Individuals with Chronic Secondary Cardiovascular and Pulmonary Dysfunction
This chapter reviews the pathophysiology and medical management in relation to the comprehensive physical therapy management of individuals with chronic secondary cardiovascular and pulmonary pathology. Exercise testing and training are major components of the comprehensive physical therapy management of individuals with chronic secondary cardiovascular and pulmonary conditions, and this topic is presented separately in Chapter 25.
This chapter specifically addresses the comprehensive physical therapy management of chronic cardiovascular and pulmonary dysfunction secondary to neuromuscular, musculoskeletal, collagen vascular and connective tissue, and renal dysfunction. Considerations in the management of people who are overweight or obese are also addressed. The neuromuscular conditions that are presented include stroke, Parkinson syndrome, multiple sclerosis, cerebral palsy, spinal cord injury, chronic effects of poliomyelitis, and muscular dystrophy. The musculoskeletal conditions that are presented include thoracic deformity (kyphoscoliosis) and osteoporosis. The collagen vascular and connective tissue conditions that are presented include systemic lupus erythematosus (SLE), scleroderma, ankylosing spondylitis, and rheumatoid arthritis (RA). Finally, management of the patient with chronic renal insufficiency and management of the person who is obese are presented. The principles of physical therapy management are presented rather than treatment prescriptions, which cannot be given without consideration of a specific patient (see online Case Study Guide). In this context the goals of long-term management of each condition are presented, followed by the essential monitoring required and the primary interventions for maximizing cardiovascular and pulmonary function and oxygen transport. The selection of interventions for any given patient is based on the physiological hierarchy. The most physiological interventions are exploited, followed by less physiological interventions and those whose effectiveness is less well documented (see Chapter 17). With respect to physical therapy treatment prescription and monitoring, these principles must be considered when chronic secondary cardiopulmonary dysfunction is the diagnosis.
Principles of Physical Therapy Management in Chronic Secondary Dysfunction
Long-Term Physical Therapy Management Goals
Physiological Management Goals
Optimize lung volumes and capacities and flow rates
Optimize ventilation and perfusion matching and gas exchange
Facilitate mucociliary transport as needed
Maximize aerobic capacity and efficiency of oxygen transport
Optimize physical endurance and exercise capacity
Optimize general muscle strength and thereby peripheral oxygen extraction
Psychosocial Management Goals
Maximize the patient’s quality of life, general health, and well-being through maximizing physiological reserve capacity
Educate patient and/or family or caregiver regarding:
As indicated, address multisystem conditions that affect presenting signs and symptoms (regarding comorbidities, see Chapters 6, 24, 25, and 31 and related parts of this chapter)
Design lifelong health and rehabilitation programs with the patient
Patient Education
Education is a principal focus of the long-term management of all patients (see general principles and guidelines in Chapter 28), but it is especially important for those with secondary dysfunction. Patients should receive instruction in and information on the following health promotion and preventative practices:
Individuals with Neuromuscular Conditions
Stroke
Pathophysiology and Medical Management
Individuals with stroke have associated problems that contribute to cardiovascular and pulmonary dysfunction. These patients tend to be older and hypertensive and have a high incidence of cardiac dysfunction. Muscle disuse and restricted mobility secondary to stroke lead to reduced cardiovascular and pulmonary conditioning and inefficient oxygen transport. Spasticity increases metabolic and oxygen demand. Hemiparesis results in gait deviations, which reduce movement efficiency and movement economy. Reduced movement economy results in an increased energy cost associated with ambulation, which may reduce exercise tolerance because of fatigue.1 In addition, ambulating with a walking aid is associated with increased energy cost compared with normal walking. This increased energy cost reduces the patient’s exercise tolerance further and increases fatigue.
The notion of a motor recovery plateau in the management of individuals with stroke has been challenged.2,3 It has been argued that individuals adapt to the training stimulus and plateau when that stimulus no longer changes. Thus individuals are deprived of therapy unless they are responding. Capacity to improve can be augmented with changes in type of activity and the introduction of new exercises, as well as changes in the intensity, duration, and frequency of the exercises. Computer-assisted motivating rehabilitation employs the use of games and unconscious limb activation and movement, rather than engaging the patient in specific limb exercises.2
Individuals with stroke are at increased risk of having intercurrent ischemic heart disease, which compromises long-term survival and increases the risk of illness and inactivity.4 Furthermore, concurrent congestive heart failure will adversely affect outcomes after stroke rehabilitation. Clinical assessment, even if patients are asymptomatic, must include a cardiac work-up to establish the degree to which cardiac insufficiency limits mobility, endurance, recovery, balance, and fatigue. An integrated multisystem approach will ensure improved rehabilitation outcomes and prevent complications.
