s chapter describes a case that illustrates the decision-making process in assigning a client/patient to either Practice Pattern A or Practice Pattern B. The preferred practice patterns adopted by the American Physical Therapy Association have strengths and limitations and these are illustrated in relation to the patient featured in the chapter. In terms of strengths, preferred practice patterns maintain a standard for the lowest common denominator of practice with respect to both physical care and psychosocial considerations. In terms of limitations, difficulties can be anticipated when one attempts to pigeon-hole patients into restrictive practice patterns, which in turn, can lead to suboptimal care. In the case described, the patient has multiple life-threatening conditions such as hypertension, hypercholesterolemia, and diabetes that independently can be amenable to physical therapy care, in addition to being risk factors for cardiovascular disease. The present structure of the practice patterns tends to consider these primarily as modifiable risk factors, thereby minimizing the primary role of physical therapy in the management of each independently. Finally, psychosocial and sociocultural considerations are highlighted. Attention to these, and an appreciation of patients as individuals who should be treated with dignity, and that of other cultures and their perspectives on health and ill health will result in truly holistic, integrative health care in the years ahead. The integration of Eastern philosophies with Western philosophies will enhance approaches to wellness and health promotion, treatment interventions, and health outcomes, and overcome the limitations of either health care philosophy individually. By having adopted practice patterns within the profession, we need to ensure that our practice does not default to the lowest common denominator. Rather, we must be aware of their limitations and continually strive toward refining their application through a broad understanding of health and health care that cross the boundaries of both culture and practice patterns.
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