The acute care setting was selected for the student’s outcomes project. In this environment, individuals are admitted for a variety of reasons, e.g., illness, injury, or surgery recovery. Patients receive active, short-term treatment in a crowded fast-paced setting and then are discharged when they are deemed healthy and stable.
A study conducted by Masley et al. describes that the major role of a physical therapist in an acute care setting is to provide patient safety while promoting functional mobility. In addition, it includes but is not limited to the following tasks: (1) collection and analysis of medical information; (2) application of knowledge to patient treatment plans; (3) continual dynamic patient assessments; and (4) appropriate decision making in regard to patient care. 1
The forthcoming section of this paper attempts to describe common neuromuscular, respiratory and cardiovascular diagnoses expected to be encountered in an acute care setting, which include etiology, pathophysiology and critical findings of each diagnosis.
A cerebrovascular accident (CVA or stroke) is defined as a disruption in blood flow to the brain that leads to a loss of neurological brain function. It can be classified as ischemia or hemorrhagic, which result from a thrombosis or bursting of an artery in or around the brain, respectively. In the United States, strokes are the fourth leading cause of death and account for the primary source of long-term disability among adults. In fact, “5% – 14% of individuals who survive a stroke will experience another one within one year”. 2
Patient presentation is dependent upon the site and gravity of the injury; Thus, history and examination should include exact times and patterns of symptoms to give an accurate diagnosis and to gain a better understanding of the severity of the injury. Associated symptoms include aphasia (impaired speech and language), dysphagia (impaired ability to swallow), cognitive dysfunction, impaired or absent sensation, muscle weakness, or involuntary spasms. Additionally, a sudden onset with worsening symptoms and decreasing level of consciousness is indicative of a hemorrhagic stroke, whereas a headache that is described as the “worst headache” is suggestive of an ischemic stroke. 2 Other physical examination assessments to consider include function of the cerebral hemispheres and cerebellum as well as cranial nerves, eyes, and sensorimotor systems. Physical activity and exercise are an effective and useful attribute of post-stroke care and can significantly reduce symptoms and degree of disability. 3
A spinal cord injury (SCI) is another neuromuscular diagnosis that may be seen in the acute care setting. Although incident rates are low, a SCI results in a great change to an individual’s life as it can may lead to paralysis below the level of damage, and thus, limitations in one’s ability to navigate his or her environment, performance of daily activities, and participation in social activities. It can be characterized as either tetraplegia and paraplegia. Tetraplegia is an injury to the cervical spinal cord and results in complete paralysis of the trunk, all four extremities and respiratory muscles. Damage to the thoracic or lumbar spinal cord is considered paraplegia, which results in complete loss of function of all or part of the trunk and both lower extremities. Neurological complications are dependent upon the location of lesion. These effects include but are not limited to spinal shock, motor and sensory impairments, autonomic dysreflexia, and spastic hypertonia as well as control of the bladder and bowel or thermoregulatory function. Prognosis depends on a variety of factors, e.g., “motor level, age, concomitant injury, preexisting health conditions, secondary complications, body type, and psychosocial support.” 2 Therapy is a vital component of fulfilling an active lifestyle following a SCI.
Multiple sclerosis (MS) is an autoimmune disease that it is characterized by progressive disability over time due to inflammation, demyelination and axon loss. Many areas of the central nervous system (CNS) may be affected, e.g., brainstem, cerebellum, cerebral hemispheres, or spinal cord, therefore, it is imperative to conduct a thorough examination to determine the degree of neurological involvement.
Optic neuritis, which is a unilateral painful decrease of loss of vision, is often the first manifestation of the disease 2, and it can be assessed utilizing cranial nerve testing of the optic nerve. Additionally, the most common and disabling symptoms that individuals experience are fatigue and burning-type pain. It is imperative to consider symptom severity, stage of the disease, and age. Other symptoms of MS include diminished fine touch sensation and proprioception, muscle weakness, impaired coordination and balance, and gait abnormalities. Progression of MS is usually unpredictable and highly variable, and in most cases daily activity and functional mobility decline over time.
