RESUMEN
BACKGROUND: A wide range of physical tests have been published for use in the assessment of musculoskeletal dysfunction in patients with headache. Which tests are used depends on a physiotherapist's clinical and scientific background as there is little guidance on the most clinically useful tests. OBJECTIVES: To identify which physical examination tests international experts in physiotherapy consider the most clinically useful for the assessment of patients with headache. DESIGN/METHODS: Delphi survey with pre-specified procedures based on a systematic search of the literature for physical examination tests proposed for the assessment of musculoskeletal dysfunction in patients with headache. RESULTS: Seventeen experts completed all three rounds of the survey. Fifteen tests were included in round one with eleven additional tests suggested by the experts. Finally eleven physical examination tests were considered clinically useful: manual joint palpation, the cranio-cervical flexion test, the cervical flexion-rotation test, active range of cervical movement, head forward position, trigger point palpation, muscle tests of the shoulder girdle, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, screening of the thoracic spine, and combined movement tests. CONCLUSIONS: Eleven tests are suggested as a minimum standard for the physical examination of musculoskeletal dysfunctions in patients with headache.
Asunto(s)
Cefalea/diagnóstico , Cefalea/fisiopatología , Dolor Musculoesquelético/diagnóstico , Dolor de Cuello/diagnóstico , Dolor de Cuello/fisiopatología , Examen Físico/normas , Adulto , Anciano , Anciano de 80 o más Años , Técnica Delphi , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fisioterapeutas , Encuestas y CuestionariosRESUMEN
The purpose was to identify risk factors for the two most common modes of death in chronic congestive heart failure (CHF) in 190 consecutive patients discharged with CHF. They were examined with clinical evaluation, blood chemistry, chest X-ray, exercise testing, echocardiography, isotope ventriculography and Holter monitoring. Mortality after one year was 21%, after two years 32%. Of 60 deaths, 33% were sudden and 49% due to pump failure. Multivariate analyses identified totally different risk factors for sudden death: ventricular tachycardia, S-sodium < or = 137 mmol/l, S-magnesium < or = 0.80 mmol/l, S-creatinine > 121 mumol/l, and maximal change in heart rate during exercise < or = 35/min. For death from progressive pump failure: New York Heart Association class 3 + 4, delta heart rate over 24 h < or = 50/min, low ejection fraction, high resting P-noradrenaline, S-urea > 7.6 mmol/l, S-potassium < 3.5 mmol/l, and maximal exercise duration < or = 4 min.
Asunto(s)
Muerte Súbita Cardíaca , Insuficiencia Cardíaca/diagnóstico , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
One hundred and ninety consecutive patients discharged with congestive heart failure were examined with clinical evaluation, blood chemistry, 24 h Holter monitoring, exercise test and radionuclide angiography. Median left ventricular ejection fraction was 0.30, 46% were in New York Heart Association class II and 44% in III. Total mortality after 1 year was 21%, after 2 years 32%. Of 60 deaths, 33% were sudden and 49% due to pump failure. Multivariate analyses identified totally different risk factors for sudden death: ventricular tachycardia, s-sodium < or = 137 mmol/l, s-magnesium < or = 0.80 mmol/l, s-creatinine > 121 mumol/l, and maximal change in heart rate during exercise < or = 35 min-1, and for death from progressive pump failure: New York Heart Association class III + IV, delta heart rate over 24 h < or = 50 min-1, low ejection fraction, high resting p-noradrenaline, s-urea > 7.6 mmol/l, s-potassium < 3.5 mmol/l, and maximal exercise duration < or = 4 min. In conclusion, this study demonstrated different risk factors for sudden death and for death from progressive pump failure.
Asunto(s)
Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/etiología , Insuficiencia Cardíaca , Adulto , Anciano , Arritmias Cardíacas/epidemiología , Causas de Muerte , Intervalos de Confianza , Bases de Datos Factuales , Dinamarca/epidemiología , Progresión de la Enfermedad , Electrocardiografía Ambulatoria , Prueba de Esfuerzo/efectos adversos , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Frecuencia Cardíaca/fisiología , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Estudios Prospectivos , Análisis de Regresión , Factores de Riesgo , Volumen Sistólico/fisiología , Análisis de SupervivenciaRESUMEN
The aim of the study was to evaluate the prognostic significance of clinical and echocardiographic data in patients referred for echocardiography in a retrospective analysis. Four hundred and fifty-six patients from a district hospital were studied. Survival after three years was 64%. Multivariate analysis identified five factors with independent prognostic information (relative risks of death are shown in brackets): left ventricular wall motion index (WMI) < or = 1.2 by echocardiography (2.5), status as in-patient (2.1), age > 65 years (1.7), clinical heart failure (1.9) and atrial fibrillation (1.5). When information on age, hospitalisation status, heart failure and heart rhythm had already been entered in the Cox model, echocardiographic results such as decreased WMI and dilated right ventricle still gave further prognostic information. We conclude that among conventional clinical and echocardiographic data WMI was the strongest predictor of long-term survival, and, despite prior knowledge of major clinical features, echocardiography provided further prognostic information.
