Transcript Cardiomegaly - WordPress.com

CARDIOMEGALY
Sarah Popernack, SPT
December 14, 2016
OVERVIEW1
 Enlarged heart- type of cardiomyopathy (hypertrophic), left ventricle
predominantly effected
 Elderly population: usually caused by high blood pressure or CAD
 Younger population: genetic contributions or congenital heart disease, highly
competitive athletes
 Pathogenesis: won’t pump blood effectively- heart is working harder to deliver
blood to rest of body- hypertrophies the muscle
 Risk factors: CAD, HTN, alcohol/ drug use, heart valve disease, family history of
SCD (sudden cardiac death)
 Diagnosis: first EKG, echocardiogram
 Clinical manifestation: might not cause symptoms until there is inc demand/
workload, SOB on exertion, dizziness, (possible) arrhythmia, exertional chest pain
 Medical Management: largely pharmaceutical, treatment of underlying cause
RISKS FOR ATHLETES2
 Enlarged heart muscle from overtraining/ conditioning after many years in highly
competitive sports
 Favorable adaptation: inc stroke volume -> inc end-diastolic volume (higher
ventricular filling) -> more blood being ejected out of heart -> higher maximal
oxygen uptake
 Differences in prevalence across sports:
 Soccer > running cross country
 Sprinting > long distance
 Strength training athletes using steroids > every other athlete
 SCD- cardiomegaly commonly found upon autopsy
PROGNOSIS
 The presence of the condition is largely discovered after a catastrophic event2
 Screening for cardiomegaly is controversial
 Relatively high amount of false positives
 Costly to do pre-screening EKG on every college athlete3
→ EKG not currently mandated as a preparticipation screening for athletes; NCAA
mandates pre-screening questionnaire from AHA to be administered to rule out
possibility of significant cardiac conditions4
 If found early on (prior to SCD):
 Young patients- encouraged to refrain from exercise for 3 months, low-to-moderate
exercise encouraged to maintain healthy heart function5
 Elderly patients- pathological cause of enlarged heart is addressed, physical activity
prescribed appropriately1
CHART REVIEW
 20-yr-old male, anterior shoulder dislocation, cardiomegaly
 Pitcher on college baseball team
 Pharmaceutical Management
 Verapamil, Lexapro, Benazepril, Paracetamol, Valium
 Referral from physician- set to be immobilized in external
rotation for 4 wks
 Symptoms upon exertion: EKG and echo to diagnose
cardiomegaly2
 Restricted from physical activity for 3 months
 Denied clearance for participation in college baseball4
Func. Drug
Category7
Relevance to
patient7
Calcium Channel
Decreases
Blocker (Verapamil) myocardial
workload6
Implications for Therapy7
Consistently monitor vitals- higher risk for hypotension, orthostatic
hypotension, exercise my produce peripheral vasodilation; encourage
adherence in absence of symptoms, systemic heating contraindicated
Antidepressant to
treat anxiety
(Lexapro)
Decrease anxiety
Have patient take 2-4 hours before therapy for max effects- more
after abrupt change focused, inc risk of falls- evaluate balance, incorporate pt education on
in lifestyle
alternative stress relief
ACE Inhibitor
(Benazepril)
Decreases
myocardial
workload
Similar to calcium channel blockers
Analgesic
(Paracetamol)
Reduction of pain
after initial injury
Pain relief allows patient to participate more readily in therapy, lack of
adverse effects on therapy- education on adverse long-term effects
Muscle Relaxant
(Valium)
Decrease muscle
spasm, promote
healing
Enhances effects of modalities, sedative effects may effect
