KNPE 355

Before beginning a clinical skills task

• Introduce yourself

• Hand hygiene

• Confirm the client’s first and last name, and ask how they would like you to address them (preferred name)

• Provide an overview of the session/rationale and obtain client’s permission

SOAP Notes

• Subjective

• Objective

• Analysis/Assessment

• Plan

Analysis statement - components

1. client profile/summary

   • D.O.B., age, gender, pronouns, significant presentation

2. present condition/diagnosis

   • Current medical diagnosis or working differential diagnoses or physical

     diagnosis or potential differential diagnoses and/or present condition

3. any risks

   • acuity/chronicity/stability, any risks – including clinician primary concerns,

     precautions, contraindications or patient primary concerns/goals.

4. prognosis and rationale

   • what is/are the possible etiology(ies) of the diagnosis(es) and/or impairments (the ‘why?’), and what possible ramifications there may be for interventions &/or for the future

   • Prognosis do they have support, do they express high or low levels of self-

     efficacy and/or motivation?)

5. potential for kinesiology or referral to other services

   • the likelihood that a RKIN has something to offer and that the client is likely to, or not to, benefit from KIN.

   • If a referral to other services is warranted (e.g., med, PT, OT, dietician etc.)

Problem list

• A list of problems that are amenable to kinesiology (within the scope of practice)

• Forms the basis of your treatment plan (next step)

• Problems can be function, impairments, activity or participation limitations

• Problems can be actual or potential (at risk for)

• Relate to the underlying cause or treatable issue

Goal setting

• Made in collaboration with the client

Based on:

• Client’s stated goals and the problem list

• Prognosis, which is based on:

  • Nature, acuity/chronicity of illness/injury

  • Prior and current level of function

  • Social supports, living environment, apparent motivation

• Must be client-driven/person-centered

• Should be SMART

  • Specific

  • Measurable

  • Action-oriented

  • Realistic

  • Time-bound

Short-term goals

Steps or milestones along the way to achieving long-term goals (outcomes)

• Short-term goals typically address:

  • Function

  • Impairments

  • Education

Can have one or more for each long-term goal

Long-term goals

• Outcomes

• Often linked to resolving the problem list and returning to performing a meaningful activity/role and/or optimizing health and well-being

• Should be prioritized by importance

Plan

A concise statement of the overall intervention plan and follow-up proposal for next session

Body Composition

• Body composition refers to the components that make up the body

  • Body weight and relative amounts of muscle, fat, bone and other vital tissues

  • Often limited to fat and lean body mass (fat-free mass) and expressed as relative (percentage) and absolute (kilograms)

• Body composition is frequently used as an outcome measure to determine the effectiveness of community-based obesity prevention strategies

Body Composition Standards

• Currently, universally accepted norms for body composition do not exist.

• A consensus opinion for an exact percent body fat value associated with optimal health risk has yet to be defined.

• However, based on skinfold percentile reference values, the “good” category for body fat values across a wide age spectrum are:

  • 12%– 23% for males

  • 17%–26% for females

Why do we measure body composition?

• Risk of metabolic diseases

• Obesity is related to health risks

• Maximize performance/health

• Research outcome

Body composition models

Two-component models

• Anthropometry (circumference measures)

• Skinfold thickness

• Bioelectrical impedance analysis

• Underwater weighing

• Plethysmography (Bod Pod)

• Ultrasound

Three-component models

• Dual-energy x-ray absorptiometry (DEXA, DXA)

• Magnetic resonance imaging (MRI)

• Computed tomography (CT)

Body composition - Valid/Reliable

• A body composition technique is considered valid if it measures what it says it measures (relative body fat).

• A body composition technique is considered reliable if the results are reproducible.

Dual-energy x-ray absorptiometry (DEXA, DXA)

• Considered the gold-standard

• A 3-component model which provides an estimate of bone, fat, and lean tissue densities

• Expensive equipment that is usually found in research and clinical settings

• Full-body x-ray is used to evaluate various tissue densities

Underwater weighing (UWW)

• Also called hydrostatic weighing or hydrodensitometry

• Considered one of the most valid methods of estimating relative body fat

• Densitometry - fat and lean tissues have different densities

  • Water density ~ 1 g • ml^-1

  • Fat density < 1 g • ml^-1 or approx. 0.9 g • ml^-1

  • Lean tissue density = 1.1 g • ml^-1

  • 2-component model

Air-Displacement Plethysmography

• Commercial name: BOD POD

• Densitometry technique

• Displacement of air in a sealed compartment

Body Mass Index (BMI)

• Proxy measure for body fat.