Asunto(s)
Cardiopatías/diagnóstico por imagen , Adulto , Anciano , Ecocardiografía , Femenino , Cardiopatías/diagnóstico , Cardiopatías/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios RetrospectivosRESUMEN
Survival in 190 consecutive patients with congestive heart failure, discharged from a general hospital, was studied. Sixteen patients were in New York Heart Association (NYHA) class I, 87 in II, 83 in III and 4 in IV. Median left ventricular ejection fraction (LVEF) from radionuclide ventriculography was 0.30 (range 0.06-0.74). Two-year survival was 68%. Wall motion index was the only echocardiographic variable with significant, independent, prognostic information on survival. The 2-year survival in NYHA classes I and II was 90.7% for wall motion index > or = 1.3, and 78.6% when < 1.3. In classes III and IV survival was 68.9% for wall motion index > or = 1.3 and 39.9% when < 1.3. Addition of LVEF gave further information about survival. This study demonstrates that echocardiography is of great value in determining prognosis in congestive heart failure patients, and that wall motion index contains the majority of the information. Wall motion index is closely correlated to LVEF, however prognostication is improved when information about LVEF is added.
Asunto(s)
Imagen de Acumulación Sanguínea de Compuerta , Insuficiencia Cardíaca/diagnóstico por imagen , Adulto , Anciano , Enfermedad Crónica , Femenino , Insuficiencia Cardíaca/clasificación , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Volumen Sistólico , Análisis de Supervivencia , Ultrasonografía , Función Ventricular IzquierdaRESUMEN
Survival in congestive heart failure is related to plasma catecholamines and atrial natriuretic peptide at rest, but the prognostic importance of changes during exercise is unknown. The aim of this study was to evaluate the prognostic value of catecholamines and atrial natriuretic peptide at rest and during maximal exercise in congestive heart failure, and to compare it to clinical and exercise test variables and left ventricular ejection fraction. One hundred ninety consecutive patients (136 men and 54 women; median age, 66 years; range, 42-75 years) with clinically stable congestive heart failure were included. Sixteen patients were in New York Heart Association class I, 87 in class II, 83 in class III, and 4 in class IV. Left ventricular ejection fraction was 0.30 (range, 0.06-0.74). Total survival after 1 year was 79%, after 2 years, it was 68%. Prognostic variables at univariate analysis were: plasma noradrenaline at rest (P < .0001), plasma adrenaline at rest (P = .049), and atrial natriuretic peptide at rest (P = .016). During exercise, plasma catecholamines and plasma atrial natriuretic peptide increased significantly; the change, however, was not related to survival. Six variables carried significant, independent prognostic information in a multivariate analysis: left ventricular ejection fraction (P = .03), plasma noradrenaline at rest (P = .009), New York Heart Association class III + IV (P = .005), increase in heart rate during exercise < or = 35 min-1 (P < .0001), serum creatinine > 121 mumol/L (P = .004), and serum urea > 7.6 mmol/L (P = .007). Patients with congestive heart failure have a poor survival despite intensive medical treatment. Plasma catecholamines and plasma atrial natriuretic peptide are elevated at rest and rises further during exercise; the increase, however, is not related to mortality. Plasma noradrenaline at rest contributes with further prognostic information despite knowledge of clinical and exercise variables and was the only neurohormonal variable with independent, significant prognostic information on survival.
Asunto(s)
Factor Natriurético Atrial/sangre , Catecolaminas/sangre , Tolerancia al Ejercicio , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/fisiopatología , Renina/sangre , Volumen Sistólico , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Análisis de Regresión , Análisis de Supervivencia , Función Ventricular Izquierda/fisiologíaRESUMEN
We compared the change in left ventricular ejection fraction during rest and exercise in 14 patients with angina pectoris and 14 patients with silent ischaemia. All patients had ischaemia defined as reversible defects at an exercise thallium myocardial scintigraphy. In the patients with angina pectoris the ejection fraction decreased from 44.0% (+/- 1 SD 13.4) at rest to 39.5% (+/- 1 SD 11.2) during exercise (p = 0.044). In the patients with silent ischaemia the ejection fraction decreased from 43.5% (+/- 1 SD 14.0) to 39.8% (+/- 1 SD 13.9) (p = 0.045). The fall in left ventricular ejection fraction in the two groups was almost identical (p = 0.77). This study confirms with a sensitive detection of transient ischaemia that silent ischaemia is accompanied with a fall in ejection fraction during exercise.