concentration during PT session
SYSTEMS REVIEW
 CVP: BPr: 120/90 mmHg




HRr: 70 bpm, strong and regular
RRr: 13 breaths per min, steady and normal
Heart sounds: WNL, apparent absence of arrhythmias
Edema: slight swelling of the R shoulder observed
 Integumentary: unimpaired
 Musculoskeletal: gross ROM assessment unable to be performed on R shoulder
due to sling
 Postural assessment: higher R shoulder due to muscle guarding
 Neuromuscular: dermatomal testing unimpaired bilaterally
 Gait and balance: unimpaired
 Reflexes: symmetrical, WNL
TESTS AND MEASURES8
(COMPLETED AT SECOND SESSION)
 Goniometry
 PROM R Shoulder Abduction: 0-55
degrees, empty end-feel
 PROM R Shoulder Extension: 0 degrees,
empty end-feel
 PROM R Shoulder External Rotation: 010 degrees, empty end-feel (pain)
 Patient unable to assume position to
perform R Shoulder Horizontal Abduction
 MMT
 R Shoulder Internal Rotation: 3/5
 R Shoulder External Rotation: 3/5
 R Shoulder Adduction: 3/5
 Special Tests
 Positive Apprehension test on R shoulder
 Positive Load and Shift test on R shoulder
 Negative Sulcus sign on R shoulder
 Outcomes measures
 Disabilities of Arm, Shoulder, and Hand
(DASH) 35/100
INITIAL VISIT: 4 DAYS-POST INJURY
Goals for Treatment
Interventions
 Pain management
 Cryotherapy
 Patient education
U/S Parameter
Value9
Frequency
3 MHz
Duty cycle
20%
Intensity
0.5 W/cm2
Duration
10 min
 Goal: pain management; cervical ice pack
over ant shoulder, 10 min
 Ultrasound over ant R shoulder
 Goal: pain management9
 Transfer training:
 Supine to sitting, sitting to standing
 Precautions:
 Movement restrictions8
 Activity restrictions
 HEP: Ice cup massage9
TRANSFER TRAINING10
• Supine to sitting, sitting to stand
transfers
• Monitoring vitals, ask pt about
symptoms
• Rolling to the left (unaffected) side
• Putting most of the force through left
elbow instead of the right hand to
push into sitting
• Using left arm to push off bed to
stand up instead of right (affected)
arm
4 WEEKS AFTER INITIAL INJURY
Goals for Treatment
Interventions
 Pain management
 Shoulder no longer immobilized
 Increasing ROM of immobilized
structures
 Cryotherapy, Ultrasound
 Anticipated patient goals: inc ROM
to be able to complete ADLs, dec pain
 Expected Outcomes: Return to active
lifestyle at low-to-moderate
intensities
 Stretching exercises8
 Golf club in supine- internal and
external rotation bilaterally
 Gear shift in sitting- IR, ER, flexion and
extension
 HEP: self stretching- horizontal
adduction and extension of shoulder
8 WEEKS AFTER INITIAL INJURY
Goals for Treatment
Interventions
 Pain management
 Cryotherapy, Ultrasound, Estim
 Increasing ROM of restricted
structures
 Stretching exercises8
 Golf club in supine- internal and external
rotation bilaterally
 Gear shift in sitting- IR, ER, flexion and
extension
 Vitals monitored
 HEP: self stretching- horizontal
adduction, abduction, and extension of
shoulder, wand exercises for IR and ER
ESTIM PARAMETERS9
 Goal: muscle spasm reduction
 Pulsed Biphasic Waveform
 Pulse frequency: 50 pps
 Pulse duration: 200µs
 On/Off time: 5/ 5 sec
 Amplitude: to visible contraction
 Ramp time: 1 sec
 Time: 10 min
 Treatment progression: estim for
muscle strengthening
12 WEEKS AFTER INITIAL INJURY
Goals for Treatment
 Continue increasing ROM
 Evaluate for exercise readiness
 Initiate walking program
Vital Sign
Pre 6MWT
Post 6MWT
BP
120/ 82
130/87
HR
65
100
RR
13
20
Pulse Ox
99%
98%
RPE
6
13
Interventions
 Cleared by physician for physical
exercise
 6 MWT: 550 ft11
 Stretching exercises
