So, you got Covid-19…now what?
Fortunately, about 80% of people who get Covid-19 will experience only mild symptoms. However, the other 20% can experience more severe symptoms and 5% may experience critical illness as a result. Recovery from moderate to severe Covid-19 can take weeks, months or longer. Generally, the longer you were in the hospital, ICU or on a mechanical ventilator, the longer you may experience residual effects, and the more protracted your recovery may be. The APTA has provided physical therapists with a wonderful resource, the PACER series (Post-Acute Covid-19 Exercise and Rehabilitation project) to help us best prepare to care for patients as they recover from Covid-10 and I have pulled together some of the most relevant information I learned from this course here for you. If you contracted Covid-19, and still don’t feel yourself despite the ‘all-clear’ of a negative test, here are some things you may be experiencing, and some information on how Physical Therapy can help you continue along the recovery process.
Fortunately, about 80% of people who get Covid-19 will experience only mild symptoms. However, the other 20% can experience more severe symptoms and 5% may experience critical illness as a result. Recovery from moderate to severe Covid-19 can take weeks, months or longer. Generally, the longer you were in the hospital, ICU or on a mechanical ventilator, the longer you may experience residual effects, and the more protracted your recovery may be. The APTA has provided physical therapists with a wonderful resource, the PACER series (Post-Acute Covid-19 Exercise and Rehabilitation project) to help us best prepare to care for patients as they recover from Covid-10 and I have pulled together some of the most relevant information I learned from this course here for you. If you contracted Covid-19, and still don’t feel yourself despite the ‘all-clear’ of a negative test, here are some things you may be experiencing, and some information on how Physical Therapy can help you continue along the recovery process.
WHAT TO EXPECT DURING COVID-19 RECOVERY:
Fatigue and Decreased Endurance: You will likely find you are more tired than normal from moving around, walking, and performing activities of daily living. This can be due to deconditioning from the bed rest and hospital stay, due to dehydration, because of decreased blood volume, or related to impaired use gas exchange and ventilation (your ability to pull oxygen out of the air and into your lungs). Anemia is also possible after Covid-19 and should be assessed for by your doctor if you are experiencing these types of symptoms.
Muscle Weakness: You may feel like your body is weaker than it was before or it is harder to carry heavy items. Muscle weakness can develop from prolonged bedrest or decreased activity, but it can also be more significant if you have been diagnosed with Critical Illness Myopathy (CIM) or Critical Illness Polyneuropathy (CIP) related to your Covid-19 illness.
Shortness of Breath or Difficulty Breathing: As Covid-19 causes damage to the lungs, you may find you continue to be short of breath at rest or with activity while you recover. You may notice you have to lean forward to support yourself to breathe deep or find yourself taking shallow breaths or breathing more rapidly when you feel out of breath. This may be due to damage to the alveoli, in the lungs, where the oxygen is extracted from the air and drawn into the blood stream, or it may be due to scarring and fibrosis that has occurred within the lungs during their healing process.
Signs of Cardiovascular Impairment: If you already had Cardiovascular disease prior to developing Covid-19, you may find your symptoms are now worse. If you suffered any cardiovascular damage during your illness, you may experience periods of angina (chest pain), a higher than normal resting heart rate, feelings of irregular heart rate or arrythmia or swelling in your legs or your feet. If you are experiencing any of these symptoms, it is important to report these to your doctor, so they can assess your need for further care. You also may experience lightheadedness when you stand up. Orthostatic hypotension is common after spending time in the hospital, and can be improved by drinking plenty of fluids, and taking extra time to come to standing, especially first thing in the morning or when you get out of bed.
Difficulty with your Balance: Whether due to impact on your neurological system or simply due to weakness and deconditioning, it is possible you may feel more off balance or unsteady when you walk. If are having falls, or even feeling like you may fall, it is worth seeking physical therapy to improve your balance and keep you from sustaining any falls-related injuries that could further set you back.
Increased Confusion, Memory Loss, Anxiety or Depression: Lastly, it is common to feel anxious or depressed after a hospital stay and especially after a hospital stay for Covid-19. If these feelings become overwhelming or are distressing, it is important to bring these to the attention of your doctor. It is also possible to have some degree of delirium or new onset memory loss after an ICU stay. This can take some time to improve, and you may benefit also from seeing a Speech Language Pathologist to help you learn recovery or compensatory strategies to address issues you may be having.
HOW PHYSICAL THERAPY CAN HELP YOU RECOVER AFTER COVID-19:
As a skilled Physical Therapist, I can help you work to get stronger after Covid-19. These are some things I would likely work with you on as part of your rehabilitation.
Functional Mobility: I will help you improve the things you may be struggling to do at home. This may include the ability to get in and out of bed, transfer on and off various surfaces around your home and in and out of your car. We will also practice walking in your home, outdoors and in more complex environments to get you safer at home and more comfortable walking within your community.
Strength and Flexibility: I will teach you exercises to improve the muscles that have become weaker. Most of these exercises will incorporate whole body functional movements that will also help make your mobility and activities of daily living feel easier. I will also teach you safe stretching exercises to address any impairments in flexibility you may have developed during your hospital stay or as a result of prolonged bedrest.