• Simple and reliable measure commonly used in clinical situations and epidemiological research.

• Used to classify underweight, normal, overweight and obesity classes in adults and children.

Method:

BMI = Wt (kg) / Ht² (m²)

BMI Strengths & Weaknesses

Strengths

• Simple, inexpensive, reliable measure.

• National and international standards are available.

• High specificity for detecting excessive adiposity with higher BMI values in adults.

Weakness

• Does not provide a direct body fat measure.

• Poor estimates of body fat in some body build/frame sizes.

• The American Medical Association recognizes that BMI is an "imperfect way to measure body fat in multiple groups given that it does not account for differences across race/ethnic groups, sexes, genders, and age-span

Waist Circumference (WC)

• Proxy method for measuringintra-abdominal fat

Method

The WHO STEPwise Approach to Surveillance (STEPS) protocol for measuring waist circumference:

• Measurement at the approximate midpoint between the lower margin of the last palpable rib and the top of the iliac crest

• Tape should be snug around the body and parallel to the floor

• Participants should stand with arms at the sides; feet positioned close together, weight evenly distributed

• Measure at the end of normal respiration

• Relaxed position

Waist Circumference Strengths & Weaknesses

Strengths

• WC is closely linked to increased risk for chronic disease in both adults and children.

• It may provide a better indicator of chronic disease risk than BMI, especially in individuals with normal BMI values.

Weakness

• Does not directly measure intra-abdominal fat

• The practitioner must be trained

• 2 measures need to be taken and averaged

Skinfold thickness

• Estimation of body fat

• Most widely used field technique

• Rationale = age-dependent proportion of body fat is deposited subcutaneously

• The amount of adipose tissue that can be pinched provides some indication of the amount of overall body fat

• Estimation of percent body fat from skinfold measures has an error of approx. 3.5%

Skinfold thickness - Method

• Using skinfold calipers, all measurements are taken on the right side of the body

• Carefully landmark and measure skinfold sites

• Generalized body density formulas using 3-7 measurement sites

• Body composition is estimated from the Siri equation:

%body fat = (4.95 / density) – 4.50

Skinfold Thickness Strengths & Weaknesses

Strengths

• Relatively easy measurement with minimal equipment

• The relationship between subcutaneous fat and total body fat varies with race, age and sex. Therefore, population-specific equations have been developed.

Weakness

• Calipers vary in quality, and some can be grossly inaccurate

• Intra and inter-rater reliability

• Not recommended for people with BMI > 30kg/m2

Factors that may contribute to skinfold thickness measurement errors

• poor anatomical landmark identification

• poor measurement technique

• inexperienced evaluator

• extremely obese or extremely lean participant

• improperly calibrated caliper

Bioelectrical impedance analysis

• Estimates fat-free mass and total body water.

• Based on the body’s ability to conduct a mild electrical current to indirectly estimate fat-free mass or % body fat.

• Impedance: opposition to the flow of current , where electrolytes in body water conduct electrical current

• Measured with BIA analyzer

• Greater total body water  current passes more easily through the body

• Fat tissue has lower water content than fat-free mass  Impedance is greater in individuals with more body fat.

• SEE = 2.7 to 6.3%

Bioelectrical impedance analysis - Strengths & Weaknesses

Strengths

• Validated equation available for adults and children

• Standard error estimates available for BIA published equation

Weakness

• Equations less valid for identifying adiposity in individuals with high or low BMI values

• Accuracy depends on following standardized procedures (normal hydration, fasting, and avoiding exercise

What are vital signs?

