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Cardiopulm Phys Ther J. 2008 December; 19(4): 123–141.
PMCID: PMC2845238

Abstracts of Platform & Poster Presentations

Platform Presentations

2008 December; 19(4): 123–141.


Purpose/Hypothesis: B-type natriuretic peptide (BNP) is a cardiac neurohormone produced and secreted by the ventricles in response to increased wall stress due to volume expansion and pressure overload. BNP has been shown to be elevated in proportion to the severity of heart failure (HF). Plasma levels of this peptide have been noted to increase with increasing New York Heart Association Classification (NYHA) and in patients with diminished left ventricular ejection fraction. The purpose of this preliminary study was to assess the effect of an exercise training program on plasma BNP levels over time in individuals with HF.

Number of Subjects: In this descriptive, prospective study, forty-two subjects (60 ± 13.8 years old) with HF were recruited to participate in the HEART CAMP study.

Materials/Methods: Participants were randomized into an Attention Control group (CON) or an Exercise intervention group (EX). Plasma BNP was obtained on all subjects at baseline. The EX group (12 men/10 women) attended cardiac rehabilitation for 3 weeks to rule out any significant arrhythmias or hemodynamic abnormalities associated with exercising. The EX subjects then attended the hospital fitness center where they were instructed in an individualized training program consisting of aerobic and resistance exercises. Participants continued their independent exercise program and attended one group education session a week. At 12 weeks, plasma BNP levels were obtained. Subjects continued their training programs for an additional 12 weeks independently. At 24 weeks, plasma BNP levels were again obtained. Subjects randomized to the CON group (12 men/8 women) attended weekly group meetings for the first 12 weeks and did not participate in any formal exercise programs. CON group subjects also had plasma BNP levels measured at 12 and 24 weeks. Complete data sets were obtained on 39 subjects for analysis. For this preliminary study, groups were compared at baseline and descriptive statistics were performed to assess trends in BNP levels.

Results: At baseline, there was no difference in plasma BNP levels between groups. We compared the percent change in BNP from baseline to assess trend changes in plasma BNP over time between subjects in the two arms of the study. Those in the CON group showed a mean increase in plasma BNP, from baseline, of +24.2% at 12 weeks and +44.3% at 24 weeks. Those in the EX group showed a mean decrease in plasma BNP from baseline of −8.1% at 12 weeks and −5.1% at 24 weeks.

Conclusions: In patients with HF, exercise training appears to have a positive impact towards maintaining or slightly decreasing BNP levels over 3-6 months, while non-exercising participants showed a trend towards increasing BNP levels, indicative of an increase in severity of their HF.

Clinical Relevance: These preliminary findings suggest exercise training has a beneficial effect, centrally, for individuals with HF based on alterations in plasma BNP levels. (Acknowledgement: This study was funded by a NIH, R-15 AREA Grant# 1 R15 NR009215-01)

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Blood flow regulation may be influenced by physical activity levels. For people post-stroke, a sedentary lifestyle and a lower metabolic demand may reduce blood flow to the hemiparetic lower limb. In previous work, we have found significant differences in resting femoral artery blood flow in the hemiparetic limb when compared to the less affected side. Therefore, we chose to use single limb exercise (SLE) as a training intervention to improve femoral artery blood flow and oxygen uptake in the hemiparetic limb. The purpose of this study was to describe the effect of SLE training on femoral artery blood flow and oxygen uptake in the hemiparetic limb post-stroke.

Number of Subjects: Five males (67.2 ± 14.5 years of age; 55.8 ± 41.3 months post-stroke) with mild to moderate stroke (lower extremity Fugl-Meyer score was 26.8 out of 34 ± 5.4) participated in the study.

Materials/Methods: Doppler ultrasound was used to obtain values for resting femoral artery blood flow at three time-points. Participants performed SLE training 3 times per week for 4 weeks using a Biodex System knee flexion/extension exercise protocol with a pace of 150 degrees per second at 40 repetitions per set. The protocol allowed for a self-paced progression to 40 sets with 30-second rest breaks in between each set. A metabolic cart was used to assess oxygen uptake during SLE at baseline and post-training. Statistical significance was set at alpha < 0.05.

Results: Using repeated measures ANOVA, we found significant improvements for femoral artery blood flow (p < 0.001) in the hemiparetic limb after SLE training. This resulted in a 40.0% increase in mean femoral artery blood flow (2822.5 mL·min−1 (baseline) and 3952.0 mL·min−1 after SLE. No significant increases (p = 0.41) were observed in femoral artery blood flow for the untrained limb. After the SLE training intervention, oxygen uptake was significantly lower (p = 0.03) during submaximal effort using the hemiparetic limb.

Conclusions: These data suggest that SLE improves cardiovascular function in hemiparetic lower extremity following stroke. We found during a steady state submaximal effort, the hemiparetic limb demonstrated improved efficiency through lower oxygen uptake values.

Clinical Relevance: Single limb exercise training using only the hemiparetic limb may be considered as an effective physical therapy intervention for people post-stroke to improve blood flow and oxygen uptake during tasks that require increased energy expenditure.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Physical therapists are routinely involved in the care of medically complex patients, and the benefits of early mobilization of such patients are increasingly recognized. One of the most fundamental therapeutic interventions utilized by physical therapists is active (AROM) and passive (PROM) range of motion (ROM). Despite therapists' routine use of these interventions, there are concerns regarding the safety of them. In patients with limited oxygen reserve, even PROM may present excessive physiological stress. Oxygen consumption (VO2) has been measured for a vast array of human activities in order to estimate energy expenditure during activity. From these values, metabolic equivalents (MET) for the activities have also been calculated. Surprisingly, there is limited information about the VO2 for AROM and PROM in adults across the lifespan and health spectrum. Therefore, the purpose of this preliminary study was to quantify VO2 for upper and lower extremity AROM and PROM in healthy adults. We hypothesized that VO2 during AROM would be significantly greater than during PROM, and that PROM would not differ from resting VO2.

Number of Subjects: 10 healthy, physiologically normal individuals between the ages of 27 and 58 years were recruited into this study.

Materials/Methods: Whole body VO2 was calculated using open-circuit spirometry throughout a 30-minute period that included five minutes each of upper extremity AROM (UEA), lower extremity AROM (LEA), a 5-minute rest, upper extremity PROM (UEP), lower extremity PROM (LEP), and a final 5-minute rest (R2). Activities were performed in a standardized sequence and manner for all subjects, and a metronome was used to maintain a steady movement rate in all conditions. Subjects were positioned in supine with the head on a pillow, and wore a non-rebreathing mask for continuous collection of expired gases. Repeated measures ANOVA were used to compare all conditions of VO2 (ml·kg·min−1) and R2.

Results: There was a significant effect of activity (p<.01), with all conditions differing significantly from each other (UEA 4.44±.09 ml·kg·min−1; LEA 6.15±.13 ml·kg·min−1; UEP 3.80±.08 ml·kg·min−1; LEP 4.10±.05 ml·kg·min−1; R2 3.65±.07 ml·kg·min−1; p<.01). In addition, METs were calculated for the ROM activities from VO2, with mean METs of UEA 1.7±.01; LEA 2.2±.06; UEP 1.5±.02; LEP 1.4±.02.

Conclusions: Both active and passive range of motion resulted in significant VO2 increases when compared to resting values. While the changes observed with healthy individuals represent minimal physiological stress, such increases in a patient with limited oxygen reserve may be meaningful.

Clinical Relevance: Changes in VO2 during AROM and PROM may challenge the oxygen reserve for medically complex individuals frequently treated by physical therapists. Quantification of VO2 in these populations would help therapists have a better understanding of the physiological stress imposed by routine exercises.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The popularity of interactive video dance gaming (IVDG), commonly known as “Dance Dance Revolution,” has grown tremendously. IVDG is an entertaining activity that requires individuals to move their feet on an interactive platform according to scrolling arrows on a video screen. This is done to the beat of music and there are many difficulty levels available to players. Studies have found that IVDG increases heart rate (HR) and energy expenditure to levels recommended by the American College of Sports Medicine. Reported benefits of regular IVDG participation include improved coordination, “feeling better,” improved sleep, and increased endurance. However, most studies have used children or adolescents as subjects, and there has been very little study regarding long-term health or wellness benefits of regular IVDG participation. The purpose of the study was to determine the effects of a 6-week IVDG program on participants' cardiovascular status, body mass index (BMI), and desire to continue an exercise program.

Number of Subjects: Participants between 30 and 65 years of age were recruited at a university campus. Twenty-eight individuals completed this study.

Materials/Methods: Pre-testing consisted of a submaximal VO2 treadmill test, and assessment of resting HR, blood pressure (BP), and BMI. Participants also completed a general health questionnaire. Thirty-minute IVDG sessions were offered 3 days per week for 6 weeks (18 sessions). Post-testing measures were identical to the pre-testing assessment.

Results: Repeated measure ANOVAs were used to compare pre-and post-testing measurements, and questionnaire data were manually coded and assessed. Participants attended an average of 13.5 sessions (75%). Significant differences were found for BMI (p=0.002), diastolic BP (p=0.018), and maximal VO2 achieved (p=0.018). Subjectively, 93% of participants reported enjoying the IVDG program and stated it was a “good workout.” Almost 90% stated that the IVDG program encouraged them to continue or start an exercise routine, 40% reported an improvement in sleep, and 43% stated they were considering or had already purchased a home version of IVDG.

Conclusions: This study is the first to report the benefits of an interactive video dance gaming exercise program exclusively in an adult population. The results indicate that a 6-week IVDG program is beneficial in decreasing BMI and diastolic BP, and increasing maximal VO2 as determined by submaximal testing. In addition, participants in this study reported enjoying the IVDG exercise and would continue with IVDG as a regular exercise program. IVDG is an effective and enjoyable exercise program for adults who wish to decrease their BMI and improve cardiovascular fitness.

Clinical Relevance: Adult fitness levels in the United States are declining; 66% of adults are overweight or obese, and 25% participate in no physical activity. Adherence to exercise programs is also poor. It is therefore important to find engaging and entertaining forms of exercise that adults will be inclined to continue on a long-term basis.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The Healthy Campus Campaign is an interdisciplinary initiative designed to develop partnerships and coalitions to increase physical activity and improve nutrition at an urban university community. The purpose of the initiative is to create environmental and policy changes combined with educational approaches based on a socioecological model to facilitate behavior change for a campus population and minimize the consequences of obesity.

Number of Subjects: Subjects included faculty, staff, and students from an urban Northeast United States university community.

Materials/Methods: A survey was developed to evaluate student, faculty, and staff perceptions of the campus environment with regards to a healthy lifestyle. Evaluations were also done by the investigators using the “Walkability Audit Tool” developed by the CDC, with additional questions to evaluate the “bikeability” of the campus. Coalitions were strategically developed to plan interventions, coordinate implementation of interventions and serve as ‘champions for change’ for the proposed environmental changes. Changes in nutrition and physical activity were measured through food volume purchasing data, self-report survey data, process evaluation, qualitative analysis of focus groups, stair usage, and bike share program data. Policy and environmental changes included point of decision prompts, media campaigns, stairwell improvements, and implementation of a bike share program.