Breathing, Pacing and Energy Conservation: To improve your ability to breathe comfortably, I will teach you specific exercises that will strengthen the muscles involved with the breath cycle like the diaphragm and the intercostals. I will also teach you ways you can pace yourself when performing self-care and household activities and coach you in ways you can save your energy for things you really need it for. If you have come home using oxygen, I will work with you to wean off, if approved by your doctor, and if not, can teach you how to manage your oxygen equipment and oxygen needs ongoing.
Fall Prevention and Safety Awareness: By working on your balance and ability to use your balance reactions, I will help you prevent losses of balance, and teach you how to respond quickly if you do experience any. We will talk also about safety awareness; I will make recommendations to improve your safety at home and when you go out and about in the community.
Aerobic Capacity and Activity Tolerance: While keeping a careful eye on your vital signs and response to activity, I will help you improve your endurance in safe and comfortable ways. It may start as small as laps around the house, but I will help you progress over time, with a goal of getting you back to doing everything you were doing before.
Home Exercise Program and Discharge Planning: While we will work together on these areas during your Physical Therapy sessions, I will also be giving you work to do on your own. This will likely be a mix of walking, strengthening, stretching and balance activities and will be scaled to what you can do right now, then progressed as you can do more. When we finish with our course of therapy, I will make sure you have a program you can continue with on your own, or we can continue to work together on a Wellness basis ongoing.
Click here to learn more about our HAE/PT Covid-19 Action plan for infection control and patient safety.
If you have experienced Covid-19, but still don’t feel back to normal, please call or email to set up a phone consult or in-person evaluation so I can help you get better.
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the HAE series: the Cardiovascular system part III
In part III of the Cardiovascular system series, I want to look at the ways we can prevent or manage cardiovascular disease. But first, a few facts and figures:
Heart disease is the leading cause of death for both men and women, and across most ethnic and racial groups in the United States; 1 in 4 deaths is attributed to heart disease in America. Coronary Artery Disease is the most common type of cardiovascular disease and nearly 7% of adults over 20 are living with CAD.
The greatest risk factors for developing heart disease are high blood pressure, high cholesterol and smoking.
Other lifestyle factors that increase risk of developing heart disease include being overweight and obese, eating an unhealthy diet, being physically inactive and drinking excessive amounts of alcohol. Diabetes is another risk factor, and while not technically a lifestyle choice, risk of diabetes is modifiable through lifestyle modification.
In part III of the Cardiovascular system series, I want to look at the ways we can prevent or manage cardiovascular disease. But first, a few facts and figures:
Heart disease is the leading cause of death for both men and women, and across most ethnic and racial groups in the United States; 1 in 4 deaths is attributed to heart disease in America. Coronary Artery Disease is the most common type of cardiovascular disease and nearly 7% of adults over 20 are living with CAD.
The greatest risk factors for developing heart disease are high blood pressure, high cholesterol and smoking.
Other lifestyle factors that increase risk of developing heart disease include being overweight and obese, eating an unhealthy diet, being physically inactive and drinking excessive amounts of alcohol. Diabetes is another risk factor, and while not technically a lifestyle choice, risk of diabetes is modifiable through lifestyle modification.
I hope in reading these facts, you can quickly see not only why it’s so important to address any risk factors you may have, but also that it is in your power to make the choices that support cardiovascular health. The way you eat, live and move has the power to increase or decrease your chance of developing heart disease. Making changes in these same areas is also key in managing this disease if you are already living with it. Let’s look at each a little more closely.
The Way You Eat
Both what you eat and how much you eat can play a role in managing your risk of developing heart disease and/or managing it once you develop it. Try to balance your intake with your output; if you eat more calories then you burn during the day, the result is weight gain and this puts added strain on your heart. If you balance what you consume with energy expended, you should maintain your current weight and if you expend more than you take in, weight loss should occur.
Eating a diet full fruits and vegetables not only provides critical vitamins and minerals, but these foods are full of healthy fiber and low in calories. Try to eat a variety of fruits and vegetables, around 4-5 servings a day.
Avoiding added sugar and refined carbohydrates (white bread, pasta, cookies, cakes) is also key to managing heart disease. These foods increase systemic inflammation and lead to impaired insulin response, resulting in weight gain, slowed metabolism and increase risk of many diseases and disorders. Choose, instead, healthy whole grains and high-fiber starchy vegetables for your carbohydrates like 100% whole wheat bread, brown rice and sweet potatoes.
Make fish your friend. Fish, especially salmon and tuna, is full of omega-3 fatty acids, and you can only get omega-3 fatty acids from what you eat. They can also be found in flax seed, chia seeds and walnuts and along with their anti-inflammatory effects that help decrease cardiac risk, they are also essential for brain and eye health and function.