Principles of Physical Therapy Management
Goals of Long-Term Management
Optimizing aids and devices to reduce unnecessary energy demands by optimizing postural alignment
Maximizing balance to also reduce unnecessary energy demands to maintain alignment
Optimizing chest wall excursion and ventilation
Optimizing secretion clearance as needed
Reducing the work of breathing
Structured, progressive rehabilitation programs for people with stroke augment therapeutic gains with respect to endurance, mobility, and balance, compared with spontaneous recovery.5
Body weight support has been examined to support an individual with stroke in the upright position to facilitate treadmill walking as a means of conditioning and gait reeducation.6
Patient Education
Engagement of the social support network can have an important role in maximizing a patient’s outcomes. Social support is recognized clinically as an important component of the comprehensive management of people with chronic conditions; however the literature in this area is scant. Family participation has been reported to improve the strength and mobility of an individual with stroke.7
Exercise
Aerobic exercise is an essential component of long-term management of the individual with stroke to optimize the efficiency of oxygen transport overall. Maximizing ventilation with mobilization is limited if the patient has severe generalized muscular weakness and increased fatigue. Although aggressive mobilization can be supported in these patients,8 appropriate selection of patients for such a regimen, judicious exercise prescription, and monitoring must be instituted to ensure the treatment is optimally therapeutic and poses no risk to a patient in this high-risk group. Chest wall exercises include movement in all planes combined with rotation. Body positioning to optimize lung volumes and airflow rates is a priority. Breathing control and coughing maneuvers are essential and should be coupled with body movement and positioning. Exercise is conducted with the patient in upright positions to minimize the work of the heart and of breathing during physical exertion. Recumbent positions reduce lung volumes and expiratory flow rates, impair respiratory mechanics, increase closing volumes, increase thoracic blood volume, and increase compressive forces on both the lungs and the heart.9 Thus, aerobic exercise for significant periods and intensities should be performed standing or sitting. Lower-extremity work is preferable to upper-extremity work in that the latter is associated with increased hemodynamic stress. Rhythmic exercise of large muscle groups is preferable to static exercise and exercise of small muscle groups, such as the arms, which produces smaller hemodynamic effects. Yoga-based exercise programs may be of some benefit for people with chronic stroke.10 Resistance muscle training for the limbs increases their muscle power in a dose-dependent relationship without increasing spasticity.11 Muscle training should be combined with aerobic training for optimal benefit and functional benefit.12
Parkinson Syndrome
Pathophysiology and Medical Management
Although chest wall rigidity and respiratory muscle weakness are associated with a restrictive pattern of lung disease in the patient with Parkinson syndrome, the obstructive type of respiratory dysfunction has been reported (e.g., reduced midtidal flow rates, increase airway resistance, impaired distribution of ventilation, and an increase in functional residual capacity).13 This obstructive defect may reflect parasympathetic hyperactivity, which has been associated with the disease. The degree to which these cardiovascular and pulmonary manifestations of the disease are offset with anticholinergic drugs (used to treat rest tremor and reverse dystonia) has not been reported.
The upper extremities are rigid and held slightly abducted from the chest wall during locomotion. The rigidity and dyskinesia associated with Parkinson syndrome lead to restricted movement and body positioning. The patient becomes deconditioned from disuse. Although the rigid, immobile chest coupled with reduced body position changes can contribute to restrictive cardiovascular and pulmonary pathology in this syndrome, chemoreceptor dysfunction has been documented.14
Multiple Sclerosis
Pathophysiology and Medical Management
Multiple sclerosis is a demyelinating disease of the central nervous system. The focal or patchy destruction of myelin sheaths is accompanied by an inflammatory response. The course of the disease consists of a variable number of exacerbations and remissions over the years from early adulthood. Exacerbations are also variable with respect to severity. The neurological deficits include visual disturbance; paresis of one or more limbs; spasticity; discoordination; ataxia; dysarthria; weak, ineffective cough; reduced perception of vibration and position sense; bowel and bladder dysfunction; and sexual dysfunction.15 Breathing disturbances, including diaphragmatic paresis, may occur. Autonomic disturbance in the form of impaired cardiovascular reflex function at rest and attenuated heart rate and blood pressure responses during exercise are relatively common in patients with multiple sclerosis.16
Principles of Physical Therapy Management
Ventilatory Strategies
Methods of facilitating effective coughing in patients with neuromuscular diseases are extremely important because they constitute life-preserving measures. Supported and unsupported coughing methods are described in detail in Chapters 22 and 23. Whenever possible, deep breathing and coughing are coordinated with chest wall movement to facilitate maximal inflation of the lungs before coughing and maximal exhalation of the lungs during coughing. Body positions are varied and changed frequently to simulate as much as possible the shifts in alveolar volume and ventilation and perfusion that occur with normal movement and body position changes.17 In addition, body positioning is used to maximize the patient’s coughing efforts.
Cerebral Palsy
Pathophysiology and Medical Management
Cerebral palsy results from insult to the central nervous system that usually occurs before birth (e.g., from substance abuse and perinatal underoxygenation).15 The clinical presentation includes spasticity and residual deformity from severe muscle imbalance, hyperreflexia, and mental retardation. Although there are varying degrees of cerebral palsy severity, patients most frequently seen by the physical therapist have significant functional deficits and require long-term care. The loss of motor control and hypertonicity of peripheral muscles often restrict the mobility of patients such that they are wheelchair dependent. Loss of motor function limits physical activity and the exercise stimulus needed to maintain an aerobic stimulus and optimal aerobic capacity. Often coupled with motor deficits are cognitive deficits and mental retardation. These afflictions limit the degree to which the patient can follow instructions, perform treatments, and participate actively in a long-term rehabilitation program. Patients with cerebral palsy who are able to ambulate do so at exceptional energy expenditure both with and without walking aids.18 Central neurological deficits, generalized hypertonicity, and musculoskeletal deformity contribute to increased metabolic demand for oxygen and oxygen transport.
Principles of Physical Therapy Management
Patient Education
Central cerebral involvement may affect the periodicity of breathing. During sleep, the effects of such dysfunction are accentuated. Loss of normal periodic breathing and interspersed sighs impairs mucociliary transport. Secretions may accumulate and contribute to airway obstruction and areas of atelectasis.
Individuals with cerebral palsy are unable to reposition themselves during the night in response to cardiovascular-pulmonary and musculoskeletal stimuli.
Patients often have poor swallowing and saliva control and thus are prone to aspiration and microatelectasis, particularly when recumbent at night. Inability to reposition themselves at night further increases the risk of aspiration and its sequelae.