Results: One hundred and forty-seven people (47 men and 100 women, 37% faculty or staff and 63% students) completed an online survey prior to implementation of interventions. Sixty percent of survey participants were classified as normal body weight based on body mass index (BMI, 18.5<BMI<25 kg/m2), while 40% were overweight or obese (BMI>25 kg/m2). Twenty-four percent report not participating in any aerobic-type activity, while 31% exercise 1 or 2 d/wk, 27% exercise 3 or 4 d/wk, and 18% exercise 5 or more d/wk. Forty-six percent reported usually using a personal car to travel between the North and South campuses, which are 5 miles apart and separated by the Merrimac River, while 24% use mass transit, 23% walk, and 1% use a bike to travel between campuses.

Conclusions: The results of the initial campus survey suggest the need for policies and programs designed to increase physical activity and improve dietary habits of the campus community. Changes in the campus environment to increase walking and biking as modes of transportation around and between campuses will be implemented over the next year, such as increasing attractiveness of stairwells, improving signage and making cross walks wider and well maintained.

Clinical Relevance: This study serves as a model for physical therapists, who are experts in human movement and function, to encourage physical activity and promote healthy communities through public education, policy and environmental changes.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Pulse oximetry has been the ideal method of measuring blood oxygen saturation and heart rate (HR) in physical therapy because it is known to be reliable, non-invasive and necessary to measure a patient's hemodynamic response to exercise. Motion is a key part of physical therapy treatment and can affect the accuracy of the pulse oximeter readings for HR. Motion sensitive technology has been integrated into pulse oximeters to improve the accuracy of HR and oxygen saturation readings; however, research has not examined the use of the pulse oximeters while ambulating with a wheeled walker. The purpose of this study is to determine which pulse oximeter technology (standard or motion sensitive) and which body location (ear lobe or finger) provided the most valid reading of HR when ambulating with a wheeled walker.

Number of Subjects: A convenience sample of thirty-four healthy able-bodied subjects (mean age ± SD, 20.68 yrs ± 0.61) participated in the study.

Materials/Methods: Subjects ambulated with a standard wheeled walker for two trials of 40 feet. Tape was placed between the walker's posterior legs to force the able-bodied subjects to lean weight into the walker. Each subject had a 4-lead telemetry electrocardiogram (ECG) unit to monitor HR while walking. For one trial, subjects had both pulse oximeters (standard and motion sensitive) on either the right or left ring finger, and for the second trial the pulse oximeters were on either ear lobe. HR readings from the ECG and two different pulse oximeters were collected at specified distances of 10, 20, and 30 feet with continuous ambulation. The HR readings from the pulse oximeters were compared to the ECG. Data collected from the pulse oximeters greater than 10 bpm different from the ECG were defined as false readings. A repeated measures ANOVA was used to determine if there was a significant difference between HR values for the two pulse oximeters and ECG. A Tukey post hoc analysis was completed if a significant difference existed.

Results: The data showed a significant difference between instruments (p<.0001, F = 8.775). The post hoc analysis revealed a difference between the ECG and the standard pulse oximeter (p<.0001) but not between the ECG and motion sensitive device (p<.125). The motion sensitive pulse oximeter on the ear revealed the least amount of false readings (14.7 %) while the standard pulse oximeter on the ear had the most (32.4 percent).

Conclusions: Results showed that the motion sensitive technology on the ear provided the most accurate HR readings and fewest false readings while the standard pulse oximeter on the ear had the most false readings.

Clinical Relevance: Accurate readings of heart rate and oxygen saturation are needed to provide safe, effective management of patients during activity. When using pulse oximeters, clinicians must consider the possibility of error, especially when motion is involved. Oxygen saturation readings from pulse oximeters cannot be accepted as accurate unless the heart rate reading closely correlates to the ECG or the radial pulse.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Because patients with cardiovascular disease (CVD) have a wide range of functional skills, it is often challenging to identify an outcome measure that is sensitive to change and has acceptable psychometric properties in this patient population. The Late Life Function and Disability Instrument (LLFDI) is a recently developed self-report outcome measure for older adults. It is administered in an interview format. The purpose of this study was to examine the concurrent validity of the LLFDI in patients with CVD and to evaluate the accuracy of information obtained from the LLFDI through questionnaire versus interview format.

Number of Subjects: This study included 32 volunteers who were patients participating in an outpatient cardiac rehabilitation program.

Materials/Methods: The Function Component of the LLFDI measures the degree of difficulty with 32 tasks and the Disability Components of the LLFDI consists of 16 items that measures frequency of participation and limitation in role activities. All items of the LLFDI use a 5-point ordinal scale with higher scores indicating better performance than lower scores. The LLFDI, Physical Activity Scale for the Elderly (PASE), RAND 36-Item Health Physical Function Subscale (RAND-36), and the London Handicap Scale (LHS) were given to study participants to complete in random order. Next, study participants completed performance-based tests (6 Minute Walk Test, Timed-Up-and-Go, Timed Sit-to-Stand, and fast / preferred walking speed) and the LLFDI a second time via interview. We used descriptive statistics, correlations, and t-tests to analyze the data (P < 0.05).

Results: All LLFDI components were significantly correlated (r = 0.36-0.83) with the PACE, RAND-36, and LHS. The Function Component of the LLFDI was significantly correlated (r = 0.56-.062) with the 6 Minute Walk Test, Timed-Up-and-Go, Walking Speed, and Timed Sit-to-Stand Test scores. The LLFDI demonstrated a ceiling effect (10%) only in the Disability Limitation component. All LLFDI component scores obtained via questionnaire were significantly correlated (r = 0.52-0.95) with scores obtained via interview. There was no significant difference between LLFDI scores obtained through questionnaire and those obtained through interview.

Conclusions: Results indicate that the LLFDI has acceptable validity with minimal ceiling or floor effect in patients with CVD. Findings suggest that this instrument can be independently completed in a questionnaire format rather than administered by clinicians in an interview format.

Clinical Relevance: The LLFDI is an appropriate outcome measure for patients with CVD that captures a wide range of abilities, can be administered via questionnaire, and has strong concurrent validity with other self-report instruments and performance-based outcome measures.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The purpose of this ongoing randomized clinical trial (RCT) is to investigate the impact of exercise counseling on muscular strength and exercise capacity in people with type 2 diabetes.

Number of Subjects: Participants meet diagnostic criteria for type 2 diabetes. A total of 26 people with type 2 diabetes have been assessed for eligibility, of which 4 people have been excluded. Eleven participants have been allocated to each group.

Materials/Methods: Participants are randomly allocated to a group who receives 8 weeks of exercise counseling (EC group) or a group who receives the same 8-week exercise program while being supervised in a laboratory (SE group). The EC group receives exercise counseling from a physical therapist based on the 5 A's strategy for health behavior counseling. The stage of exercise behavior is assessed using a reliable, valid questionnaire. Exercise counseling is tailored to the stage of exercise behavior. The EC group receives faceto-face exercise counseling at baseline and 4 weeks after baseline. At baseline, each participant in the EC group is provided a written copy of a prescribed resistance and aerobic training program consisting of training on 2 days per week for 8 weeks. The EC group also receives weekly exercise counseling phone calls. The EC group is provided daily access to a local fitness center. Muscular strength for each participant is assessed in kilograms (kg) using 1-repetition maximum testing of the chest press, row, and leg press exercises. Exercise capacity for each participant is assessed using a graded exercise test and is defined as the total duration (minutes) of the graded exercise test. An intention-to-treat analysis of the data will be performed. Parametric tests with an alpha level of 0.05 will be used to assess changes in outcomes within and between the groups.

Results: Preliminary results of this RCT are reported. One participant in the EC group withdrew from this RCT for reasons unrelated to this RCT. Baseline and follow-up data have been collected for 6 participants in the EC group and 7 participants in the SE group. Raw effect sizes of 38.67 kg for gain in muscular strength and 0.88 minutes for gain in exercise capacity have been found within the EC group. Within the SE group, raw effect sizes of 43.50 kg for gain in muscular strength and 1.73 minutes for gain in exercise capacity have been found.

Conclusions: Preliminary results indicate that either exercise counseling or supervised exercise can improve muscular strength and exercise capacity in people with type 2 diabetes.

Clinical Relevance: No research on the minimal clinically important difference in muscular strength and exercise capacity for people with type 2 diabetes exists. Yet, in people with type 2 diabetes, loss of muscular strength has been associated with loss of physical function and loss of exercise capacity has been related to mortality. This RCT is observing trends of gains in muscular strength and exercise capacity within the EC group and SE group, which may prevent complications of type 2 diabetes.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The purpose of this qualitative study was to explore factors that influence patient adherence to exercise, feelings about health and quality of life (QoL), and perceived activity limitations in patients recovering from coronary artery bypass (CAB) surgery.

Number of Subjects: Participants were 28 people aged 60 and older, prospectively recruited from two local hospitals following CAB surgery and prior to hospital discharge. Patients who were unable to understand English, living in an extended care facility, had significant cognitive deficits (Rancho level <6), or were non-ambulatory pre-CAB surgery were not included in the study.

Materials/Methods: Data collection took place by phone interview 12 months (± 1 week) after surgery. Participants were asked a series of open-ended questions related to their feelings about exercise, health and QoL, and perceived activity limitations. Responses were audio recorded, transcribed, and analyzed. Data were coded by identifying significant statements, grouping them into meaningful units or ‘themes,’ and generating rich, thick descriptions of participants' perceptions.

Results: The data revealed nine themes reflecting factors that facilitate exercise: physical health and well being, companionship, environment, enjoyment, a need to exercise, mental health and well being, habit, longevity, and recreation. Eight themes emerged concerning factors that discourage exercise: other commitments, physical health and well being, weather, mindset, lack of companionship, access, already active, and nothing specific. Feelings about health and QoL exposed five themes: feeling good, not feeling good, feeling about the same, healthy behaviors, and reflections on pre-surgical health. Finally, three themes emerged regarding perceptions of activity limitations: poor physical health, impact of aging, and no activity limitations.

Conclusions: Physical health and well-being and companionship were the two most commonly cited reasons for adhering to exercise. Poor physical health and having other commitments were the most common barriers to exercise. Health and QoL perceptions were most often positive, despite the fact that participants had undergone major cardiac surgery. A decline in physical health and the impact of aging were perceived as significant factors limiting activity.