Lastly, choose heart-healthy fats. Fats can either be unsaturated (mono or polyunsaturated) or saturated (or trans fats). Unsaturated fats are typically liquid at room temperature and are essential for your body to run. They help with muscle function and make the messages move more quickly from your brain to the body. Research has shown consumption of plant-based monounsaturated fats in particular can lower your risk of cardiovascular disease and overall mortality. These fats include olive oil, avocados and avocado oil, and most seeds and nuts. Polyunsaturated fats are those that include omega-3 and omega-6 fatty acids and best choices for these include fish, flax seed, chia seeds, sunflower seeds and walnuts.
The Way You Move
Very simply, move more. The most basic recommendation from the American Heart Association is to perform at least 30 minutes of moderate physical activity on most days of the week. It is okay to break this activity into multiple bouts and it is great to get it done doing things you enjoy like walking, gardening and by participating in other active hobbies.
There are benefits of both aerobic exercise and strengthening activities. Participation in regular aerobic exercise improves cardiac circulation and decreases blood pressure, lowering the workload on the heart. It also improves the strength and tone of the cardiac muscle, allowing the heart to be more efficient, and able to pump the same amount of blood with at a lower heart rate. Aerobic exercise reduces cortisol levels in your blood stream; this lowers stress, reduces inflammation and better manages your mood and sleep patterns. It also raises the level of healthy, High Density Lipoproteins (HDL) and lowers the level of unhealthy Low Density Lipoproteins (LDL), improving cholesterol ratios and decreasing the risk of developing atherosclerosis. Lastly, regular exercise, and strengthening in particular, helps regulate insulin sensitivity and aides with weight loss and weight management. Maintaining a healthy weight lowers the strain in the heart and makes every day activities easier to perform with less effort.
HAE/PT can help you develop a fitness plan you can follow to become and stay physically active in ways that will have meaningful impact on your life - and reduce your risk of developing cardiovascular disease. If you are already living with heart disease, HAE/PT will work with you to create a program that will meet you where you are, that you can participate in safely, and that you can follow ongoing to mange your disease and prevent further complication. Click here to discuss your needs and set up a consultation.
The Way You Live
The greatest lifestyle factors you can change, after making healthy food choices and participating in regular exercise, come from avoiding the bad stuff. Smoking and excessive alcohol intake not only increase your risk of developing heart disease, but also of developing many other pathologies like COPD, liver failure and cancer. Cessation of smoking and moderation of alcohol intake is critical not only for heart health, but on your overall wellness. For more resources to support you in making these changes, check out SmokeFree.gov and Alcohol.org.
Lastly, if you are already living with cardiovascular disease, managing your health through adherence to your medication regimen, by regular communication with your medical team and awareness of the signs and symptoms that indicate you need emergent help are all key to staying healthy with CAD. Take any prescribed medications at the same time each day, and promptly if you realize you’ve forgotten. Be aware of side effects, interactions and always keep an updated list of your medications. Signs and symptoms that may indicate you need to visit the hospital for further assessment include anginal pain that does not resolve with nitroglycerin (3 doses or 15 minutes), sudden change in your heart rate or rhythm, shortness of breath or wheezing, feeling lightheaded or fainting or sudden and severe chest pain, left arm pain or nausea or vomiting. Be education also of signs of stroke, as this is also associated with cardiovascular disease. Use the acronym ‘FAST’ to help you remember; F is for facial drooping, A is for arm weakness, S is for speech difficulty and T is for time - always call 911 if you think you may be experiencing a heart attack or stroke as getting help quickly may be the difference between life or death.
Think you may be at risk of developing heart disease? You can use this calculator from the Mayo Clinic to find out. If you find that you are, I hope that you can use this guide to help you manage your risk, and contact HAE/PT to help you develop an individualized Wellness program to help you get on a path to better health today.
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the HAE series: the Cardiovascular system part II
Now that we’ve gotten through the basics (and if you missed it, you can read about it here), it’s time to look at what can go wrong within the cardiovascular system. First, there’s the changes we all experience due to normal aging. Decreased blood flow to the heart cells, fewer pacemaker cells and decreased cardiac elasticity will lead to decreased excitability (how easily the myocardium depolarizes to trigger a contraction), decreased maximum cardiac output and stroke volume (how much blood can be pumped out), less venous return (how much blood gets sent back), decreased maximum heart rate and increased resting blood pressure. Basically, the heart gets a little weaker, a little slower and a little less powerful over time.
Now that we’ve gotten through the basics (and if you missed it, you can read about it here), it’s time to look at what can go wrong within the cardiovascular system. First, there’s the changes we all experience due to normal aging. Decreased blood flow to the heart cells, fewer pacemaker cells and decreased cardiac elasticity will lead to decreased excitability (how easily the myocardium depolarizes to trigger a contraction), decreased maximum cardiac output and stroke volume (how much blood can be pumped out), less venous return (how much blood gets sent back), decreased maximum heart rate and increased resting blood pressure. Basically, the heart gets a little weaker, a little slower and a little less powerful over time.
There are also problems that can occur due to pathology. I like to look at these in three ways; problems with the Pump, problems with the Pulse and problems with the Periphery.
