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Cardiopulm Phys Ther J. 2009 March; 20(1): 13–18.
PMCID: PMC2845259

Use of High Fidelity Human Simulation to Teach Physical Therapist Decision-Making Skills for the Intensive Care Setting

Michael J Shoemaker, PT, DPT, GCS,corresponding author1 Lena Riemersma, PT, MPT,1 and Ron Perkins, BSN, RN2

Abstract

Introduction and Purpose: There is a paucity of discussion in the professional literature about the use of high fidelity human simulation (HFHS) as a teaching intervention in physical therapist educational programs. Therefore, the purpose of this paper is to provide an example of the design and use of high fidelity human simulation (HFHS) to facilitate teaching of cardiopulmonary and intensive care concepts in a physical therapist education program. Case Description: HFHS was used at the end of the fourth of 9 semesters in a Doctor of Physical Therapy program. An intensive care unit case scenario was developed that required students to perform procedural skills and apply biomedical knowledge/concepts to clinical decision-making during simulated patient mobilization. Outcomes: Students successfully completed the HFHS session objectives, though there was variability in how quickly they recognized and responded to alarms and changes in patient status. Psychomotor performance of skills was generally correct but awkward, consistent with novice performance. Students were universally positive about HFHS as a teaching strategy for preparing for an acute care clinical education experience. Discussion: One session using HFHS as a laboratory activity may have a substantial impact on students' perceptions and confidence prior to entering an acute care clinical experience. Physical therapist educational programs with access to HFHS resources should consider its incorporation into cardiopulmonary or acute care content. Given the high cost of acquiring and maintaining HFHS resources, programs without such resources should carefully consider the extent to which they would use HFHS in their curricula.

INTRODUCTION AND PURPOSE

The ultimate goal of physical therapist education is to train students to be clinicians. This requires students to possess an extensive, diverse set of theoretical knowledge, practical knowledge, and procedural skills. Perhaps one of the greatest challenges faculty must address is how to best facilitate students' abilities to transfer and apply knowledge to clinical settings. This is the primary reason that a substantial portion of physical therapist education is devoted to clinical education. However, a common anxiety expressed by students and echoed by clinical instructors is whether students are sufficiently prepared to begin a clinical education experience in a particular setting. This can be due to several factors, including where in the curriculum the clinical experience occurs relative to the theoretical and practical content necessary for that setting. However, this can also be due to difficulty in a student's ability to use his or her knowledge in a clinically meaningful and relevant manner. Patel and Kaufman1 provide a detailed analysis of the possible reasons for this difficulty. Chief among these reasons is that didactic material that does not emphasize clinical reasoning may prohibit the use of biomedical concepts to support clinical reasoning.1 Furthermore, they state that basic science “does not provide the axioms, the analogies, or the abstractions required to support clinical problem solving.” Thus, they argue, theoretical (biomedical) information should be presented in applied clinical problem contexts where students can be allowed “to derive the appropriate abstractions and generalizations to further develop their models of conceptualization.” For example, a student may have learned that electrolyte imbalances such as hypokalemia can have various manifestations including cardiac arrhythmia and muscle cramping. They may also have learned that diuretic medications can cause hypokalemia. However, if the student clinician has recently initiated an exercise program with a patient with heart failure, he or she may inappropriately explain any muscle symptoms as being associated with exercise, instead of considering the patient's diagnosis, medical therapy, and the associated side effects. However, if the student had the opportunity to encounter a similar context through case study, live patient simulation, actual experience, or some other clinically applied learning opportunity, the student might have been able to consider a much broader range of possible explanations for the patient's complaints. Thus, physical therapist education programs should challenge students to apply and use newly-gained biomedical knowledge in a clinical context.