Clinical Relevance: It is important that patients adopt exercise as a lifestyle behavior for secondary disease prevention following CAB surgery. The results of this study will give health care providers insight on patient's perceptions of factors that affect exercise adherence positively and negatively, feelings about health and QoL, and perceived activity limitations one year after CAB surgery. This information may allow educational strategies and treatment interventions to be directed more specifically to enhance exercise compliance and subsequently improve function and quality of life in this patient population.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Long-term complications of critical illness are common and include ICU-acquired weakness. Critical illness and sedative-induced immobility may be linked to poorer neuromuscular outcomes. We sought to determine the efficacy of pairing daily interruption of sedation (DIS) with early physical and occupational therapy (PT/OT) on functional outcomes.

Number of Subjects: One hundred and four patients undergoing sedation and mechanical ventilation (MV) were enrolled.

Materials/Methods: Medical ICU patients were screened daily to identify adults (≥18 years of age) undergoing MV for < 72 hours who met criteria for baseline functional independence (defined a priori as a Barthel index score > 70 collected from a proxy describing patient health two weeks prior to admission). Patients were excluded for the following reasons: rapidly evolving neuromuscular disease, admission after cardiopulmonary arrest, irreversible conditions with six month mortality estimated > 50%, elevated intracranial pressure, multiple absent limbs, or enrollment in another trial. A randomized, controlled study was completed. Patients were randomly assigned in a 1:1 manner to management with early PT/OT (Intervention) beginning on the day of enrollment or standard care with PT and/or OT delivered as referred by the primary team (Control). Patients in both Intervention and Control groups were managed by goal-directed sedation guided by the Richmond Agitation-Sedation Scale (RASS) and underwent daily interruption of sedatives and/or narcotics. Intervention patients (n=49) received exercise, progressive mobilization and ADL training by therapists during periods of DIS, which continued until functional independence or hospital discharge. The primary endpoint, return to independent functional status at hospital discharge, was defined as the ability to perform all activities of daily living as well as walking independently (all assessed by a therapist blinded to randomization). Secondary endpoints included the duration of delirium, ventilator-free days, and the following indices at hospital discharge: Barthel Index, number of independent ADLs and independent walk distance.

Results: The groups had similar baseline characteristics. Compared to control, intervention patients achieved greater functional independence (59.2% vs 34.5%, p=0.02) and walked further without assistance (110 ft [0, 300] vs. 0 ft [0, 100], p=0.004). Intervention patients had reduced ICU delirium (2.0 [0.0,6.0] vs. 4.0 days [2.0,8.0], p=0.02), and spent more days alive and breathing without assistance (23.5 [7.4, 25.6] vs. 21.1 [0, 23.8] ventilator free days, p=0.05), but no difference in hospital length of stay or mortality.

Conclusions: Early mobilization of patients undergoing MV via a protocol pairing DIS with early PT/OT demonstrates superior functional outcomes at hospital discharge and a reduction in the duration of delirium.

Clinical Relevance: Earlier implementation of PT/OT in patients undergoing sedation and MV should be considered for routine care.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Maximal inspiratory pressure (MIP), a measure of volitional inspiratory recruitment, is used to estimate inspiratory strength. Although MIP identifies the peak pressure generated during a maximal effort, it does not reflect the time required to generate pressure and is a poor predictor of weaning success. Thus we analyzed the role of pressure development in early inspiration as a potential training marker and indicator of weaning success. The primary objective of this study was to contrast training-induced changes in MIP to alterations in the pressure-time characteristics of sub-maximal inspiratory maneuvers. We hypothesized that rate of inspiratory pressure development would significantly increase following inspiratory muscle strength training (IMST), reflecting enhanced inspiratory power.

Number of Subjects: Seven adults who experienced prolonged mechanical ventilation consented to an IRB-approved clinical trial of IMST to facilitate ventilator weaning.

Materials/Methods: This trial examined the effect of IMST on pressure-velocity characteristics of sub-maximal inspiratory maneuvers. Subjects underwent IMST 5 days per week, for 28 days or until weaning occurred. Training occurred using a threshold device capable of delivering a 4 to 20 cm H2O inspiratory load. Subjects were briefly removed from the ventilator and completed 4 sets of 6 breaths, with the trainer set at the highest tolerated load. IMST was accompanied by daily progressive spontaneous breathing trials until ventilator weaning was achieved. Sub-maximal inspiratory maneuvers were tested using a 10-cm H2O threshold load, at baseline and on the day of weaning from the ventilator. The following measurements were obtained with a manometer, CO2SMO respiratory monitor and computer: maximal inspiratory pressure, rate of inspiratory pressure development, and pressure impulse. The data were analyzed with SPSS, and significance level established at 0.05.

Results: All patients weaned from the ventilator, and averaged 11 IMST sessions to wean. MIP significantly increased (pre: 52.6 ± 24.6 cm H2O, post: 64.9 ± 25.9 cm H2O, p<.05) in response to training. Pressure development significantly improved in the first 0.1 second (-3.94 ± 3.17 cmH20 vs −6.14± 3.97 cmH20, p<.01) and 0.2 second (−7.27 ± 2.64 cm H2O vs −8.85 ± 3.72 cm H2O, p<.05) of inspiration. In addition, the inspiratory pressure impulse significantly increased at 0.1 second (0.162 ± 0.122 vs 0.374 ± 0.303, p<.05) and 0.2 second (0.768 ± 0.426 vs 1.16 ± 0.620, p<.05). Post-IMST pressure development and MIP were strongly correlated (r=0.828, p<.05). Neither time to peak pressure (p=0.61) nor total inspiratory time (p=0.75) varied.

Conclusions: Upon weaning, patients demonstrated the greatest IMST-induced improvement with rate of pressure development, and additional gains with inspiratory strength and power.

Clinical Relevance: IMST may yield clinical benefit to people with respiratory muscle weakness, by generating improved pressure power during conditions of increased inspiratory work, and by improving the inspiratory phase of protective reflexes.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The purpose of this study is to establish interrater and intrarater reliability for chest wall expansion in apparently healthy adults ages 19-30. The secondary purpose of this study is to provide normative values to establish a standard protocol for evaluating chest wall expansion. There are no normative values currently defined to identify normal chest wall expansion.

Number of Subjects: Data was initially collected from 113 participants (63 females, 50 males). The participants included for data analysis (n=100; 55 females, 45 males) consisted of apparently healthy adults between the ages of 19-30 having no current or previous respiratory infection within the last month, who are not current smokers, have no obstructive or restrictive lung disorders, have had no recent injury or trauma to the thoracic region, and have a BMI under 30.

Materials/Methods: Participants' height and weight were assessed to determine BMI. Measurements of maximal inhalation and maximum exhalation were taken, in centimeters, around the circumference of the thoracic cavity at the level of the participant's third rib and xiphoid process; landmarks recommended by LaPier. The difference between the measurements of maximum inhalation and maximum exhalation at each level was calculated to determine 2 values of chest wall expansion. Two raters took 4 measurements on each participant; 2 measurements at the third rib and 2 measurements at the xiphoid process. SPSS version 12.0 was used for data analysis.

Results: The ICC values calculated for chest wall expansion for Rater 1 are ICC upper = 0.765, ICC lower = 0.860. The ICC values calculated for Rater 2 are ICC upper = 0.873, ICC lower = 0.925. SEMs approximated using ICCs for intrarater reliability for rater 1 were 0.580 cm and 0.357 cm for upper and lower chest expansion measurements, respectively. SEMs for rater 2 were 0.332 cm and 0.233 cm for upper and lower measurements, respectively. The results of ICCs calculated for interrater reliability were ICC upper = 0.073, ICC lower = 0.529. SEMs approximated using ICCs for interrater reliability were 1.275 cm for upper chest wall expansion and 0.898 cm for lower chest wall expansion measures, respectively.

Conclusions: This study suggests that, when measuring chest wall expansion, intrarater reliability is moderate to high and interrater reliability of measuring chest wall expansion is poor. Therefore, normative values were not able to be established from this study.

Clinical Relevance: The results of this study contradict inter-rater reliability results found by LaPier, who found interrater reliability to be high. Unlike LaPier's study, this study did not include the use of skin pencils to mark the reference landmarks, rather relied on palpation. Palpation to determine the location of measurements is more clinically applicable when a patient is measured for disease progression. Therefore, to ensure that progression measurements are reliable, the same clinician should consistently take the measurements.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Following cardiac surgery via mid-sternotomy, patients nationwide are advised to follow sternal wound precautions which may include limiting upper extremity lifting to 10 lbs or less, limiting shoulder elevation to 90° and restricting driving or being a passenger in a car with the potential for airbag deployment. The purpose of this study was to survey the compliance rates of sternal wound precautions and to determine the impact these precautions have on function and disability.

Number of Subjects: 50 male and female patients, over the age of 18, returning to our medical center for their postoperative visit following mid-sternotomy took part in this study.

Materials/Methods: 52 patients reporting for their 2-3 week post-operative clinic visit from October 2007 through June 2008, at times that were convenient for the investigators to be present, were approached to participate in this study. 50 patients agreed to complete the survey. Each questionnaire took 5-10 minutes to complete by self report. The questionnaire consisted of three main questions. Since discharge from the hospital: 1) Did you find it necessary to lift heavy objects? 2) Did you complete any activities that required you to reach overhead? 3) Did you drive or have you been been a passenger in a car seat with the possibility of airbag deployment? Each main question had a follow-up question that focused on the perceived functional limitations related to that sternal wound precaution.

Results: The majority of patients complied with the sternal wound precautions of lifting no more than 10 pounds (76%) and not driving a car (96%). Patients admitted to being a passenger in a car with the possibility of airbag deployment at a rate of 71%. Few patients (12%) refrained from lifting arms above horizontal. When asked about limitations to activities at home, 46% of respondents reported that they were either non-compliant with the sternal wound precaution of lifting or indicated that restricted lifting limited their function at home. With regards to limiting shoulder elevation above 90°, 96% of patients were not compliant or felt functionally limited. When asked about limitations outside of the home, 73% of patients were either non-compliant with restricting driving or being a passenger in a seat with airbag deployment or expressed a limited ability to access their community.

Conclusions: The majority of patients followed the precautions that restricted lifting more than 10 pounds and driving. The majority of patients did not follow the precautions for limiting range of motion or being a passenger in a car. Most patients asserted that sternal wound precautions limited their functional abilities within their home as well as limited their ability to access their community.

Clinical Relevance: According to the ICF definitions, postoperative sternal wound precautions has an effect on activity limitation (46%-96%) and a major effect on participation (73%).

2008 December; 19(4): 123–141.


Background & Purpose: Mediastinitis resulting in sternectomy is a potential complication of cardiothoracic surgery. Sternectomy involves partial or total debridement of the sternum to remove infected bone. Preoperative risk factors that may predispose patients to mediastinitis include: obesity, COPD, smoking, renal dysfunction, diabetes, PVD, age> 70, poor nutrition, CHF, pre-existing infection, tracheostomy, confusion, pre-op ICU stay, and LOS> 5 days. Little evidence regarding functional outcomes following sternectomy exists. The purpose of this case series is to describe the functional outcomes of 7 individuals with sternectomy.