First, let’s talk about the Pump. As we reviewed in the Basics, the heart is responsible for pumping oxygenated blood from the left side of the heart to the body, and then returning deoxygenated blood into the right side of the heart to get sent back to the lungs. The heart relies on it’s myocardium - it’s thick muscular wall - to create this force, and when disease affects its strength or flexibility, the pump becomes less efficient. The most common disorders of cardiac efficiency include Coronary Artery Disease and Angina, Myocardial Infarction, Cardiomyopathy and Congestive Heart Failure. Lastly, there can also be issues in valve function, causing Valve Disorders.
Coronary Artery Disease (CAD)
40% of adults ages 65-74 experience Cardiac Artery Disease; 50% will develop it by age 75. Due to atherosclerosis, the coronary arteries can become narrow and, at times, blocked, causing impaired blood flow to the heart. What was once thought of as simple fat deposit problem, atherosclerosis is now understood to be an interaction between systemic inflammation and low-density-lipoprotein (LDL) cholesterol plaque that can build up in the intimal wall lining of cardiac blood vessels. This can cause periods of intense pain, called angina. While men typically describe angina as crushing chest pain, or pain down the left arm, women experience it more atypically. Some will have symptoms of gastrointestinal distress, others report dizziness, anxiety or jaw pain. Those experiencing anginal pain will consistently report, however, that it increases with exertion, emotions, extreme temperatures or after eating, and that it resolves with rest or after taking prescribed nitroglycerin. Nitroglycerin acts as a vasodilator; it makes the arteries transiently wider to allow more blood to flow to the heart. Should anginal pain not resolve after three doses of nitroglycerin, or the equivalent of fifteen minutes, it is time to call 911, as this may result in areas of myocardial cell death or myocardial infarction (heart attack!).
When conservative treatments become ineffective, or when atherosclerotic lesions cause more than 50% blockage (identified by cardiac catheterization), surgical management is often then considered. Catheter-based techniques to reduce plaque and restore blood flow are the least invasive option and typically include Percutaneous Transluminal Coronary Angioplasty (PTCA) or Percutaneous Coronary Intervention (PCI). Coronary Artery Bypass Grafting is an open-heart surgery during which the rib cage is open and a section of healthy vein (typically from the saphenous vein in the upper leg) is used to bypass the area of blockage within the coronary artery to restore blood flow to the heart. This procedure is typically more difficult to recover from and patients can expect to take up to twelve weeks to fully heal.
Myocardial Infarction (MI)
When blood flow is blocked long enough to an area of the heart, causing unmitigated ischemia, a myocardial infarction, or the infamous ‘Heart Attack,’ can develop. Typically, MIs will occur when a blood clot formed within the coronary arteries travels towards the heart and becomes lodged, blocking flow and cutting off blood to the the area of the heart it is supposed to perfuse. An MI can be small or catastrophic, and even ‘silent’ depending on the degree and location of the damage. These so-called ‘silent’ MIs make about a quarter of all cases, occur without any precipitating symptoms. If you have diabetes, you are at higher risk for these types of infarctions. Another quarter of cases will be catastrophic and the individual will die before reaching the hospital. Though there are risks of other complications from MI including later heart failure, blood clots or stroke, those who remain free of other problems within a few hours after the MI occurs have a good chance of full recovery.
The most effective way to reduce your risk of CAD and related sequelae (or mange your condition if you have already been diagnosed) is to reduce the demand on your heart. Managing your blood pressure, whether through medications or diet and exercise is the most important aspect of CAD care. Participating in regular aerobic exercise and conditioning decreases the strain on your heart not only through weight management, but by decreasing how much oxygen your body requires to function, making your musculoskeletal system more efficient. Addressing any other medical conditions, like hyperthyroidism, anemia or chronic hypoxia are also critical to address as these diagnoses in particular also cause strain on the heart. Certain lifestyle factors like smoking, stress and depression can also increase risk of CAD and should be addressed as part of your plan as well.
Cardiomyopathy/Congestive Heart Failure (CHF)
Uncontrolled CAD can eventually lead to Cardiomyopathy and Congestive Heart Failure. When the cardiac muscle becomes weaker and less efficient, blood pools within the cardiac chambers and stretches out the atria and ventricles. With this onset of cardiomyopathy, an over-stretched heart can begin to “fail” - or pump less effectively. Congestive Heart Failure is the most common reason for hospital admission in individuals over 65 years of age and can affect the left, the right or as it progresses, both sides of the heart, and can lead to problems with the filling (diastolic) or pumping (systolic) aspects of the cardiac cycle.
Left heart failure decreases the amount of blood send to the extremities, brain and visceral organs, and leads to impairments associated with decreased tissue perfusion - weakness, fatigue and decreased activity tolerance. If the blood backs up from the ventricle into the atria, it can wind up back into the lungs and can cause pulmonary edema. People experiencing pulmonary congestion typically complain of difficulty lying flat, waking up out of breath and frequent cough with frothy sputum. When the right side fails, blood flow backs up instead into the periphery. In this case, with the right heart pumping inefficiently, the right heart remains too full, and fluid backs up into the venous system, causing systemic edema - often in both legs, ankles and feet and occasionally into the abdomen. People may also experience gastrointestinal distress and weight loss.