Measures of the body’s core ability to stay alive

• pumping blood through the heart

• breathingmaintaining a core temperature

Vital signs are the most frequently measured objective data for monitoring vital body functions and are often the first and most important indicator that the patient’s condition is changing

Four vital signs are internationally recognized and accepted in medicine:

• Respiration (ventilation)

• Pulse or heart rate (HR)

• Blood pressure (BP)

• Temperature

Three other signs may be considered:

• Pulse oximetry

• Pain rating scales

• Level of perceived exertion

Vital signs are used to establish:

• Baseline physiological information to guide exercise program development

• Physiological response to activity to guide continuation, modification, or discontinuation of an exercise program

• Patient’s/client’s immediate health risk (physiological risks, contraindication, and/or improvements)

• Emergency cardiac or respiratory interventions

What’s the point of measuring Heart Rate (HR)?

Goal = to determine the client’s physiological response to activity

To obtain an accurate picture of a client’s cardiac response to an activity, we typically assess:

• Resting HR (5 minutes before activity)

• Activity HR (during or immediately following activity)

• Recovery HR (1 to 5 minutes post-activity)

What is Heart Rate (HR) and what’s documented?

• Heart rate (pulse) is an indirect measure of the rate and rhythm of the contraction of the left ventricle.

• Three characteristics are documented:

1. Rate (bpm)

2. Rhythm

3. Intensity

How to measure Heart Rate (HR)

• Count begins with the first beat that occurs after the time interval has begun (“one count method”)

• HR is a measurement of beats per minute therefore, you should count for one full minute

• Once you have established a baseline pulse rate (and it is regular and strong) you can use the 30 seconds x 2 method

Measuring HR – carotid pulse

Caution, if you decide to assess the carotid

pulse:

• Stand on the same side of the carotid artery you are assessing (never reach across)

• Do not press too hard

• Carotid sinus reflex = massage-like actions can decrease HR and produce bradycardia

• Never palpate bilateral carotid arteries, this can potentially cut off blood supply to the brain

Measuring HR – radial and brachial pulse

1. Support the left arm on a stable surface or with your arm at the level of their heart with their elbow extended and forearm supinated

2. Using your 2nd and 3rd digits, palpate gently for the:

• brachial pulse: medially on the elbow crease

• radial pulse: 1-2 cm above the wrist crease, lateral to the flexor tendons

3. Measure the number of beats in 1 minute

4. Record your findings in beats per minute (bpm)

Safety – Heart rate and exercise

• HR increases with progressive workloads at a rate of approx. 10 bpm per 1 metabolic equivalent of a task (MET)

• HR should decrease by at least 12 beats during the first minute of recovery.

• HR should decrease by 22 beats by the end of the second minute of recovery.

Respiratory Rate (RR)

It’s actually ventilation that we measure, the movement of airflow. Ventilation is characterized in 4 main ways:

1. Rate: # breaths per minute (bpm)

2. Pattern

• eupnea: a ventilatory rate within normal limits (~12 breaths per min)

• tachypnea: an elevated ventilatory rate

• bradypnea: a low ventilatory rate

• apnea: absence of ventilations

3. Mechanics

RR – Mechanics

Inspiratory to Expiratory Ratio (I : E ratio)

• Ratio of time for inspiration versus expiration

• Normal is 1:2 or 1:3

• In obstructive disease, the expiratory time is increased because the patient has increased expiratory resistance, and it takes longer to empty the lungs before the next breath.

RR mechanics – accessory muscles

Blood Pressure (BP)

• Blood pressure is a physiological variable which reflects the effects of cardiac output, peripheral vascular resistance and haemodynamic factors.

• Use of a blood pressure cuff is an indirect measure of the pressure inside an artery caused by blood flow through the artery.

• BP is recorded as millimeters of mercury (mmHg).

• Systolic Pressure: the pressure at the time of contraction of the left ventricle.

• Diastolic Pressure: the pressure at the time of ventricular filling (‘resting’ pressure).

Blood Pressure - equipment

• Clean equipment before using and ensure it is fitted to your client

• Check stethoscope is situated correctly 

Blood Pressure Measurement

Korotkoff’s Sounds: assessment of blood pressure by auscultation, using a sphygmomanometer and a stethoscope:

• the systolic pressure is indicated by the first faint clear tapping sounds heard upon gradually releasing the air in the cuff

• the diastolic pressure is indicated by the disappearance of all sounds (last sound heard).

Safety – Blood pressure

• SBP increases with increasing workloads at a rate of approx. 10 mm Hg per 1 MET

• Normally no change in DBP or a slight decrease during exercise.