Case Description: The records of 7 patients treated for sternectomy at a rehab hospital were reviewed retrospectively. Subjects were identified by ICD-9 and discharge disposition codes at the acute hospital. Patients included 6 males and 1 female ages 65-78 years (x=70.1). Information obtained from the medical charts included: age, pre-op risk factors, prior level of function, comorbidities, acute and rehab LOS, repair type, discharge disposition, and admit/discharge FIM. The following risk factors were excluded from analysis: nutrition, pre-existing infection, tracheostomy, and LOS> 5 days.

Outcomes: Patients had a mean acute LOS of 9.14±7.45 days; rehab LOS of 29.5 ± 12.05 days. Mean total admit FIM = 79.29; d/c= 104.43. Total mean FIM Δ during rehab stay =25.14 ± 2.97, and FIM Δ/day =1.05 ± 0.7. Other FIM Δ: mean motor FIM Δ 23.14 ± 3.67 with FIM Δ/day= 0.99 ± 0.73; self care FIM Δ 9.86 ± 2.85 with FIM Δ/day of 0.45 ± 0.38; mobility FIM Δ 5.86 ± 2.48 with FIM Δ/day of 0.21 ± 0.15; cognition FIM Δ 2 ± 2.52 with FIM Δ/day of 0.05 ± 0.08; locomotion FIM Δ 6.57 ± 2.07 with FIM Δ/day of 0.27 ± 0.19. Average categorical FIM gains for self-care, mobility, and locomotion were calculated to determine improvement in each area based on the number of items per category: self-care 1.97, mobility 1.95, and locomotion 3.2. Patients had a mean of 4.57 ± 1.51 out of 10 pre-op risk factors for developing sternectomy. Frequencies include: diabetes= 4, COPD= 4, Obesity= 5, smoker= 5, age > 70= 4, preoperative ICU stay= 1, confused/agitated= 1; renal dysfunction= 3; PVD= 1; CHF= 3.

Discussion: Patients requiring sternectomy following cardiothoracic surgery have an increased length of acute care and rehabilitation stay versus patients who do not have complications following surgery. Patients are able to make significant functional gains during rehabilitation, as evidenced by increases in FIM score. Greatest functional gains occurred in locomotion, followed by self-care, then mobility. Furthermore, all 7 patients discharged home following rehabilitation. Because this case series was limited to 7 patients, analysis of correlations between preoperative risk factors, LOS, type of surgical repair, medical events and functional outcomes is not possible. Recommendations for future studies would include a larger number of subjects to investigate these potential correlations as well as longitudinal analysis to evaluate long term impact of sternectomy on function.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The need for effective interventions aimed at preventing and reducing childhood obesity have become important as the prevalence of cardiovascular disease risk factors in children who are obese have reportedly increased. Effective interventions involve activity, education (nutrition & health), and parental involvement. This project was designed as a ‘best-practice’ model aimed at improving the overall wellness in children who are overweight. The model was derived from reported effective interventions and the apparent needs of the children in this region. The intervention and its outcomes are reported below.

Number of Subjects: Twenty-nine (29) elementary school-aged children (with BMI > 24) from the Northeast Arkansas region participated in the intervention and completed the pre & post battery of measures.

Materials/Methods: Multidisciplinary Intervention Design: Pre & Post anthropometric, physical performance, and vital/blood marker measures were taken (see results below). Children participated in the 16 week program which included one week pre-testing and one week post-testing. Children were required to participate 3 days per week. Two of these days were supervised & structured overall conditioning programs with an emphasis on cardiovascular fitness. One of the days was a flex day when children participated in various forms of activities. Parents were encouraged to use fitness facility in which program is housed and were required to attend at least one nutrition class per month (4 total). Pre & Post data were analyzed using paired-t tests with significance accepted at p<0.05.

Results: Cohort averages are reported as pre vs. post measures (mean, standard deviation), respectively. Anthropometric: BMI and 2-site skin fold body-fat estimate decreased (29.4 ± 2.8 vs. 27.1 ± 3.0) (43.7 ± 11.5 vs. 40.7 ± 10.9). Overall 6-site body circumference total did not change pre vs. post. A decrease in waist circumference (32.1 ± 2.6 vs. 31.4 ± 2.0) and an increase in calf circumference (13.4 ± 1.1 vs. 13.75 ± 1.1), thigh non-significant (p=0.054) trend increase (20.0 ± 1.9 vs. 20.5 ±, 1.5). Physical performance: HR after 3-min step test decreased (137 ± 20 vs. 126 ± 12). Push-up (1.0 ± 1.8 vs. 5.6 ± 3.8), sit-up (23.6 ± 12.7 vs. 33.2 ± 13.8), sit & reach (13.8 ± 3.0 vs. 16.6 ± 2.2) increased. Vital/Blood: Systolic BP increased (102 ± 10 vs. 108 ± 9). Glucose (90 ± 5 vs 87 ± 6), total cholesterol (179 ± 38 vs. 162 ± 30), ALT (41 ± 9 vs. 35 ± 8), bilirubin (0.36 ± 0.13 vs. 0.33 ± 0.12), and BUN (14 ± 3 vs. 12 ± 3) decreased.

Conclusions: Multidisciplinary interventions designed specifically for elementary-aged children who are overweight, or obese, that involve activity, education, and parental involvement can positively affect measures of fitness and health status in these children.

Clinical Relevance: Physical therapists, physicians, dieticians, exercise physiologists, and persons involved in health promotion can have a positive impact on the health and wellness of elementary-aged children who are overweight, or obese, through collaborative efforts and planned interventions which involve both the children and their parents.


2008 December; 19(4): 123–141.


Purpose/Hypothesis: Exercise and increased physical activity level are important lifestyle modifications for patients with cardiovascular disease (CVD). These positive lifestyle changes have many benefits for patients with CVD, including increased quality of life, and ability to carry out daily activities and live independently. Further, by adopting positive health behaviors like exercise, patients with heart disease can learn to manage their own health. The purpose of this study was to collect data on self-motivation, readiness for change, and adherence to exercise among patients with CVD.

Number of Subjects: Fifty-one patients hospitalized for a CVD-related diagnosis were prospectively recruited from a regional medical center. Patients who had undergone cardiac transplantation or ventricular assist device placement, had cardiac arrhythmia without a concurrent diagnosis of CVD or heart failure, were unable to understand English, or had significant cognitive deficits (Rancho level <6) were excluded from participating.

Materials/Methods: Each patient completed three self-report survey instruments: Self-Motivation Scale for Compliance, Change Readiness Assessment, and the Exercise Adherence Questionnaire. Study investigators obtained background information via chart review and history taking.

Results: Participants were predominantly Caucasian (96%) and men (64%), 65±11.5 (mean ± SD) years old with a BMI of 31±6.6. Most participants (63%) scored below the Self-Motivation Scale for Compliance threshold (scores <24 are highly suggestive of drop-out prone behavior). Results of the Change Readiness Assessment indicated that only one-third of subjects exercised regularly (action or maintenance stages of the model) while the majority of subjects (67%) were in the pre-contemplation, contemplation or preparation stages for adopting exercise as a positive health behavior change. However, responses to the Exercise Adherence Questionnaire revealed the following motivators for exercise: knowing it helps me be healthier (86%), and makes me feel better/have more energy (73%). Respondents also identified factors that might prevent them from exercising: often feel too fatigued/tired (47%), causes unpleasant sensation like shortness of breath or sweating (39%), lack of motivation (39%) and forget to do it regularly (35%).

Conclusions: Results suggest that participants hospitalized for CVD related conditions are aware of many common motivators for and benefits of exercise. Despite this finding, most respondents did not exercise regularly, and scored low on the compliance instrument suggesting they were likely to quit exercising if they did begin a routine.

Clinical Relevance: Physical therapists need to carefully consider factors that influence self-motivation, readiness for change, and adherence to exercise in order to effectively educate patients about the successful implementation and maintenance of an exercise program to reduce cardiac mortality and morbidity.

2008 December; 19(4): 123–141.


Background & Purpose: Ependymomas are the most common intrinsic spinal cord tumor, involving the cervical cord in 67% of cases. Treatment including tumor resection for cervical spine ependymomas can result in incomplete tetraplegia and possible diaphragm impairment. Most individuals with incomplete motor injuries recover the ability to ambulate. The purpose of this study is to present the challenge and outcomes of rehabilitation in a patient with incomplete tetraplegia and diaphragm paralysis after tumor resection. Preservation of lower extremity function combined with bilateral diaphragm paralysis is a rare complication, and has not previously been reported.

Case Description: Patient is a 61 year old male with incomplete tetraplegia due to C2-3 intramedullary tumor (ependymoma). Patient underwent tumor resection and C2-4 laminectomy. Two weeks following initial surgery the patient underwent surgical revision and duroplasty for cerebrospinal fluid leak. Post-operatively, the patient was dependent on a ventilator, had no diaphragm activity, and demonstrated weakness in all four extremities (upper extremities greater than lower extremities) and trunk. The patient's past medical history was significant for hypertension. The patient was treated in the acute hospital setting for 5 weeks followed by a total of 20 weeks of inpatient rehabilitation, and an 8 week out-patient program. Rehab stay was lengthy to facilitate respiratory muscle strengthening and ventilator weaning. This case study is a retrospective chart review. Serial data collected included physical and occupational therapy initial evaluations and progress notes, FIM, pulmonary function measures, chest X-ray, diagnostic ultrasound, and MRI.

Outcomes: After completion of a 20 week in-patient rehabilitation program, the patient was successfully weaned off of the ventilator, continued using CPAP at night, and only required supervision to minimal assistance for all mobility and ADL's at time of hospital discharge (FIM 6 in bed mobility, transfers, gait). The patient was able to participate in rehabilitation initially without any evidence of diaphragm activity (0/5), progressing to minimal diaphragm activity at time of hospital discharge (1/5) and it continued to improve during the out-patient rehabilitation program (2/5).

Discussion: This study showed that despite bilateral diaphragm paralysis and significantly compromised pulmonary function, a patient with incomplete tetraplegia could successfully progress with mobility and ADL's and return home with family without mechanical ventilation dependency. Individuals with spinal cord injury who require mechanical ventilation rarely are candidates for functional ambulation. By modifying therapy according to the patient's respiratory status, including aggressive positioning and airway clearance techniques, and balancing respiratory muscle fatigue with strengthening the accessory muscles of respiration, this patient was able to achieve a level of function beyond that which would be anticipated.

2008 December; 19(4): 123–141.


Background & Purpose: Parkinson Disease is a chronic, progressive and debilitating disease that is generally accompanied by impaired coordination, balance, and tone, which contribute to limited endurance and increased energy expenditure to perform daily activities. The purpose of this case report was to assess the outcomes of a 6 week endurance training program on endurance and quality of life (QoL) for a patient with Parkinson Disease.