Heart failure can be further classified as either systolic or diastolic. Systolic heart failure is more common than diastolic. In systolic heart failure, the heart isn’t able to contract as well due to the overstretched, thinning chambers, resulting in less blood pumped out with each heart beat. People in systolic heart failure will have a reduced ‘ejection fraction,’ a ratio that compares the amount of blood in the heart to the amount of blood pumped out. This value helps give a measure to how well the heart is pumping blood out. When a person experiences diastolic heart failure, the heart struggles to relax, due to thickened, stiffer cardiac chambers, preventing the heart from filling adequately during between beats. In these cases, the ejection fraction is preserved, as the heart isn’t filling well enough to change the ratio significantly. In healthy individuals, a normal ejection fraction is between 50-70%; in cases of borderline CHF, this ratio is reduced to 41-49% and symptoms may become noticeable with activity and in more advanced cases, the ejection fraction drops under 40% and symptoms may be now be noticeable at rest.
The goal of CHF management is to keep the system ‘compensated.’ By reducing salt intake, under 2000 mg/day, and taking medications like beta blockers, diuretics and other anti-hypertensive drugs, the workload on the heart can be reduced to slow progression of the disease. Daily monitoring of signs and symptoms can allow people with CHF to quickly identify signs of decompensation bring them to the attention of the medical team to address. Signs to beware of include sudden weight gain (increase in weight by 2-3 pounds over night or 5 pounds over the course of a few days), increased cough or trouble laying flat or unusual increase in fatigue.
Research has found both strength and aerobic conditioning to be beneficial in individuals with CHF. Participation in regular exercise has shown to improve activity tolerance and functional capacity and can increase energy levels. Regular exercise improves circulation and electrical stability and reduces the risk of death from CHF. It is important, however, to keep in mind you should not participate in exercise if you ever find your CHF has become ‘uncompensated’ and if you have developed any signs of exacerbation. You should always report changes to medical team immediatly and hold off on activity until your condition is more stable.
The American Heart Association also has some great information about CHF here.
Or, you can watch a video about CHF here.
Valve Disorders
Lastly, issues can arise within the valves. While the valves between the atria, the ventricles and the veins and arteries are designed to be one-way, opening upon pressure and closing upon release, abnormal stress from CAD and hypertension can cause wear and tear. Leaving valve to remain open longer, blood may flow backward through the cardiac system instead of forward, causing increased risk of clotting and stroke. Valves can either become stenotic and narrowed and slow flow to and from the chambers, or incompetent and weak, allowing blood to flow back into the chamber it just left. Valve disease results in cardiac hypertrophy, placing the heart at increased risk of cardiomyopathy and resulting heart failure. While many cases of valve dysfunction may be asymptomatic, some may experience fatigue or dizziness, fainting or irregular heart beats. Your doctor may pick up on valve dysfunction during regular auscultation when they hear a murmur and this condition will need to be monitored and potentially addressed surgically if the case is severe. Keeping a heart-healthy diet, regularly taking any prescribed blood-pressure medications and participating in regular physical activity are all ways you can prevent heart valve disease.
The next area of potential problem is the Pulse. As introduced in the Basics, the cardiac cycle relies on the heart beat; the SA node fires first, communicating to the AV node, and the Purkinje fibers then pass along this message across the mycoardium to initiate contraction. When a problem occurs, somewhere along this network, you may develop arrhythmias, or irregular heart beats. While the type of arrhythmia varies depending on where the beat initiates, or where the message is dropped, Atrial Fibrillation is both common and problematic.
Atrial Fibrillation and other Arrhythmias
3-5% of individuals will develop A-Fib after the age of 65, and this rate doubles with each decade following. A-Fib develops when the message to contract becomes chaotic along the atrium and results in quivering instead of sustained contraction. Your heart rate will feel fast and light - upwards from 100-150 beats per minute. People often experience a sensation of fluttering in their chest, lightheadedness with activity and fatigue when they are in a period of atrial fibrillation. This can put you at an increased risk of stroke as this pattern may result in clot formation. Clots become problematic when they enter the bloodstream and travel towards the brain.
Individuals with A-fib are usually on a rate-regulating medication to keep their heart rate regular; when these meds fail, and a person enters A-fib that does not resolve on it’s own, they may have to enter the hospital for a cardioversion procedure. Some people will remain in A-fib for periods intermittently, and remain on a blood thinner ongoing to reduce their risk of stroke. While participation in exercise may not improve this condition specifically, it can improve the conditions that place you at risk of developing it. A-fib can develop from hypertension or CAD - the risk of developing these conditions can be mediated with exercise. It may also be triggered by hyperthyroidism or exposure to stimulants like caffeine, tobacco, alcohol or certain medications. Regardless, it is safe to work at light to moderate levels if you have diagnosed A-fib, which will benefit you in many other ways.
Other common arrhythmias include Premature Ventricular Contractions (or PVC’s) which are fairly common and benign, and the more ominous Ventricular Tachycardia which requires emergent medical attention. Regardless, becoming familiar with your heart rate, and being able to identify change, is a good way to stay on top of your heart health. You can watch this video here about how to assess your own heart rate.