• Post-exercise SBP returns to pre-exercise levels or lower by 6 minutes of recovery

Blood Pressure Emergencies

BP changes during exercise or other high-level activity serve as serious warnings.

These warning signs include the following:

• Systolic reading greater than 250 mm Hg

• Diastolic reading greater than 115 mm Hg

• A drop in the systolic pressure of more than 10 mm Hg from baseline

• Failure of the systolic pressure to increase with the increasing workload

STOP! Any one of these BP findings should result in immediate cessation of activity.

Blood Pressure sounds heard can be broken down into five phases

Oxygen Saturation

• Percent saturation of arterial oxygen (SpO₂) = estimate of how much oxygen is travelling through your body in your red blood cells

• 95% - 100%

• Pulse oximeter

• Exercise-induced hypoxemia = decrease in SpO2 greater than or equal to 5% during exercise

Cardiorespiratory fitness

Total body health: reflects the ability of our heart, blood vessels, lungs, and muscles to use and transport oxygen to do physical work (exercise, move, daily activities of living)

Benefits of improving CRF

Reduced risk of:

1. Developing dementia and Alzheimer disease

2. Adverse health outcomes such as developing prediabetes, metabolic syndrome, and type II diabetes

3. Developing cardiovascular disease

4. Developing breast cancer, lung cancer, and cancers of the gastrointestinal system 

5. Disability later in life

Maximal Oxygen Uptake - What is VO2max?

• VO2max is the measurement of the maximum (max) rate of volume (V) of oxygen (O2) your body can use during exercise.

• An individual’s VHO2max is determined by measuring gas exchange during intense physical exercise.

• The VHO2max test involves incrementally increasing exercise intensity (work rate) to ensure maximal aerobic energy transfer.

How do we measure VO2max?

The four different ways of measuring CRF are:

1. Cardiopulmonary exercise tests (CPET)

2. Maximal Exercise Test (GXT)

3. Submaximal Exercise Test

4. Estimated CRF (eCRF)

Submaximal exercise testing

• Measures VO2 max indirectly through predictive equations based on the HR –workload relationship

• Not as accurate as VO2max prediction from max tests

• Uses submaximal work rates (i.e., less than 85% HR max)

• Limited diagnostic capabilities

• More accessible in the community or clinical setting:

  • easier to administer

  • less expensive

  • safer(?)

Factors can either increase your heart rate during submaximal exercise testing

1. Caffeine: Drinking caffeine within 3 hours of completing your test can increase your heart rate at rest and during activity

2. After eating a meal: After eating a meal, your heart rate will increase. Your heart needs to pump additional blood to the stomach to aid digestion. After eating and digesting food, your heart rate should return to normal

3. Feeling anxious: Any form of emotional stress can increase your heart rate.

4. Smoking: Smoking damages the cardiovascular system and can affect the heart by increasing blood pressure, narrowing the arteries, and increasing heart rate.

5. Humid weather/environment: High temperatures and high humidity result in more blood flow to the skin as the body attempts to cool itself off. This can cause the heart to beat faster while circulating twice as much blood per minute than on a normal day.

Disadvantages to be aware of when using submaximal exercise testing

1. For some people, this type of test could be a maximal test.

2. The Individual’s motivation and pacing strategy during the test can have a profound effect on the final outcome,

3. Does not allow comprehensive monitoring of both HR and BP during the test.

4. Relatively large standard error of the estimate (SEE) ± 10% - 15%

Field tests (submaximal exercise tests) are generally not recommended for sedentary individuals who have been identified in pretesting screening to be at moderate or high risk of cardiorespiratory or musculoskeletal complications

We must consider the ___ and ___ effects of testing – especially when using submaximal exercise testing

• Ceiling effect: the test is too easy to produce sufficient CV response to get an accurate functional capacity (e.g., not enough stages or peak intensity).