Case Description: The patient is a 68 year old male with a 27 year hx of early onset Parkinson Disease. The pt. lives at home with his wife, is independent in ADLs/IADLs w/minimal assistance for toileting activities, relying on walls and furniture to ambulate in the home w/out a device, using a rolling walker for community walking. Patient has a hx of pneumonia and recent falls, chief c/o of increasing fatigue and limited endurance performing daily activities. Pt. participated in a weekly support group that included stretching and strengthening exercises. Meds remained constant throughout program. On assessment, pt. exhibited resting tremors, rigidity, bradykinesia, impaired coordination and balance, marked accessory breathing, elevated resting respiratory rate and dyspnea with low level activities. Assessment included a 6 minute walk test (6MWT) recording HR, BP, RR, dyspnea, O2 sat, VO2max and RPE. The Nottingham Quality of Life (NHP) was used to assess QoL. The endurance training program included: breathing strategies, cough production, spirometry, chest expansion exercises and graded ambulation on land and water. Patient and wife were instructed in energy conservation and self monitoring (RPE, dyspnea, MET levels, HR, signs/symptoms of distress). Pt. received in-clinic therapy 1-2x/week, 30-45 min/session for 3 weeks, augmented w/community/home sessions 1-2x/week, followed by 3 weeks of a self-directed program, videotaped for home use. A metronome was provided to self-monitor walking speed. A home visit was conducted at week 3 to assess home environment, with weekly phone calls and patient journals used to monitor progress.

Outcomes: Endurance improved as measured by an increase in 6MWT from 135 m to 325 m., calculated VO2max from 8.03 liters to 13.73 liters and O2 saturation from a low of 79% at minute 6 of initial 6MWT to 95-95% maintained throughout final 6MWT. The NHP did not show improvement, however, pt. and wife reported increased endurance and participation in community activities e.g. swimming for longer distances in pool. Discussion: Outcomes suggest a patient with long standing Parkinson Disease can benefit from an endurance training program, demonstrating decreased work of breathing and increased endurance in performing ADLs and IADLs. It is possible the NHP did not show an improvement as it has limited application to assessing change in endurance. The pt. was very motivated and compliant with his program, but progression was limited due to patient illness, natural disaster and family demands. Further research is needed to establish the relationship between endurance training and functional activity performance.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Exercise is important for patients with coronary heart disease (CHD) to prevent reoccurrence, treat, and manage the disease. Although exercise is a powerful therapeutic intervention, many barriers exist for patients to adopt and maintain this health promoting behavior. The presence of functional limitations and disability represents a barrier to exercise participation. Often, those individuals who could benefit most from exercise are least able, which creates a vicious cycle of deconditioning, activity restriction, and chronic disease. The purpose of this study was to identify and determine prevalence of specific functional limitations and disabilities in patients with CHD.

Number of Subjects: This study included 32 volunteers who were patients over the age of 50 years participating in an outpatient cardiac rehabilitation program.

Materials/Methods: We used the Late Life Function and Disability Instrument (LLFDI), a self-report outcome measure for older adults. The LLFDI measures degree of difficulty with 32 functional tasks and measures frequency of participation and degree of limitation in 16 role activities. We calculated response frequency for each item on the LLFDI.

Results: For the function section, greater than 50% of the study participants had difficulty with 15 out of 32 activities. Many study participants were unable to perform high intensity tasks such as a 1 mile brisk walk. Over half of the study participants had difficulty with some basic daily tasks such as going up and down 1 flight of stairs and standing up from a sofa. Also, greater than 50% of study participants felt limited in their ability to manage household responsibilities and take part in recreational activities. The 3 activities that study participants most commonly reported engaging in “very often” included: taking care of their own health, taking care of their own personal needs, and taking care of local errands.

Conclusions: The results suggest that even “functioning patients” with CHD experience difficulty with some basic and instrumental activities of daily living. Patients with functional limitations and disability may have barriers to exercise participation due to their activity restrictions. Patients recovering from an acute cardiac event may be particularly prone to activity restriction due to fear of physical activity and/or adverse disease related symptoms. Difficulty with functional activities may not only restrict activity participation, it may also be a precursor to loss of independence with functional activities.

Clinical Relevance: Identification and treatment of functional limitations and disability in patients with CHD may improve exercise adherence, increase habitual physical activity, and delay onset of dependence.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Physical therapists require accurate energy expenditure measures (EE) for basic mobility and self care activities to develop safe, effective rehabilitation protocols. However, current EE for activities commonly used in rehabilitation have primarily been estimated from similar movement patterns. Therefore, EE reliability for these activities is not known. This study measured EE during five activities commonly used in rehabilitation and compared measures to estimated values.

Number of Subjects: 28 apparently healthy adults, 4 males and 24 females, aged 18 to 35 years.

Materials/Methods: Baseline and activity EE was measured three times and then averaged. EE measures were obtained using open circuit spirometry by oxygen uptake analysis with Sensormedic's Vmax Spectra metabolic cart.

Results: Baseline EE was 3.07 milliliters per kilogram per minute (ml/kg/min). Highest EE (in ml/kg/min) were for donning a shirt (4.06 ± 0.96), brushing hair (4.13 ± 1.04), and donning a sock (4.21 ± 0.75); lowest EE were supine to sit transfers (3.66 ± 0.71), and sit to stand transfers (3.78 ± 0.76). EE measures in this study were significantly lower than published estimates for donning a shirt (4.06 ± 0.93 vs. 7.0 ml/kg/min) and brushing hair (4.13 ± 1.04 vs. 8.75 ml/kg/min). Of interest was that the highest EE (12.6 to 18.9 ml/kg/min) occurred within one minute following completion of the activities.

Conclusions: Study results suggest EE measures for basic mobility and self-care activities are different than estimated values. Moreover, the highest EE occured immediately following the activities, which represented a 2.3 to 3.5 times greater EE than any single activity.

Clinical Relevance: This study provides evidence for EE measures for five basic mobility and self care activities commonly used in rehabilitation. Further study of EE measures and patterns is recommended for individuals undergoing rehabilitation or who have chronic disease conditions to enable development of safe and effective rehabilitation protocols.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: High blood pressure affects nearly one in three American adults. According to the APTA's Vision 2020, physical therapists (PT) have an essential role in providing community-focused health and wellness education and programming. At health fairs, PTs may be the first line of care in screening for cardiovascular disease risk factors including hypertension. The skill of taking blood pressure (BP) is a standard component of PT education; however, obtaining accurate BPs and counseling individuals with abnormal BPs is an advanced skill requiring increased experience. The purpose of this study is to determine if a focused educational module on BP screening including education on prevention and risk factor reduction of hypertension will improve confidence and competence of 1st year DPT students participating in a health fair.

Number of Subjects: Thirty-one 1st year DPT students from Creighton University were recruited via flyers and verbal presentations.

Materials/Methods: After consent was given, students participated in a 2-hour educational program consisting of a lecture-based module focusing on etiology, prevention, and risk factors for hypertension, a small group discussion using case scenarios related to a health fair setting, and lab practice with individualized feedback for accurately taking blood pressures. A 10-question Likert scale was used to determine student's opinions about the role of PT in performing BP screening and to describe individual student's confidence level. Competence was assessed through a 10-question pre/post-quiz regarding didactic content and patient-based problem-solving. In addition, each student accurately performed 5 BP measurements with a minimum 75% pass rate in order to complete the educational session. Accuracy was measured as +/− 5 mmHg of systolic or diastolic BP measured simultaneously via dual stethoscope with an instructor.

Results: Students' confidence in accurately taking blood pressure and counseling individuals increased significantly (Mann Whitney U=205.83, z=-4.295, P=.001), while the students' attitudes about the PTs role in health fairs changed minimally (Mann Whitney U=425.25, z=-1.098, P=0.450). Change in competence measured by the pre-post quiz using paired t tests was not found to be statistically significant (p = .093). All students successfully obtained accurate blood pressure readings within +/− 5 mmHg on five different individuals.

Conclusions: This study demonstrates that a 2-hour focused, educational training session can increase the confidence and competence of 1st year DPT students. Recommendations for further study would include a follow-up longitudinal study of these students after applying these skills in an actual health fair, as well as comparing this educational model to others.

Clinical Relevance: As PTs and PT students continue to play a more active role in community health and wellness, especially in a health fair setting, being confident in the skill of accurately taking BP and competent in counseling the public is essential for our profession.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Roskell showed that physical therapists choose to not work in critical care settings because of: 1) fear-avoidance secondary to the high mortality rate in this patient population; 2) dissatisfaction with their professional skills and training related to working in a critical care unit; and 3) dissatisfaction with their professional skills and training related to responding to specific emergency medical procedures. The purpose of this pilot project was to determine if the use of high-fidelity human patient simulators would improve the confidence of physical therapy students related to some of the specific skills needed to work in critical care settings.

Number of Subjects: The subjects were 30 physical therapy students.

Materials/Methods: The students received their training for critical care settings as done in past years after which they completed a pilot survey instrument regarding their confidence related to those tasks/skills. The survey used a 5 point Likert scale. The students then completed 2 laboratory sessions utilizing high-fidelity human patient simulators. The simulators were used for case presentations of common emergencies in critical care settings. At the completion of the second lab the survey was completed again. Survey data taken before and after the simulation labs was analyzed using SPSS v15.0 and a Wilcoxon signed-ranks test for nonparametric data.

Results: Students reported a significant increase in their level of confidence for: taking blood pressure with an accuracy of ± 5 mm Hg; recognizing the signs and symptoms associated with a myocardial arrhythmia or developing myocardial infarction; recognizing the signs and symptoms that necessitate calling a “Code Blue” and how to respond when a “Code Blue” has been initiated.

Conclusions: The results of this pilot study suggests that high-fidelity human patient simulators can be used to increase the confidence of physical therapy students related to the tasks/skills required to work in a critical care setting. We believe that a similar format could be used to improve the confidence and willingness of physical therapists currently employed in other areas for work in critical care setting.

Clinical Relevance: Most physical therapy students never witness nor participate in recognizing and responding to a medical emergency. As a result the first time most physical therapists witness a medical emergency is after they have completed their formal training. We believe that we can use human patient simulators in a safe environment that increases the skills and confidence of physical therapy students and clinicians for work in critical care settings and for recognizing and responding to medical emergencies.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: To evaluate the influence of the Nike + iPod Sport Training Kit and standard pedometer use on fitness measures in a group of 7th grade students over a six month period.

Number of Subjects: Seventy-nine 7th grade students (12-13 yrs old) from two separate classes participated. The Nike + iPod class had 43 students (24 males & 19 females) and the control group (pedometers) class had 36 students (13 males & 23 females). A subgroup of 9-10 males from each class (n=19) also completed a lab based maximal aerobic test. A second subgroup of 8-10 females from each class (n=18) also completed a vertical jump height assessment.