Pacemakers and Implantable Cardioverter Defibrillators
Conditions like CHF with bundle branch block, sick sinus syndrome (aging-associated degeneration of the sinoatrial node), or patients that have survived sudden cardiac arrest or MI may be candidates for pacemaker or IACD implantation. These devices may be rate-responsive, biventricular pacers or AV pacers and may be combined with an implantable cardiac defibrillator (ICD). They all act to optimize normal heart rhythm and ensure maximum heart rate, stroke volume and cardiac output are all maintained in response to exercise and activity.
Lastly, we will take a look at the how problems in the Periphery can affect the heart. The heart relies on a system of vessels, veins and arteries, to carry blood to, then from, each of the organs, muscles, bones and tissues that perform all of your daily essential functions. Arteries are vessels that leave from the heart and they bring oxygen-rich blood to the periphery. Oxygen is extracted at their terminal destination for the purpose of energy production, then deoxygenated blood returns transfers back into the venous system for transport back to the heart. Ever wondered why your veins are blue? Oxygen-rich blood is red, due to the bound hemoglobin, while oxygen-poor blood is blue.
Hypertension
When problems develop along the periphery, slowing down the flow, it can also affect the heart function due to the increased strain this puts on the heart. Blockages or narrowing in the arterial system makes forces the heart to compensate by either pumping harder or pumping faster. Increasing the blood pressure, this compensatory cardiac reaction, places the the body in a state of hypertension, which is a precursor for all sorts of other heart conditions. However, and fortunately, hypertension something we can mitigate through lifestyle modification and exercise. The system becomes hypertensive either due to increased blood volume (cardiac output) or due to a problem with flow (increased peripheral resistance). When the system has too much volume, generally due to increased salt intake or kidney dysfunction, the heart has to work that much harder to pump it out each cycle. When the system develops problems with flow, the heart must work against higher resistance to pump the blood through vascular network. Atherosclerosis within the arterial system affects the flow. With atherosclerosis (the same atherosclerotic process that affects the cardiac arteries we talked about before), the arteries become harder and more narrow. High stress levels, releasing catecholamines, also increases the tone in the arteries, making the pathway tighter and more resistant to flow.
Peripheral Artery Disease (PAD)
When atherosclerosis develops in non-cardiac arteries, you can develop Peripheral Artery Disease. The reduction in peripheral blood flow can cause painful and intermittent cramping in the legs, buttocks and calf, though two thirds of individuals with PAD do not experience these symptoms. The pain associated intermittent claudication (IC) is triggered by activity, when active use makes the muscles demand more oxygen, and will then resolve with rest. While treated with the same medications as hypertension, more advanced disease may necessitate surgery to bypass the affected arteries. However, and the exciting thing (for me, at least) is that they’ve found that exercise CAN BE AS effective at improving this pain as surgical options. Progressive walking programs, designed to push slightly into pain, have been found to improve oxygen uptake in surrounding tissues and decrease vessel tone, and as such, can delay onset of IC pain and improve the experience of PAD-related symptoms.
Deep Vein Thrombosis and Pulmonary Embolism
Lastly, problems can occur along periphery when clots form and break loose. When a clot forms, but remains in place, this is called a Deep Vein Thrombosis, or DVT. When it breaks loose, and travels to the lungs, it is called a Pulmonary Embolism, or PE. Clots can also form and break loose and travel elsewhere, and if they make it to the brain, can cause a stroke, or to the heart, a heart attack. Fortunately, lifestyle modification can reduce your chances of developing these conditions. DVT risk is higher among smokers, in people who are sedentary and when you don’t follow your prescribed medication regimen. Many people at risk for DVT, either due to chronic A-fib or temporarily due to immobility after surgery, are put on a blood thinner. While some blood thinners are prescribed at a consistent dosage, others require ongoing monitoring of your clothing factor, or INR. These types of medications (usually coumadin) will require dosage adjustments depending on this value, and your doctor, INR clinic or nurse will help you determine what this daily dosage should be.
Prevention and Management of Cardiovascular Disease
Now that I’ve probably got your heart racing in fear (tachycardia, if you want another new fancy cardiac word to learn), I want to get to the important stuff.
You. Have. The. Power. To. Decrease. Your. Chances. Of. Developing. Scary. Heart. Conditions.
Did I say that clearly enough? Yes, these are not just things you have to live with because you are getting older. These are things you can control. Read on to part III in the HAE Cardiovascular series to learn more.
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the HAE series: the Cardiovascular system part I
In starting this Healthy Aging Essentials Series, it makes sense to start at the top - with the one organ you can’t live without. Despite it’s incontrovertible importance, the heart is actually a pretty simple device. The heart is a pump. It plays two roles; it pumps out oxygenated blood to all the organs in the body, and then collects the deoxygenated blood back and routes it into the lungs to get reoxygenated before sending it out again. Let’s look closer at this process.
In starting this Healthy Aging Essentials Series, it makes sense to start at the top - with the one organ you can’t live without. Despite it’s incontrovertible importance, the heart is actually a pretty simple device. The heart is a pump. It plays two roles; it pumps out oxygenated blood to all the organs in the body, and then collects the deoxygenated blood back and routes it into the lungs to get reoxygenated before sending it out again. Let’s look closer at this process.