• Floor effect: the test is too difficult (from a vascular or physical perspective) so that the test is not limited by the cardiovascular system but by other barriers (e.g., anxiety, peripheral claudication, Aimexercise specificity (e.g., LE muscle fatigue during cycle ergometry testing or in UE muscles during arm ergometery testing, osteoarthritis)

Submaximal exercise testing: Aim & Objective measures collected

Aim: to determine the HR response to one or more submaximal work rates and use the results to predict VO2max

Objective measures collected:

• HR

• BP

• Workload

• RPE

• SpO2

• Symptoms

Results of exercise testing: Exercise Prescription

Information to develop an individualized aerobic exercise prescription based on:

• Peak HR during exercise (and how that relates to the predicted HR max for age and sex)

• BP responses to exercise

• VO2max

• Functional capacity as a calculated estimate of maximal oxygen uptake in Metabolic Equivalents of Task (METs)

Results of exercise testing: Other

• Educating clients about their present fitness status relative to age and sex- matched norms

• Collecting baseline and follow-up data to evaluate progress

• Motivating patients by establishing reasonable and attainable exercise goals

• Providing information to inform return-to-work (RTW) decisions

• Disability/mobility assessment

How do we obtain the most accurate estimate of VO_2max?

• A steady state HR is obtained for each exercise work rate

• A linear relationship exists between HR and work rate

• The difference between actual and predicted maximal HR is minimal

• Mechanical efficiency (i.e., VO₂ at a given work rate) is the same for everyone

• The client is not on any HR altering medications

• The client is not consuming high quantities of caffeine, is ill or in a high-temperature environment

Pretest procedure - Submaximal exercise testing

• Review the client’s medical history, exercise clearance, reasons for the chosen test, recent symptoms (if any) and current medications

• Explain the test/procedure to the client

• Inform the client that the test may make them feel uncomfortable and that they should let you know if they feel any symptoms, including:

  • Chest discomfort

  • Dyspnea

  • Claudication

Rockport Fitness walking test (one-mile track walk test)

• Developed for a wide age range (30-79 years) of males and females

• Prediction equations developed using sex, age, weight, time and HR

Rockport Fitness walking test - Pros & Cons

Advantages

• Applicable to a wide range of individuals

• Limited equipment needed

• Familiar activity

Disadvantages

• Inability to monitor physiological variables during test

20-meter shuttle test (Beep test)

• Multi-stage shuttle run test used to estimate VO2max and maximal aerobic speed

20-meter shuttle test - Pros & Cons

Advantages

• Multiple stages allows for a wide range of fitness levels to be tested

• Limited amount of equipment needed

• More than one participant can be tested at once

• Paces individuals with pre-recorded sound signals

Disadvantages

• Frequent stopping and starting

• Pacing

• Inability to monitor physiological variables during test

• How do we ensure this is a submaximal test?

6-minute walk test

• The 6MWT has been primarily used to assess individuals with chronic obstructive pulmonary disease and heart failure and healthy older and elderly populations.

• Widely considered a measure of functional status that represents the capacity to carry out ambulatory activities of daily living.

• Standardized protocol

• May be max for low fitness/severe disease, yet it can produce a ceiling effect for others

• < 300 m = poor short-term survival

6-minute walk test - Pros & Cons

Advantages

• Simple, inexpensive test

• Corresponds to a functional activity of daily living

• It can be used with a wide population with a variety of diagnoses

• Standard time rather than a predetermined distance may provide a better test of endurance

• Allows participants to set their own pace and stop if necessary

Disadvantages

• Requires 2 practice tests

• Inability to monitor BP during test

Single Stage Submaximal Treadmill Walking Test (SSTWT) - Pros & Cons

Advantages

• Suitable for people with various diagnoses

• Familiar activity

• Single stage

Disadvantages

• Based on HR therefore, factors that affect HR must be controlled

Astrand-Rhyming Cycle Ergometry Test - Pros & Cons

Advantages

• Set pedal rate (50rpm) and predetermined workload

• Short test

Disadvantages

• Underestimates VO2 for men

• Overestimates VO2 for women

• May be limited by LE discomfort rather than CV status

Selecting the appropriate test

• Inappropriate test selection can lead to under-stressing or overstressing the client.

• The goal of the test should be to produce a sufficient level of exercise stress without physiologic or biomechanical strain.

Things to consider when selecting the appropriate test

• Has the test been validated in this population?

• Effect of a person’s condition on daily function and abilities

• Cognitive status

• Age

• Weight

• Mobility, use of orthotics or prosthetics, balance, gait

• Current level of pain

• Client’s goals