Materials/Methods: Both classrooms received instructions about health/fitness and integrated the two training devices into their curriculum. All students participated in the 1.0 mile walk/run field test pre and post training to estimate VO2max. In addition, nineteen male students were assessed using a maximal aerobic treadmill test (SensorMedics, Yorba Linda, CA) and eighteen female students were assessed by measuring the maximum vertical jump height (based on their center of mass) of five trials using a force platform (Bertec Corporation, Columbus, OH). Independent t-tests and repeated measures analysis of variance tests were performed to evaluate estimated VO2 and peak vertical jump height pre and post training.

Results: Between groups there was no significant difference in baseline VO2max. Both groups demonstrated a significant improvement in estimated VO2max (baseline 40.9 ± 5.6 ml·kg−1min−1; post 43.6 ± 5.9 ml·kg−1min−1; p=0.004) over the six month period. There was a significant difference in the change VO2max value estimated from the field test between Nike + iPod and the pedometer group (Nike + iPod 2.1 ± 3.1 ml·kg−1min−1; pedometer 3.4 ± 2.7 ml·kg−1min−1; p=0.04). There was a significant difference between groups in improvement in VO2max for females (n=42; Nike + iPod 0.8 ± 2.4 ml·kg1min−1; pedometer 2.8 ± 2.9 ml·kg−1min−1; p=0.02) but not males (n= 37; p=0.15). There was no difference in change VO2max between groups for the subgroup males shown by the gas analysis (Nike + iPod 1.51 ± 3.1 ml·kg−1min−1; pedometer 3.0 ± 4.0 ml·kg−1min−1; p=0.39). There were no differences in muscle performance (vertical jump height) for the subgroup of females for pre/post (baseline 0.26 ± 0.04 m; post 0.27 ± 0.04 m; p=0.07) or improvement between groups (Nike + iPod 0.006 ± 0.4 m; pedometer 0.02 ± 0.2 m; p=0.06).

Conclusions: A school based physical activity program increased aerobic fitness in 7th graders. Females showed greater improvements in aerobic fitness using a pedometer over the Nike + iPod Sport training kit. Activity monitoring devices did not appear to improve muscle performance (vertical jump) over a six month period.

Clinical Relevance: Gender may be an important consideration when selecting an activity monitoring device to facilitate students to be more physically active.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: We sought to determine the feasibility and safety of early physical and occupational therapy (PT/OT) on patients undergoing mechanical ventilation.

Number of Subjects: 49 patients were enrolled; 46 actively participated in PT/OT.

Materials/Methods: Medical ICU patients were screened daily to identify adults (≥18 years of age) undergoing MV for < 72 hours who met criteria for baseline functional independence (defined a priori as a Barthel index score > 70 collected from a proxy describing patient health two weeks prior to admission). Patients were excluded for the following reasons: rapidly evolving neuromuscular disease, admission after cardiopulmonary arrest, irreversible conditions with six month mortality estimated > 50%, elevated intracranial pressure, multiple absent limbs, or enrollment in another trial. After daily interruption of sedation, the early mobilization group began PT/OT. Therapy was provided daily, progressing from sitting at the edge of the bed to higher level tasks (e.g. standing, transfers, activities of daily living, ambulation).

Results: The first day of PT/OT occurred earlier in the intervention group [1.4 (0.9, 1.8) vs. 7.8 (6.2, 12.4) days after intubation; p<0.001]. PT/OT occurred on 88% of MV days after enrollment. Days from intubation to milestones include: edge of bed 1.7 days (n = 45), chair transfer 3.1 days (n = 44), standing 3.2 days (n = 44), marching in place 3.3 days (n = 39), walking 3.8 days (n = 39), walking>100 feet 5.8 days (n = 32). Vasoactive infusions were ongoing during 22% of PT/OT sessions. Adverse events occurred during 16% of PT/OT sessions: desaturation (6%), tachycardia (4%), and ventilator asynchrony (4%) were most common. PT/OT was stopped as a result of adverse event in only 4% of sessions. Major adverse events were rare (zero extubations, falls, or SBP <90 or >200 mmHg; one arterial catheter removal, one desaturation <80%).

Conclusions: Patients undergoing mechanical ventilation can undergo very early PT/OT. Functional milestones (sitting in chair, completing ADL tasks, standing, and walking) are possible and safe during mechanical ventilation in the MICU.

Clinical Relevance: Critical illness often leads to severe deconditioning. Early PT/OT in patients undergoing mechanical ventilation in the medical intensive care unit has not been well described or studied. Our research shows that patients were able to participate in early physical and occupational therapy with few adverse events. Understanding the feasibility and safety of early therapy in patients who might otherwise become deconditioned may lead to change in practice and improved functional outcomes.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Obesity causes autonomic dysfunction which may result in reduced heart rate recovery (HRR) following exercise. There have been many reports indicating that abnormal HRR is related to mortality in subjects with and without cardiovascular disease. However, most studies have been conducted in subjects without confirmed patent coronary arteries (PCA), so that it was difficult to rule out whether the abnormal HRR is caused by atherosclerosis. We sought to determine whether obesity is associated with reduced HRR and possible influential factors in male subjects with angiographically PCA.

Number of Subjects: Patients who were suspected of having ischemia underwent a maximal exercise test and cardiac catheterization procedure. Analyses were based on 62 men who had reached 85% of age-predicted MHR and had confirmed PCA.

Materials/Methods: Subjects were divided into 3 groups according to their body mass index (BMI): NOR (BMI<24), OW (24≤BMI<27), and OB (BMI>27). HRR was defined as the difference between the MHR obtained during exercise and the HR at 1, 3, and 5 minutes after exercise stopped.

Results: One way repeated measures ANOVA was used to analyze the difference in HRR. Logistic analysis was performed to provide odds ratios (OR) and 95% confidence intervals (CI) of independent variables related to HRR. There were no differences in baseline characteristics. Subjects reached similar absolute work load but NOR reached higher percentage of age-predicted MHR when compared to OW and OB. No difference was found in HRR. In logistic regression analyses, the higher HRR1 was mostly associated with lower resting HR (OR 0.95, CI 0.91-0.98, p<0.001), and the same was found in HRR3 and HRR5.

Conclusions: In conclusion, there was no difference in HRR with different degrees of BMI in subjects with PCA. Resting HR was probably the most influential factor contributing to HRR.

Clinical Relevance: BMI as a measurement of obesity may not be sensitive enough to detect autonomic imbalance. BMI itself does not provide information about the location of fat distribution. It is also recommended that resting HR should be paid more attention because it is relevant to HRR.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: To compare the outcomes of a diabetes exercise training program using a combined aerobic and high-force eccentric resistance exercise to that of an aerobic only exercise program.

Number of Subjects: Fifteen participants with Type 2 diabetes mellitus (T2DM) participated in a 16 week exercise training program.

Materials/Methods: Seven (3 women, 4 men; mean age 50.7 ± 6.9 yrs, BMI 35.5 ± 6.0, HbA1c 7.1 ± 1.2) completed a combined aerobic and eccentric resistance exercise program (AE/RE); eight (4 women, 4 men; mean age 58.5 ± 6.2 yrs, BMI 32.3 ± 8.2, HbA1c 6.8 ± 2.1) completed an aerobic only exercise program (AE). Thigh lean tissue and intramuscular fat (IMF), glycosylated hemoglobin (HbA1c), BMI, and 6-minute walk (6MW) distance were compared within and between-groups pre and post training. Mean thigh lean tissue and IMF cross-sectional area (CSA) of the mid thigh region was quantified by magnetic resonance imaging.

Results: Both groups experienced a significant decrease (p=0.02) in mean A1c post-training, with no significant difference between groups (AE/RE mean within-group difference A1c −0.59% [95% CI −1.5–0.28], AE mean within-group difference A1c −0.31% [95% CI −0.60–−0.03]). There was a significant interaction (p<0.01) between group and time with respect to change in thigh lean CSA (mean between group difference = 20.4 cm2 [95% CI 13.2-27.7]). Both groups experienced a significant decrease (p<0.01) in mean thigh IMF CSA post-training with no statistical difference between groups (AE/RE mean thigh IMF CSA −115.3 cm2 [95% CI −257.1-26.4]; AE mean thigh IMF CSA −216.0 cm2 [95% CI −347.2–−84.7]). Both groups experienced a significant increase (p<0.01) in mean 6MW distance post-training, with no significant difference between groups (AE/RE mean 6MW distance 45.5 m [95% CI 7.5–83.6], AE mean 6MW distance 29.9 m [95% CI −7.7-67.5]). There was a significant interaction (p<0.01) between group and time with respect to change in BMI (mean between group difference = −2.1 kg/m2 [95% CI −3.4–−0.9]).

Conclusions: Significant improvements in long-term glycemic control, thigh composition, and physical performance were demonstrated in both groups after participating in a 16-week exercise program. Those who participated in a combined aerobic and lower extremity resistance-training program demonstrated additional increases in thigh lean tissue and decreases in BMI.

Clinical Relevance: There is a high prevalence of T2DM in physical therapy practice settings. Increases in thigh lean tissue may be important not only as a means to improve glucose control, but also to increase protein reserve, exercise tolerance, functional mobility, and to decrease fall risk.

2008 December; 19(4): 123–141.


Background & Purpose: Children worldwide carry between 15% and 20%, and even as much as 46% of their body weight in their backpacks. Recent literature has shown that heavy backpacks are associated with postural changes and changes in pulmonary function similar to restrictive lung disease. In restrictive lung disease, patients may have impaired inspiratory measures in pulmonary function tests, including decreased vital capacity (VC). Pascoe et al. demonstrated that carrying a backpack weighing 17% of body weight caused significant forward trunk lean in children. Li et al. showed a significant positive linear relationship between load weight, trunk inclination angle, and breathing frequency. Postural changes due to load carriage affect the efficiency of the diaphragm because of its attachment to the lumbar spine. D'Angelo and Agostoni found that lung volumes change with changes in posture. The purpose of this study was to describe the effects of weighted backpacks on trunk posture and the subsequent influence on respiratory function of two children.

Case Description: Two children, one female age 10 (subject M) and one male age 11 (subject K), participated in the study. Forced expiratory volume (FEV1), maximal inspiratory pressure (MIP), peak expiratory flow rate (PEF), chest wall excursion (CWE), incentive spirometry (IS) and forced vital capacity (FVC) were measured on both children at baseline and three backpack weights of 10%, 20%, and 30% of their body weight. Measurements were done in a random order for each testing condition. The children wore the backpack for two minutes while walking prior to testing and were given 10 minutes rest between conditions.

Outcomes: The two subjects demonstrated differences in the resulting respiratory measures. Subject M had an increase in inspiratory measures (MIP, Spirometry) and a decrease in expiratory (FEV1, PEF, and FVC) measures, while subject K had a decrease in inspiratory measures and a decrease in expiratory measures. There were also differences in the postural responses to the backpack load. Subject M demonstrated an observable lordosis with increasing backpack loads, whereas subject K demonstrated an observable forward lean of the trunk with cervical extension and forward head.