The heart is a muscle. In fact, it’s the hardest working muscle in the body, able to pump out at least 2,500 gallons of blood a day. It is broken up into two halves, and each half into two chambers, each chamber connected by a one-way valve. The left side of the heart is the side that sends the oxygen-rich blood out into the body. Oxygen-rich blood first enters the left atrium from the lungs via the pulmonary vein. When the atrium is full, it will contract, forcing the mitral valve to open, and blood to flow through into the left ventricle. The mitral valve then shuts, and the process repeats as the left ventricle then contracts, forcing the blood through the aortic valve, into the aorta and heads towards the rest of the body.
As your blood flows through your arteries and into your tissues and organs, oxygen is pulled out to fuel all your energy needs. Oxygen-poor blood then returns to your heart via your veins and ends up in either the inferior or superior vena cava. The vena cava veins empty the oxygen-poor blood into your right heart. It is your right heart's job to get the blood back to the lungs to be reoxygenated before returning to your left heart to be sent back out to your body again. Once the blood fills the right atrium, it contracts and sends the blood through the tricuspid valve into the right ventricle. Once full, the right ventricle now contracts and pumps blood through the pulmonic valve, into the pulmonary artery and into the lungs to get reoxygenated.
While this process is essentially simple plumbing, it also relies on a system of electrical impulses to initiate the contractions that pump the blood from right heart to the lungs, then from the left heart to the body. This network of nodes and fibers makes up the heart's conduction system.
The sinoatrial node (SA node) starts the party. This small bundle of cells in the right atrium triggers that first chamber to contract, sending the oxygen-poor blood from your right atrium into the right ventricle. It is the heart’s natural pacemaker; it is this impulse that sets your heartbeat and keeps you in a normal sinus rhythm when it fires regularly.
The atrioventricular node (AV node) is located in the center of the heart, between the right and left atria and the ventricles. It acts to slow the electrical signal before it hits the ventricles, giving the atria time to contract fully before the ventricles get the signal to do the same.
The Purkinje fibers are the ‘wires.’ They are responsible for translating the impulsive along the myocardial walls to trigger them to contract. Once they receive the message, that cycle, one heartbeat, is complete and the SA node fires again. Your healthy heart beats 50-100 times a minute. It can beat over three billion times over the course of your life.
To watch this system in action, check out this National Geographic video here.
Now that you understand how the healthy heart works, it’s time to look at some of some of the things that can happen over time when you age, and in states of pathology, when things go wrong in the HAE series: the Cardiovascular system part II.
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Ten Things I’ve Learned About Therapy That I Didn’t Learn in School
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Use your brain - literally. Use neuroplasticity to your favor. Learn about it, love it and make it a part of everything you do. To make change in the brain, you must perform activities intensely, repeatedly and specifically. They must have meaning to the person doing them. They must be specific; learning how to play basketball won’t make you a good swimmer. They must be intense; the typical ‘do a set of 10 ankle pumps’ isn’t doing anyone any favors. Activities must be performed in a way that provides challenge - if you aren’t working near the point of failure, neuroplastic change cannot occur. And the activities must occur repeatedly. This can be applied to every thing you do as a therapist, from strengthening, to functional mobility to balance reeducation. Turns out, practice does make perfect.
It’s not the hand you’re dealt, but how you play your cards. The most inspiring patients I’ve worked with have been those that remain positive and engaged in their lives despite facing the most challenging of circumstances. My years spent working neurorehab taught me that traumatic physical events don’t have end life as you know it, but it may be start of a new one. Yes, life will never be the same after such injury, but different can still be good. I love to be a part of that redirection - helping a patient start to look forward instead of back and focus on how their rehabilitation can help lay the groundwork for their new life.
Age means very little. I’ve met seventy year olds who look like they’re a hundred and centenarians who look (and act!) like they’re seventy. My favorite advice on living a long life came from one of my very oldest ladies: “Avoid men, and drink lots of white wine.” Another told me she has lived to be a hundred by reading the Smithsonian every day and highlighting the important facts. Then there are those who mistreat their bodies and are disabled by chronic illness quite young. Regardless, don’t judge a book by its cover - or a patient by their wrinkles. They may surprise you.
Educate. The average patient knows very little about the body they live in - from their ‘rotary cuff’ to their ‘prostrate’ gland. But knowledge is power. How can we expect them to take care of themselves without knowing why they need to in their first place. Being told to cut out salt to avoid CHF doesn’t mean much until you can understand why it causes volume overload. Who would work through the pain of ROM after a knee replacement if they don’t understand the process of healing and formation of scar tissue? Take the time to teach and it will pay off in dividends.
Ask the right questions. I can figure out what someone needs better through a carefully crafted subjective, than an hour of special tests. Asking if you’ve had any falls doesn’t tell you much. But asking where they happen, how they tend to land, how they were feeling before (and the 800 other questions I tend to ask) allows me to identify the patterns and then efficiently address the issue.