Pulmonary function abnormalities can be classified as obstructive lung disease (OLD), restrictive lung dysfunction (RLD), or both. Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe the obstruction of expiratory airflow due to a combination of obstructive lung diseases, e.g., emphysema, chronic bronchitis, and/or asthma.
The severity of COPD is classified as mild, moderate, severe, or very severe according to the FEV1 value and presenting symptoms. Categories include the following: (1) mild: mild airflow limitation with an FEV1 80% or greater predicted; (2) moderate: worsening airflow limitation with an FEV1 less than 80% predicted value; (3) severe: further worsening airflow limitation with an FEV1 between 50% and 30% predicted; (4) very severe: severe airflow limitation with an FEV1 less than 30% predicted. 4
Although it is preventable and treatable, COPD is the fourth leading cause of morbidity and mortality in the United States. 2 Patients with COPD typically have a history of cigarette smoking and experience symptoms such as a chronic cough with mucus and exertional dyspnea. A loss of elastic recoil and hyperinflation of the lungs leads to an alteration of the thorax, particularly, an increased anterior-posterior diameter of the chest wall. Ultimately, this modification results in decreased chest excursion and a barrel-chested appearance upon physical examination.
Restrictive lung dysfunction, or RLD, is characterized by a reduction of pulmonary ventilation due to restriction of expansion by the chest wall or lungs. 2 Essentially, the parenchyma and pleura (i.e., lung tissue and membrane, respectively) are damaged due to a variety of causes, e.g., infectious or environmental agents. As a result, chest expansion is decreased, and thus, lung volumes and capacities are reduced. Tachypnea, or an increased respiratory rate, occurs to overcome decreased pulmonary compliance, and therefore, maintain minute ventilation. During the acute phase, respiratory rate may increase significantly resulting in an increased minute ventilation as well as alveolar hyperventilation. Hypoxemia may occur due to ventilation-perfusion mismatching.
Individuals with RLD typically experience three hallmark symptoms, which includes dyspnea, a nonproductive cough, and emaciated appearance. 2 Additionally, decreased breath sounds and dry inspiratory crackles at the end of inspiration are seen in individuals with RLD. Crackles, or rales, are present due to atelectatic alveoli openings, i.e., a quick “popping” noise made by the opening of a previously collapsed portion of the lung. Cor Pulmonale, or right-sided heart failure is also associated with RLD, and it occurs as a result of increased work of the right ventricle, usually secondary to pulmonary hypertension.
Pneumonia is an inflammatory process of the parenchyma due to a lower respiratory tract infection, which is acquired by inhalation or aspiration of bacterial, viral, fungal, or mycoplasma agents. 2 Pneumonia may be categorized as community-acquired, hospital-acquired, healthcare associated, or ventilatory associated, which are further outlined as pneumonia that occurs less than two days following hospitalization, two or more days following hospitalization, among outpatients in contact with the healthcare system, or more than 48 hours following endotracheal intubation, respectively.
Ultimately, this inflammatory process progresses to infection. Symptoms of bacterial pneumonia include a high fever, chills, dyspnea, tachypnea, productive cough, and pleuritic pain, while symptoms of viral pneumonia include a moderate ever, dyspnea, tachypnea, a nonproductive cough and myalgias (i.e., muscle pain). 2 In the United States, community-acquired pneumonia is the sixth leading cause of death in individuals 65 years, and it affects approximately 5.6 million individuals annually.
When managing patients with heart disease certain lab values are vital components within an individual’s chart review, e.g., hemoglobin & hematocrit (H&H), electrolyte, renal function (BUN, BNP, and creatinine), and glucose levels. Further, examining physiological parameters such as HR, BP, respiratory rate, and perceived exertion before and after activity participation are used to assess hemodynamic response to given workloads.2
Cardiovascular disease (CVD) is the leading cause of mortality and disability in the U.S, with the most prevalent CVD being hypertension (HTN). A persistent increase in systolic blood pressure (SBP) above 140 mmHg or a diastolic blood pressure (DBP) greater than or equal to 90 mmHg is indicative of HTN. The two major divisions of HTN are primary and secondary.2 Primary HTN has no known cause but is influenced by a variety of factors such as genetics, environmental factors, stress, glucose intolerance, and alcohol consumption. Secondary HTN is known to be caused by a distinguished medical condition such as renal, endocrine, or vascular complications.