Discussion: Both children had observable postural changes with increasing backpack weights. However, each child's postural strategy for adapting to the increasing load was different. The position of the lumbar spine affects the position of the diaphragm thus altering its length-tension relationship and efficiency. The position of the diaphragm in each strategy may contribute to the different patterns in the values of the pulmonary function tests.

2008 December; 19(4): 123–141.


Purpose: Exercise is important for patients with coronary heart disease (CHD) to prevent reoccurrence, treat, and manage the disease. This health-promoting behavioral change has many benefits for patients with CHD. Although exercise is a powerful therapeutic intervention, many barriers exist for patients to adopt and maintain exercise. Successful implementation and maintenance of exercise requires that patients have skills for self-management. Patient education and exercise self-management skills can be provided using a variety of methods. Written materials are a common and feasible method to provide health education in a variety of settings, and should ideally be used in combination with other instructional techniques. Use of newer technologies may provide another method of delivering information to enhance patient self-management of CHD. For example, computer and Web-based instruction have emerged as educational strategies for the secondary prevention of CHD. However, to deliver education using these methods, patients must have access to and be competent using the requisite associated technology. The purpose of this project was to create a comprehensive patient education and exercise program for patients with CHD.

Description: Based on results from a previous study on availability of and confidence using technology within this patient population, the research team determined that providing a digital video disc (DVD) program was the most feasible as both an exercise mode and educational conduit. Patient education curriculum was selected, evaluated for suitability, and pilot tested with a small group of patients with CHD. The educational content of this DVD includes the following topics: CHD pathology and risk factors, self-monitoring, aerobic exercise prescription, exercise mode and equipment selection, footwear selection, relaxation techniques, environmental considerations, medication considerations, posture and body mechanics, weight control, and diabetes. The exercise component of this DVD includes stretching, strengthening, and aerobic exercises, each divided into beginner, intermediate, and advanced sections, allowing for individualization and progression of exercise.

Summary of Use: This video was designed to be used by patients either in the absence of, or ideally in conjunction with, a formal rehabilitation program. It provides information for patients to begin and sustain an exercise program safely and independently. The education modules can be used together or as individual sections, based on the patients' needs and interests. The exercise education sections also allow patients to review and reinforce information necessary for exercise self-management and improve self-efficacy for this behavior.

Importance to Members: This patient education and exercise DVD will be a useful resource for physical therapists working with patients who have CHD to facilitate home exercise programming and the transition to independent, lifelong exercise behaviors.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Exercise is an important health-promoting behavior for patients to adopt following coronary bypass (CAB) surgery. Self-efficacy for exercise is an important determinant for adoption and maintenance of this behavior. The purpose of this study was to longitudinally examine exercise self-efficacy in patients 3, 6, and 12 months following CAB surgery.

Number of Subjects: This study included 28 patients hospitalized following CAB surgery. Study participants were over 65 years of age, within 2 days of discharge, and able to understand English. Patients having concurrent heart valve replacements, new onset of stroke, or significant cognitive deficits were excluded from the study.

Materials/Methods: This prospective descriptive study used a sample of convenience recruited from a regional medical center. The Self-Efficacy for Exercise Behaviors (SEB) Scale was used to quantify patient perceived confidence in exercise participation. The SEB Scale is composed of 2 components, the first has 5 items related to resisting relapse to sedentary behaviors and the second had 6 items pertaining to making time for exercise. Patients responded using a 0-4 scale with 0 being not sure I could do it and 4 being sure I could do it. Higher scores on the SEB Scale indicate better self-efficacy than lower scores. The SEB Scale was administered to study participants via telephone interview at 3, 6, and 12 months following CAB. We analyzed data using descriptive statistics and single factor ANOVA. (P = 0.05)

Results: Study participants were predominately Caucasian (100%) and men (82%), 73±7 (Mean±SD) years old with a BMI of 28.1±2.6 kg/m2. Mean percentile scores on the SEB Scale were: Self-efficacy for Resisting Relapse at 3 mo 87%, 6 mo 85 %, and 12 mo 90 % and Self-efficacy for Making Time at 3 mo 81 %, 6 mo 83 %, and 12 mo 82 %. We found no significant difference between mean SEB Scale scores across time for study participants.

Conclusions: Patient self-efficacy for exercise remains relatively stable during the first year following CAB surgery. This suggests that patients with good self-efficacy for exercise 3 months following CAB maintain their confidence to exercise despite adverse conditions throughout the first year of recovery; conversely the opposite may be true also. Although mean SEB Scale scores for study participants were > 80% suggesting overall low risk for exercise nonadherence, a number of study participants did score below this threshold value.

Clinical Relevance: It is important to identify patients recovering from CAB surgery who have low exercise self-efficacy and are therefore less likely to adopt and maintain this health-promoting behavior. Physical therapists can identify and minimize exercise barriers related to functional limitations and thereby improve exercise self-efficacy in this patient population.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: The purpose was to summarize overall and demographic-specific data on COPD mortality and hospitalizations in Arizona, as well as trends over time. Physical therapists should understand the scope and burden of COPD in patients as a primary diagnosis and a co-morbid condition.

Number of Subjects: The subjects for this study were the 45 and older population in the state of Arizona.

Materials/Methods: COPD is defined as a preventable and treatable disease of progressive airflow limitation that is not fully reversible, and includes chronic bronchitis and emphysema. The ICD-9 codes for mortality data were 490-496 (Chronic lower respiratory diseases), and for hospitalizations was 491 (chronic bronchitis). The Arizona Health Status and Vital Statistics Report (mortality) and Hospital Inpatient Discharge Report (hospitalization) were obtained from the Arizona Department of Health Services, Division of Public Health Services. Population estimates (age, sex, race, and county-specific) came from the Arizona Department of Economic Security and were based on projections from the 2000 US Census. The age groups 45-64 and 65+ were utilized for age adjustment using 2000 US Census as the standard population. The results were analyzed by year for age, sex, race, and geographic area, to look for trends over time. Results: 1. COPD is the 3rd leading cause of death in Arizona with an age-adjusted mortality rate of 124.9/100,000 population in 2006. Hospitalizations for chronic bronchitis in 2006 were 297.2/100,000 population. 2. From 1999-2006, males had higher mortality rates than females. In 2006, the rates were 133.8/100,000 population and 117.6/100,000 population, respectively. In contrast to mortality, females had a higher hospitalization rate than males, with a crude rate of 317.0 compared to 286.0/100,000 population, respectively. 3. In 2006, Non-Hispanic Whites had a significantly higher mortality rate compared to all other racial/ethnic groups (age-adjusted rate of 141.7/100,000 population). Similar to mortality rates, Non-Hispanic Whites had the highest chronic bronchitis hospitalization rate. The crude rate for 2006 was 344.7/100,000 population. 4. From 1999-2006, the highest mortality rates were found in urban areas in Arizona, although the highest county rates were found in rural counties. The average age-adjusted rate for urban counties was 128.8/100,000 population, as compared to rural, at 121.8/100,000 population. In 2006, the rural counties had higher chronic bronchitis hospitalization rates (351.9/100,000 population) compared with urban counties (282.2/100,000 population).

Conclusions: COPD is a significant problem in Arizona. Understanding hospitalization and mortality rates at a single point in time as well as over time can help target prevention and treatment interventions.

Clinical Relevance: Increasing awareness of the scope of COPD as a primary diagnosis and a co-morbidity is beneficial for a physical therapist. By understanding the higher risk population, physical therapists can develop interventions for prevention and treatment.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Practice of yoga and meditation has been shown to reduce heart rate, blood pressure, respiratory rate and several other physiological measures. As the popularity of the complementary approach in medicine increases, physical therapists need to be aware of the potential advantages in using yoga and meditation as their clients become more open to complementary approaches. The purpose of this study was to determine the effects of yoga and meditation on the cardiopulmonary response to sympathetic stimulation in college-aged students.

Number of Subjects: 12 adults (mean age = 23.7; 4 male and 8 female) participated in this pilot study. All had a BMI of less than 35, and had no history of smoking, hypertension, arrhythmias, asthma and not exercised more than 3 times a week prior to entering the study. Six were included in the experimental group and the remaining 6 were in the control group.

Materials/Methods: The experimental group was taught a yogic breathing and meditation routine, while the control group was taught a warm-up/exercise routine. Both groups practiced their routine for 30 min each day (5 days/week) for 4 weeks. All participants were tested before starting the program and after 4 weeks of practicing their routine. Each testing session consisted of measuring heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen consumption (VO2) and carbon dioxide production (CO2) before and after 3 min of walking on a treadmill at a speed of 4 mph. In addition, the heart rate change during 3 min of walking on treadmill was measured. A self well-being inventory was given to each subject on the day of testing.

Results: The percentage increase in HR from resting levels decreased significantly during treadmill walking in both experimental (p<0.05) and control group (p<0.05) after 4 weeks of practice when compared to their respective pretest values. The percentage increase of systolic BP during treadmill walking decreased significantly (p<0.05) in the experimental group when compared to their pre-test values while no such changes were observed in the control group. Results also indicate that well-being inventory scores of the experimental group improved significantly (p<0.05) when compared to their pre-test values while no changes were observed in the control group. Our results do not show significant changes in RR, VO2, and CO2 in both experimental and control group after 4 weeks of practice schedule.

Conclusions: For the participant population, findings indicate that yogic breathing and meditation has a significant influence in reducing the sympathetic stimulation induced elevation of HR and systolic BP in college-aged students and improving the sense of well-being.

Clinical Relevance: Stress has the potential to alter physiological functions especially cardiovascular functions through increasing sympathetic activity. Based on this pilot study, it is apparent that the practice of yogic breathing and meditation may be beneficial in reducing cardiovascular changes during sympathetic stimulation especially in stressful situations.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Data from the World Health Organization indicate that people in Western cultures have a significantly higher risk of developing a thrombotic event than those in Asian cultures. This may be due in part to the habitual consumption of Natto, fermented soybean. Oral administration of an over-the-counter nutritional supplement, Nattokinase (NK), is purported to enhance circulatory parameters. There have been few studies examining the effect of the over-the-counter dosage of NK on various hematological factors. The purpose of this study is to examine changes in blood composition and flow related to exercise following supplementation with an over-the-counter dosage of NK.

Number of Subjects: Twenty healthy Azusa Pacific University graduate students participated in this study. They were without a history of vascular disorders, non-smokers and clear of any conditions which would prevent moderate intensity exercise using the APTA Outpatient History form.

Materials/Methods: Baseline blood parameters (hematocrit (Hct), hemoglobin (Hg), prothrombin time (PT), partial thromboplastin time (PTT)) as well as blood flow in the pedal artery (using the Titan Ultrasound Doppler by SonoSite) were measured at rest and immediately following a 20 minute moderate intensity exercise bout on the treadmill. Subjects then took two capsules/day (50 mg each) of Nattokinase (NK) for five consecutive days. Blood composition and flow parameters (vessel diameter, Time Average Mean (TAM) velocity, volume flow (VF), and Resistance Index (RI) were again measured at rest and following exercise.