Learn everything you can from the people around you. Find a coworker, a mentor, or a PT community and suck all the knowledge you can out of them. Watch your colleagues work. Take note of their ideas and store them away in your toolbox. Read. Take classes. Never stop learning. I am sure I drove my professors and Clinical Instructors crazy with my non-stop questions, but I always got my money’s worth. If you find yourself in a rut, or using the same old exercise routine with patients, that’s the best time to take a class. Pre-kids, I took every class I could get the time off to take. My priorities changed for a while while they were little, but this forced Covid-sabbatical I’ve found myself on has given me the time and reason to start up again. I joined the APTA for the first time in years and signed up for my GCS exam. I’ve been ingesting Podcasts, online courses and journal articles nonstop. I haven’t been this excited to treat in years. If you every find yourself in a rut, make time to learn.
Go with your gut. Advocate for your patients. If something doesn’t seem right, chances are, it’s not. This can be anything from vital signs that make you nervous, a patient who ‘just seems off’ or a coworker who isn’t giving a patient what you think they need. Don’t just let it go, because it may be life or death for your patient. This is a competence I didn’t develop fully until I worked in home care. By nature, working in home care entails constantly triaging and independent decision-making. Sure, you can call a manager for advice, but at the end of the day, it’s your eyes, your hands and you have to make the call. Every time I send a patient out by ambulance, I apologize, but tell them I’d rather be safe than sorry, any day of the week, rehospitalization rate be damned. You may feel embarrassed the two of three times the patient ends up fine and gets sent home, but let me tell you, that third time it turns out to be a pulmonary embolism, you’ll never second guess yourself again.
Treat holistically. You’re treating a person, not an impairment or even a functional limitation. Their needs will always span past ROM, strength deficits or even pain. A lot of people just need to be heard. Many rarely find people who know how to listen without judging, or don’t want to burden their loved ones with their stress so they hold it all in. Others desperately need community referrals or education about their medical condition or any other list of non-PT activities you may find yourself doing. During home care visits, I’ve taken out trash, opened up stuck jars, looked up addresses on google - and more often than not, it’s these small things that are more helpful than even the most well planned session you can provide.
Talk to your patients. It’s the science that brings us here, but it’s the people who keep us around. You’ll learn amazing things from your patients. The oldest among them have seen things and experienced things that you can’t even fathom. They’ve bought houses for $5000 that are now worth half a million. They’ve met spouses at USO events and then went off to war. They’ve had babies at home. They’ve experienced unimaginable losses. They have stories that could be written into New York Bestsellers and they give amazing advice. One of my favorite questions to ask my older couples is what is their best advice for a successful marriage. My all-time favorite response came in very simple older gentleman who responded “just stay married.” Think on that one for a bit…
Don’t be afraid of change. I’ve always been the kind of person to keep a job forever - I literally held the same job from the age of eleven until I finished college. Straight out of graduate school, I took a job with the rehab hospital I had been interning for. Twelve years later, I’ve held six different positions between six different hospitals, skilled nursing facilities, outpatient centers, home health agencies and private practices. I would never have predicted this trajectory for myself, but between moves, and babies and life, this is where I’ve ended up. But the beauty with all of this change is that I’ve gained something special from each place I’ve worked. It is this mix of experiences that has made me the clinician I am today. I’ve gotten to see what life is like along the continuum for patients after they experience an illness or catastrophic event from the rehab to the discharge home to the transition back to community. I’ve learned from amazing mentors and colleagues and made friends and strong networks. I’ve developed a different set of skills to function in each setting, and had the ability to adapt these to benefit patients I treat in the next. I truly think the rich variety of experiences has made me a stronger therapist, a more mindful clinician and helped me be more empathetic to the patients with whom I work. The funny thing is, among all these travels, never once have I considered opening my own practice. I’ve been asked by friends and family if I’d ever considered it, and my answer has always been a staunch no (‘I want to work, come home and not deal with any extra stress I don’t have to.’) But, as we’re all too keenly aware, this year, the notorious 2020, has forced us all to take stock, assess our lives and make changes we never expected to have to make. Leaving my home health job of seven years was something I hadn’t even been considering. I love the work, I love the company, it worked well with my life and I honestly assumed I’d be there till I retired. But, with my needs at home taking priority, I found myself on extended leave, at home, ‘crisis schooling’ my kids. Ten weeks at home later, with nothing to do but think, sleep and watch Netflix, I found myself considering heading in a different direction. What if I could combine all the things I loved about treating in outpatient with all the things I loved about treating in home into one? What if I could do this on my own, fit the hours in around my family’s needs - and be able to work through the upcoming and very uncertain year? As you can imagine, the next thing I knew (and if you know me at all, I’m sure you can imagine because you know I’m a crazy person once I come up with an idea), I decided to launch HAE/PT and created a new plan for myself. So, long story short, without change, we can’t grow. Don’t be afraid of change - it’s a part of life, it’s definitely a part of being a PT and in closing, I’ll leave you with one of my favorite passages: “Will you be troubled by every passing wind, or will you be the calm in the storm?” By accepting change, you’ll not only be the calm, but you’ll be able to make it work to your advantage.