 Patient education: when to stop
exercise, monitoring vitals, target HR
(115 bpm)
 HEP: continue stretching, walk for 10
min outside, three times per week12
16 WEEKS AFTER INITIAL INJURY
Goals for Treatment
Interventions
 Initiate resistive exercise program
 Cleared by physician to participate in
resistive exercises12
 Increase aerobic exercise capacity
 Submaximal isometric and concentric
exercises for all shoulder directions8
 Protective weight bearing
 Manual resistance provided by therapist
 Therabands- scapular and shoulder
muscles
 UE ergometer, 10 min, vitals monitored
 HEP: self-applied isometrics, wall
washing exercise, walk 20 min outside12
PATIENT DISCHARGE
Outcomes
Special PT Considerations for
Cardiomegaly
 HEP strengthening exercises
progressed
 Get clearance from physician for
exercise (initially contraindicated)
 Pt gained full ROM to complete ADLs
without pain
 Establish a target heart rate,
consistently monitor vital signs6
 DASH questionnaire: 1/100 (MCID
present)
 Be aware of drug side effects
(hypotension)7
 6MWT: 575ft, RPE 10, vitals- normal
response11
 Educate patient to monitor own
vitals, take medications, remain at
low-to-moderately active lifestyle6
 Pt referred to “Phase III” cardiac
rehabilitation12
 Delay rehabilitation of other
comorbidities if exercise is required12
QUESTIONS?
REFERENCES
1.
What is an enlarged heart (cardiomegaly)? WebMD. http://www.webmd.com/heartdisease/guide/enlarged-heart-causes-symptoms-types#3. Accessed November 18, 2016.
2.
Urhausen A, Kindermann W. Sports-specific adaptations and differentiation of the athlete's
heart. Sports Medicine (Auckland, N.Z.) [serial online]. October 1999;28(4):237-244. Available
from: MEDLINE with Full Text, Ipswich, MA. Accessed November 18, 2016.
3.
Sheffle N, Bowden T. Pre-participation screening for hypertrophic cardiomyopathy in young
athletes. British Journal of Cardiac Nursing. 2014;9(11):551–559. doi:10.12968/bjca.2014.9.11.551.
4.
Piper S, Stainsby B. Addressing the risk factors and prevention of Sudden Cardiac Death in
young athletes: a case report. The Journal Of The Canadian Chiropractic Association [serial online].
December 2013;57(4):350-355. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed
November 18, 2016.
5.
Morse E, Funk M. Preparticipation screening and prevention of sudden cardiac death in athletes:
implications for primary care. Journal Of The American Academy Of Nurse Practitioners [serial
online]. February 2012;24(2):63-69. Available from: MEDLINE with Full Text, Ipswich, MA.
Accessed November 18, 2016.
6.
Pediatric Hypertrophic Cardiomyopathy: Background, Pathophysiology, Etiology.
http://emedicine.medscape.com/article/890068-overview#a7. Accessed November 18, 2016.
REFERENCES CONT.
7.
Ciccone CD. Pharmacology in rehabilitation (contemporary perspectives in rehabilitation).
3rd ed. Philadelphia: F.A. Davis Company; November 1, 2001.
8.
Kisner Colby L. Therapeutic Exercise: Foundations And Techniques. 6th ed. Philadelphia,
PA: F. A. Davis Company; 2012:577-580.
9.
Cameron MH. Physical agents in rehabilitation: From research to practice. 4th ed. United
States: Elsevier Health Sciences; 2013.
10. Fairchild S. Pierson and Fairchild’s principles & techniques of patient care. Saunders; June
22, 2015.
11. Rehab measures: 6 minute walk test.
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=895.
Accessed November 18, 2016.
12. Lorring D. Lecture Presented: Cardiac Rehabilitation and Exercise Prescription at
Cleveland State University. October 2016; Cleveland, OH.