Asunto(s)
Angina de Pecho/fisiopatología , Isquemia Miocárdica/fisiopatología , Función Ventricular Izquierda/fisiología , Adulto , Anciano , Angina de Pecho/complicaciones , Prueba de Esfuerzo , Humanos , Persona de Mediana Edad , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/diagnóstico por imagen , Ventriculografía con Radionúclidos , Volumen Sistólico , Radioisótopos de Talio , Factores de TiempoRESUMEN
The prognosis, and clinical findings related to prognosis, were examined in a consecutive series of 190 patients under 76 years of age (mean 64 years) with congestive heart failure (CHF). The aetiology of CHF was ischaemic heart disease in 66%, hypertension in 11% and cardiomyopathy in 23%. The 2-year mortality was 32%. Median left ventricular ejection fraction (LVEF) was 0.30, range 0.06 to 0.74. Eight per cent were in New York Heart Association (NYHA) class I, 46% in II, 44% in III and 2% in IV. Multivariate analysis, excluding exercise test variables, revealed seven variables with independent, significant prognostic information, (hazard ratios for death in brackets): ln (natural logarithm) (LVEF) (3.19), NYHA class III+IV (2.72), plasma urea > 7.6 mmol.l-1 (2.22), serum creatinine > 121 mumol.l-1 (2.05), serum sodium < or = 137 mmol.l-1 (2.03), pulmonary congestion on X-ray (1.86), and age > 65 years (1.86). Multivariate analysis, including exercise testing, showed the following variables to contain independent, significant prognostic information: increase in heart rate during maximal exercise < or = 35 min-1 (3.5), ln (LVEF) (3.7), serum creatinine > 121 mumol.l-1 (2.9), maximal exercise time < or = 4 min (2.3), serum sodium < or = 137 mmol.l-1 (2.5), ischaemic heart disease (2.0) and plasma urea > 7.6 mmol.l-1 (1.9). In conclusion, patients with CHF have a high risk of death despite intensive medical treatment. LVEF is a strong predictor of mortality. Both NYHA class and exercise variables have strong independent prognostic information as regards mortality in combination with LVEF, but are mutually exclusive.
Asunto(s)
Insuficiencia Cardíaca/fisiopatología , Función Ventricular Izquierda , Adulto , Anciano , Prueba de Esfuerzo , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios Prospectivos , Volumen Sistólico , Tasa de SupervivenciaRESUMEN
The purpose of the study described here was to study plasma immunoreactive Neuropeptide Y (NPY) at rest and during exercise in patients with congestive heart failure (CHF) and in healthy subjects. Thirty-five patients, mean age 64 years, with CHF in optimal treatment and with a mean ejection fraction of 32%, were studied at rest and during exercise. Twelve age and sex matched healthy subjects were compared for resting values. Another nine healthy subjects were studied at rest and during exercise at a constant low load of 75W and at a high load defined as 80% of their individual maximal capacity. In patients with congestive heart failure mean plasma immunoreactive NPY at rest was 10.3 pmol l-1 and was not significantly different from the control group. No differences between patients with slight and severe CHF were found and there was no correlation between plasma immunoreactive NPY and left ventricular ejection fraction. Mean maximal exercise time was on average 6.3 min. Only three patients exercised more than 10 min. At maximal exercise mean plasma immunoreactive NPY was 10.6 pmol l-1 the same as at rest. Plasma noradrenaline was increased in CHF patients compared to healthy subjects, and rose further during exercise. In healthy subjects plasma immunoreactive NPY rose significantly on both workloads, but more on the high load (p < 0.05), when the rise was first significant after 10 min. Plasma immunoreactive NPY at rest and during exercise was not increased in CHF patients in optimal medical treatment. Consequently plasma immunoreactive NPY is not a useful marker of the severity of CHF in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Ejercicio Físico/fisiología , Insuficiencia Cardíaca/sangre , Neuropéptido Y/sangre , Adulto , Anciano , Epinefrina/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Norepinefrina/sangre , DescansoRESUMEN
The aim of this study was to assess whether an interaction exists between the renin-angiotensin system and the sympathetic nervous system at the level of the adrenal medulla during insulin-induced hypoglycemia in normal humans. Seventeen healthy volunteers were studied in a randomized, single-dose, double-blind, cross-over fashion using 25 mg captopril v placebo followed by an intravenous injection of 0.15 IU/kg insulin. Blood samples were obtained before and at 15 min intervals after insulin injection. Both plasma glucose level and heart rate were identical during captopril and placebo at rest and after insulin. Plasma renin activity increased after insulin and captopril. The increase in plasma epinephrine was lower after insulin and captopril compared to after insulin and placebo. Likewise the increase in plasma norepinephrine was blunted on insulin and captopril. Thus, when the generation of angiotensin II was blocked by captopril the insulin-induced rise in epinephrine and norepinephrine was blunted. This indicates that an interaction exists between the renin-angiotensin system and the sympathoadrenal system.