Congestive heart failure (CHF) or HF is a chronic, progressive condition impacting the physiological functioning of the heart. Generally, fluid tends to localize on either the right or left side of the heart depending on the type of the heart failure. Certain pathologies such as myocardial infarction (MI) and HTN cause left sided HF. Right-side heart failure tends to develop from progressive worsening of left-sided HF or right ventricular failure, and the patient typically presents with ascites and bilateral lower extremities edema. In addition to the pathologies listed above, there are many other causes of heart failure including scarring and remodeling of the myocardium post MI, cardiomyopathy, and valvular disorders.2 According to Essentials of Cardiopulmonary Physical Therapy, determining whether the nature of the heart failure is systolic or diastolic is the most useful distinction in CHF. The most characteristic signs and symptoms often demonstrated in patients with CHF include, but are not limited to breathing abnormalities (dyspnea, tachypnea, paroxysmal nocturnal dyspnea, orthopnea), peripheral edema, weight gain, rales, S3 heart sound, increased fatigue, and decreased exercise tolerance. 4
Coronary Artery Disease (CAD) and Acute Coronary Syndrome (ACS) are generally caused by dysfunction occurring in the left, right, or both ventricles as a result of injury. Generally, symptoms associated with CAD are usually not felt until coronary arteries are 70% occluded, therefore, many subacute occlusions go unnoticed. 4 ACS ranges from the least severe condition (unstable angina) to the worst (sudden cardiac death). The most common clinical presentations of ACS and CAD are associated with inadequate myocardial oxygen supply and consist of angina, injury and infarction. When differentiating between ischemic and non-ischemic chest pain observing the signs and symptoms associated with compromised cardiac output is important. These signs and symptoms include dizziness, weakness, diaphoresis, and fatigue. Blood work and ECG changes are also very important aspects when helping to determine the presence of an MI. 2,4
Cardiac dysrhythmias are characterized by extremely rapid or slow heart beats that impair the function one or both ventricles. Abnormalities in these heart rates may be caused by a heart block, rapid atrial fibrillation/flutter, or ventricular tachycardias. Oftentimes, 1st, 2nd, and 3rd degree heart blocks are caused by adverse reactions to medications. To help treat and control abnormal heart rhythms, a permanent pacemaker can be implanted within the heart. Atrial fibrillation or flutter can be treated by positive inotropic medications such as verapamil or digoxin.4 Implantable cardiac defibrillators (ICDs) are used to treat recurrent ventricular tachycardia or fibrillation when antiarrhythmic medications fail to work. A PT must determine the level of reliance the patient has towards his/her pacemaker to adequately rate responsiveness during activity. 2,4
Cardiac muscle dysfunction (CMD) may also result from heart valve disease. Abnormalities associated with heart valve disease include valvular stenosis and insufficiency. These valve disorders cause increased myocardial contractions of either the atria or ventricles, consequently resulting in myocardial hypertrophy. An insufficiency is the mitral or tricuspid valves leads to ventricular dilation, whereas ventricular dilation is associated with aortic or pulmonary insufficiency. The irregular hemodynamics caused by the combination of hypertrophy and atrial dilation often produce CMD. 4
Cardiomyopathy is an umbrella term used to characterize impaired contraction and relaxation of myocardial fibers. These impairments can be caused by a dysfunction in the myocardium impacting its contractility or by systemic disease processes. There are three basic categories of cardiomyopathies: dilated (genetic), hypertrophic (acquired), and restrictive (mixed). Dilated cardiomyopathy results from dysfunctions within myocardial mitochondria, impacting energy production. This makes it extremely difficult for the left ventricle to contract or relax properly in response to increased workload. 4 Hypertrophic myopathy, a diastolic dysfunction, is associated with increased left atrial, left ventricle end-diastolic pressure (LVEDP), and pulmonary artery/capillary pressures – leading to a hypercontractile LV. Typical findings related to hypertrophic myopathy are rapid ventricular emptying and high ejection fraction (EF). Restrictive cardiomyopathy, also a diastolic dysfunction, is associated with myocardial fibrosis, hypertrophy, and myocardial relaxation defects. 4
Individuals are admitted to the acute care setting for a variety of reasons, thus, it was of extreme importance to utilize outcome measures that might be applied across a wide range of diagnoses. The outcome measures chosen to assess the preceding diagnoses include Five Time Sit to Stand (FTSTS), the Activity Measure for Post-Acute Care (AM-PAC), and the two-minute walk test (2MWT).