Results: Both before and after Nattokinase supplementation, exercise resulted in a significant increase in the diameter of the pedal artery, the TAM velocity, and volume flow above baseline (p<0.01). The resistance index decreased (p<0.01) post exercise without, but not with, supplementation. Following Nattokinase supplementation, there was no significant difference in blood composition or clotting time. However, the velocity of flow (TAM) showed a significantly greater increase post exercise and throughout recovery compared to the response without supplementation.

Conclusions: Exercise resulted in a significant increase in velocity and volume blood flow, with and without Nattokinase supplementation. The increase in velocity was augmented and sustained following supplementation with NK. This increase is not associated with a change in the composition of blood, or clotting time. Further study is needed to confirm these results.

Clinical Relevance: Exercise increases volume blood flow and flow velocity in the distal lower extremities. This may provide an important benefit to patients with compromised circulation. The value of Nattokinase supplementation with exercise is unclear and requires further study.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: Adolescent obesity is prevalent in the US and can lead to a multitude of health problems. Most children spend 30% of their day at school. New Jersey (NJ) mandates 120 min of physical education (PE) class/wk. Some schools meet the mandate using blocks of time with and without PE class. Vocational high schools (VHS) often face a lack of adequate facilities for PE. The purpose of this study was to identify the effects of block scheduling of PE class on full-time NJ VHS students in a school without a gym.

Number of Subjects: 51 (28 males, 23 females) freshman VHS students in NJ participated in the study. A sub-group (n=17; 11 males, 6 females) of the students also participated in follow-up data collection.

Materials/Methods: 3 PE teachers were instructed by the researchers in a modified PE class of aerobic exercise, stretching, and strength training and strategies to accommodate for no gym. Data was collected in September at the start of the PE block including the Pediatric Quality of Life Scale Version 4.0 (QOL), the 1 mile walk/run, height, and weight. PE block consisted of PE classes 3x/wk for 90 min/class for 14-wks. Data was again collected in January at the end of the PE block. Follow up data for the sub-group was collected in June, 20 wks after the cessation of the PE block. Descriptive statistics, T-Test, and Wilcoxon signed rank test were used to analyze data.

Results: BMI was estimated from height and weight. VO2 max was estimated from the 1 mile walk/run. At the start of the PE block, mean BMI = 25.43 ± 6.43 kg/m2 indicating “at risk” for being overweight. After the PE Block: BMI (p=0.124) and QOL (p=0.494) did not change significantly; VO2 max decreased (p=0.003). For the sub-group, the prospective study found no significant changes in BMI, QOL, or VO2 max between September, January, and June. In September, the sub-group was 19% and 14% below standard fitness levels for adolescent males and females, respectively. In both January and June, they were 21% and 31% below standard fitness levels for adolescent males and females, respectively.

Conclusions: Students were initially found to be at risk for being overweight and below standard fitness levels. Despite modifications, 14-wks of PE class did not change BMI or QOL. A decline in VO2 max during this time may indicate students returned to school after active summer activities which could not be maintained through a block of PE classes. The prospective study sub-group did not change their BMI, VO2, or reported QOL. This group was below standard fitness levels for their age and gender throughout the year.

Clinical Relevance: Physical therapists can impact trends of increasing obesity through the promotion of health, wellness, and education. School is one venue to impact upon adolescent fitness levels. VHS students have special challenges often without access to gym facilities or convenient after school athletic programs. This study found block PE class, even with modifications, could not positively impact the fitness of VHS students. Future study is warranted to identify effective interventions for this “at risk” population.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: In addition to impaired aerobic endurance, musculoskeletal impairments are not uncommon in patients with cystic fibrosis (CF), including decreased skeletal muscle strength, flexibility, motor performance and bone mineral density. The benefits of aerobic exercise training (AT) and resistance exercise training (RT) in CF include increases in life expectancy, peak aerobic capacity, body mass, and quality of life. Although the benefits of exercise are known, little to no research has been done on: 1) exercise training during an inpatient stay for a CF exacerbation, 2) patients with lower FEV1 values, or 3) the efficacy of combined AT and RT. Thus, the purpose of our study is to determine if a standardized moderate-to-high intensity aerobic, resistive, and flexibility exercise training program is better than aerobic training alone for physical therapy management of a cystic fibrosis (CF) exacerbation during an inpatient hospital stay.

Number of Subjects: 18 of an anticipated 30.

Materials/Methods: Randomized controlled trial of patients ages 6-21, with an FEV1 < 60%, were admitted for a ≥ 10 day hospitalization for CF exacerbation. Experimental group received 1 hour of RT and flexibility training 3 days/week and 20-30 minutes of AT 2 days/week. Control group received “standard care,” which included 20-30 minutes of variable intensity AT 5 days/week. The modified shuttle test (MST) and multiple measures of peripheral muscle performance and length were assessed within 24 hours of admission and discharge.

Results: Data analysis included a matched, paired t-test. The experimental group had a significant improvement in MST distance (m) compared to the control group 168 (129) vs. 48 (104), respectively; p = 0.045. Pectoralis minor length and shoulder flexion also improved in the experimental vs. control group (p=0.032 and 0.064). There were improvements in upper and lower extremity and abdominal muscle performance in both groups between admission and discharge (p=0.022, 0.002, and 0.002, respectively), but there was no difference between groups. There was no difference in FEV1 between groups.

Conclusions: Despite the small sample size, a standardized, combined moderate-to-high intensity AT and RT protocol as part of the physical therapy plan of care resulted in dramatic improvements in aerobic capacity of children and adolescents hospitalized with a CF exacerbation. Shoulder muscle length also improved in this short time period. Short-term RT does not appear to improve muscle function using the measures we choose, but it may play a role in the improved aerobic capacity. Future studies should examine the role of combined AT and RT versus just AT.

Clinical Relevance: A combined moderate-to-high intensity aerobic and resistance training program, like that recommended for general fitness and wellness in healthy populations, but often not used in patients with chronic systemic disease, is effective in treating children and adolescents with CF.

2008 December; 19(4): 123–141.


Background & Purpose: Globally more than one million patients will be diagnosed with congestive heart failure (CHF) per year. This necessitates heart transplants and VAD placements to prolong and improve quality of life. A VAD is utilized as either an alternative-to-transplant (destination therapy) or as a bridge-to-transplant. The REMATCH Study Group reports a 48% decrease in mortality rates in patients diagnosed with CHF who have undergone VAD implantation due to ineligibility for heart transplant versus those who were medically managed. Morales et al. states that LVADs are successfully utilized as a bridge in nearly 70% of heart transplant candidates. Physical therapy (PT) is an integral part of improving functional status, overall recovery and return to independence in this expanding patient population. The purpose of this case review is to highlight the importance of PT for a complex patient requiring a LVAD (Heartmate II) and the process of overcoming barriers encountered during his 190 day hospital stay.

Case Description: Patient is a 37 year old male admitted to the cardiac care unit with CHF; co-morbidities included: cardiogenic shock, morbid obesity, mitral valve regurgitation, tricuspid valve regurgitation and decreased ejection fraction (EF). The patient underwent a tricuspid valve annuloplasty and implantation of a LVAD. His post-operative course was complicated by hemodynamic instability, prolonged intubation, bilateral metatarsal amputations, acute renal failure (ARF), gastrointestinal bleeding, multiple infections and pain. During his hospital stay, forty-two sessions of PT were provided to address these functional limitations: decreased balance, strength, endurance and poor functional mobility. Additional deficits of decreased pulmonary function and lack of education related to VAD management existed. Factors hindering the delivery of PT included patient's fear, lack of social support, lifestyle, varied schedules for hemodialysis (HD) and multiple interventions. Open lines of communication existed between PT and nursing for pain control. Patient's ability to participate was maximized by extensive communication between occupational therapy, speech language pathology, PT wound care, VAD team and PT. HD unit was contacted to facilitate scheduling PT visits at optimal times for this patient. Patient progressed from initially requiring maximal assist of 2 persons to perform bed mobility to being independently discharged home. This case review will highlight importance of collaboration and interdisciplinary teamwork to improve patient care.

Outcomes: At discharge, the patient's quality of life (QOL) had been increased by achieving the outcomes that included independent transfers, ambulation with a rolling walker, stair navigation, car transfers, VAD management, increased endurance and strength.

Discussion: Despite barriers encountered, patient was provided with physical therapy which allowed him to return to independent living including driving an automobile.

2008 December; 19(4): 123–141.


Purpose/Hypothesis: This study compares aerobic capacity and oxygen efficiency of active individuals with lower-limb amputation with age-matched sedentary individuals without amputation. Our hypothesis is that the fitness level in active individuals with lower-limb amputation is better than that of sedentary individuals without amputation.

Number of Subjects: Four subjects participated in the study and informed consent was obtained. One subject, who had nonvascular below-knee amputation and was walking with a cane and prosthesis, engaged in supervised fitness training over 8 weeks. Another subject, who had hip disarticulation and was walking with two axillary crutches, engaged in regular resistive exercises and aerobic exercise for over one year. Two age-matched individuals without amputation did not participate in regular exercises in the past.

Materials/Methods: Two one-hour testing sessions were conducted for each subject. The first session was used for collecting basic information, informed consent, and conducting health risk screening, a self-selected walking velocity test, and a six-minute walk test. The self-selected walking velocity was conducted on a 44-foot segment of hallway for 5 minutes with the average speed determined. For the six-minute walk test, subjects were instructed to walk as far as possible on a 150-foot segment of hallway according to the guidelines of the American Thoracic Society. The second testing session was for a 4-staged incremental (15, 25, 50, 75 watts) submaximal exercise via an arm-leg recumbent cycle ergometer with gas analysis (CPXD, Medgraphics, St. Paul. MN). Descriptive statistics were used for data analysis.

Results: The distance of the six-minute walk test was short in the two subjects with amputations when compared to that of the age-matched individuals without amputation. However, the oxygen consumption at each stage of submaximal exercise was lower in the subjects with amputation when compared to the data of the two age-matched individuals, which indicated better oxygen efficiency in the active subjects with amputations.

Conclusions: Regular fitness exercise in individuals with lower limb amputation is beneficial and could improve their efficiency of oxygen utilization. Results were limited due to a small sample size and should be substantiated in further studies.

Clinical Relevance: Regular fitness training programs are likely beneficial for individuals with lower-limb amputation. The training programs could be promoted in communities with aims to improve survival rates and quality of life in people with lower-limb amputations. Acknowledgement: We appreciated the funding support from the Research & Sponsored Programs of the Texas Woman's University.

Articles from Cardiopulmonary Physical Therapy Journal are provided here courtesy of Cardiopulmonary Physical Therapy Section of the American Physical Therapy Association