Cardiovascular and pulmonary physical therapy is an area of practice that relies heavily on biomedical knowledge. Teaching interventions that help students organize and access this knowledge in a clinically relevant manner include the use of paper-based cases, standardized patients, and simulations using human patient simulators. It is our observation that students generally have the greatest difficulty assimilating to the acute care setting, particularly when this clinical rotation occurs earlier in the curriculum. This difficulty is compounded when the student is introduced to the intensive care unit (ICU) setting. The ICU poses numerous challenges to students, including the physiologic instability of patients, involvement of multiple physiologic systems, the need for close monitoring of physiologic responses to movement and other physical therapy interventions, and the number and complexity of invasive and noninvasive monitoring and interventional devices (chest tube, feeding tube, electrocardiogram leads, tracheostomy tube with ventilator circuit, arterial line, etc).

High fidelity human simulation (HFHS) mannequins such as Laerdal's SimMan™ (Laerdal Medical Coporation, Wappingers Falls, NY) or METI's Human Patient Simulator™ (Medical Education Technologies, Inc., Sarasota, Fla) allow students to practice procedural and decision-making skills within a realistic, dynamic clinical environment.2 These human patient simulators are able to simulate real-time changes in heart rate, blood pressure, oxygen saturation, respiratory rate, heart rhythm, and pulmonary artery pressures. Additionally, many clinical examination findings such as pulses, heart sounds, and lung sounds can also be simulated. High fidelity human simulation mannequins can also have a number of invasive and noninvasive monitoring and interventional devices attached. The extensive amount of clinical data and simulated examination findings can be manipulated in real-time according to the circumstances of the clinical scenario, allowing for a dynamic interaction between the student clinician and the simulated patient whereby the student can observe the results of his or her decision-making and be required to respond appropriately. With respect to the use of HFHS in physical therapist education programs, there perhaps is no better setting than the ICU.

Use of simulation has long been used in the aviation industry to facilitate decision-making in emergency situations.35 The use of simulation in health care was first used to assist in teaching anesthesiologists in the early 1990s,6,7 and has subsequently been used in many other health professions. The goal is to provide students a context in which clinical decision-making and procedural skills can be practiced without risk to actual patients.8 Regarding the preparation of nursing students, Henneman et al9 suggest that “students' experiences in simulated environments translate into a heightened awareness of patient safety issues in clinical settings.” Preparation for the ICU clinical setting may also be enhanced by simulations that emphasize a team approach to care and the interaction among various disciplines.1012

Regarding the efficacy of simulation in the education and training of health professionals, outcomes can be evaluated at a number of different levels: knowledge, skill performance, learner satisfaction, critical thinking, and self-confidence.2 Few studies have examined the efficacy of simulation-based training compared to traditional instructional/training methods,1315 and no studies to our knowledge have examined its efficacy in physical therapist education. Rosenthal et al13 demonstrated equal efficacy of simulation-based training for airway emergency management skills compared to training with an expert attending physician. Abrahamson, Denson, and Wolf14 demonstrated a decrease in time required to become proficient with endotracheal intubation. Tan et al15 demonstrated enhanced performance on a knowledge test of key physiology concepts in first-year medical students. Issenberg et al16 performed a systematic review of 109 studies, the majority of which centered on laproscopy and similar psychomotor skills. They identified 10 key considerations for designing simulations, including deliberate, progressive practice and provision of feedback. Other studies have investigated student perceptions of simulation as an instructional strategy,1720 which appears to be almost universally well-received by students. Thus, the preponderance of evidence has focused on simulation design and learner satisfaction, but not on whether simulation-based instruction/training results in superior outcomes compared to traditional teaching strategies.

The only authors to study the use of HFHS in physical therapist education are Geyer and Biearman,20 who investigated student perceptions of the inclusion of human patient simulation into their curriculum. They found that students perceived the simulation experience to be helpful in learning psychomotor tasks and identifying strengths and weaknesses. Only half of their students felt more confident following the simulation, citing the videotaping of the session as the reason for their lack of confidence. Nearly all of the students perceived the need for more simulator practice time. However, only an abstract is available and thus there is a paucity of discussion in the professional literature about the use of this potentially beneficial teaching intervention in physical therapist educational programs. Therefore, the purpose of this article is to provide an example of the design and use of HFHS to facilitate the teaching of cardiopulmonary and ICU concepts in a physical therapist education program. The requirement for informed consent was waived by the Human Research Review Committee of Grand Valley State University.