The FTSTS provides an objective measurement of functional and lower extremity strength that can be utilized over days or months across all populations in a variety of settings. Richard Bohannon conducted a systematic review that evaluated the literature regarding the test-retest reliability of the FTSTS. The analysis included ten studies and a total of 779 individuals. The intraclass correlation coefficients (ICC) ranged from 0.64 to 0.96, with an adjusted mean of 0.81. It was concluded that the confidence in repeatability of the test could be interpreted as “good to high” in most populations and settings. 5
The AM-PAC “6-clicks” is a new tool that is designed to assess patients’ activity limitations in acute care settings. Results of the retrospective study, Mobility Short Forms, support the validity of the AM-PAC to assess activity limitations in patients with a variety of conditions across different healthcare settings over time. 6 Basic mobility and daily activity scores were found to be highly correlated to Functional Independence Measure (FIM) scores: specifically, basic mobility: r = 0.69, CI 95% and daily activity: r = 0.65, CI = 95%. Additionally, a receiver operating characteristic curve, or ROC curve, was determined to establish a cutoff score of 43.7 for the AM-PAC, i.e., individuals required more than one day of physical therapy in the acute care setting if they scored below this value. If they scored above 43.7, however, they required only one physical therapy session. This may prove useful in clinical decision making with respect to the amount of physical therapy visits an individual may require. Although there is limited research about the AM-PAC 6-Clicks, this outcome measure may be completed quickly to assess patients’ activity limitations in acute care settings.
The two-minute walk test (2MWT) is a clinically feasible objective measure to identify walking distance and functional status for individuals in a variety of settings. In a study by Leung et al., reliability, validity, and responsiveness of a 2-minute walk test (2MWT) was assessed in 54 patients with moderate to severe COPD. Significant improvements in mean 2MWT walking distance were found to be 17.2 +/- 13.8, with a moderate effects size of 0.61. 7 High correlation was found between changes in the 2MWT and 6MWT (r = 0.70; p < 0.05). In an alternate cross-sectional study by Bohannon et al., 1137 adult participants walked an average distance of 180.9m. 8 The test-retest reliability of the 2MWT was ICC = .82 (95% confidence interval, .76–.87). The minimum detectable change (MDC) for the 2MWT was 42.5m, with a standard error of measurement (SEM) of 15.3m. In a meta-analysis, Bohannan set out to establish normative values for the 2MWT using data from four separate articles. 9 Three electronic databases (PubMed, CINAHL, and Scopus) were utilized during the search for studies reporting normative values for the 2MWT. A large same size provided better indication of normative preference that individual studies. The I2 values were found to be less than 40.0%, suggest homogeneity in the data. Results indicated that men (217.9 m, 20 to 29 tears) walked further than women (150.3 m, 70 to 79 years), and a group made up of younger ages traveled further than older age groups. This study found an increased mean for the walking distance for older adults residing in long-term care (77.4 m) as well as those for pathologies or conditions such as lower limb amputations (27.9 m), chronic stroke (58.5 m), late-onset sequelae of poliomyelitis (136.0 m), cardiac disease (138.0 m), and COPD (150.0 m). The data derived from this meta-analysis may provide better normative references compared to individual studies for interpreting the two-minute walk test performance of adults.