CASE DESCRIPTION

Curricular Context

The ICU simulation was used toward the end of a 2-semester course series on cardiopulmonary physical therapy. This course series begins at the end of the first year within a 3-year, 9-semester entry-level Doctor of Physical Therapy Program. Content pertaining to the acute care setting is presented during this time in cardiopulmonary, wound care, and neurorehabilitation courses. The cardiopulmonary course series initially focuses on anatomy, physiology, and pathophysiology in a didactic, lecture-based format where clinical implications of these concepts are explicitly highlighted. The second half of the course series emphasizes all elements of patient/client management for individuals with primary and secondary cardiovascular and pulmonary disease, as well as prevention and wellness. The majority of the second cardiopulmonary course is in a clinical laboratory format with a variety of paper-based cases, clinic visits with actual patients, and students acting as patients across a variety of settings. However, we felt as though we had not been providing a sufficient opportunity to apply their knowledge and skills to low-level patients in the acute care and ICU settings. After various informal discussions with clinical instructors and students, we decided that mere knowledge about invasive and noninvasive monitoring and interventional devices was insufficient in preparing students to enter the hospital setting where they would begin to learn to mobilize patients with these devices and make clinical decisions about patients with unstable or rapidly changing physiologic responses.

Simulation Design Principles

Principles of the simulation design were based on the work of Jeffries and Rizzolo.21 Key principles in simulation design include: (1) clear objectives, (2) fidelity/sense of realism, (3) an opportunity for real-time problem solving appropriate to level and preparation of the learner, (4) student support/ability to facilitate the students' resolution of the clinical problem, and (5) an opportunity for reflection. More specific guidelines developed from their empirical work are outlined in Table Table11.

Table 1
Simulation Design Guidelines2,21

The objectives

The specific objectives for the simulation were for students to: (1) assess the patient's clinical status and readiness for physical therapy intervention, (2) assess and respond appropriately to the patient's physiologic changes during mobilization, (3) respond appropriately to ventilator alarms, (4) safely mobilize the patient to sitting on the edge of the bed while observing all precautions associated with various lines, leads, and tubes, and (5) suggest additional interventions that may be beneficial.

The case history

The patient was a 59-year-old male with a 60 pack per year history of smoking who presented to the emergency department 7 days ago with severe, progressive dyspnea, cough, and fever. His wife stated that he has not seen a physician in 15 years and that he thought that he would get better “on his own.” He was found to have sepsis and respiratory failure secondary to right lower lobe pneumonia with empyema. He was mechanically ventilated, a chest tube was placed, and medical management of his sepsis was initiated. He had been slow to wean from the ventilator and thus had a tracheostomy tube placed. He is now on pressure support ventilation, and the ICU team would like physical therapy to begin to mobilize the patient. He did not have an established medical history as the patient had not a seen a physician in 15 years. He did have newly discovered hyperlipidemia. The patient works in an auto parts factory. His father and uncle both died of a myocardial infarction.

The simulation set-up

Two different types of HFHS mannequins were used: Laerdal's SimMan™ (Laerdal Medical Corporation, Wappingers Falls, NY) and METI's Human Patient Simulator™ (Medical Education Technologies, Inc., Sarasota, Fla). The same scenario and set-up was used for both mannequins.

Each mannequin was equipped with the following: a cuffed tracheostomy tube, ventilator circuit with in-line suction catheter, electrocardiogram leads, right-sided chest tube with a collecting unit, indwelling urinary catheter, a percutaneous endogastric tube, a peripherally-inserted central catheter, and a finger-probe pulse oximeter. The display for the telemetry data included a running single lead electrocardiogram, heart rate, oxygen saturation, and noninvasive blood pressure. Because we did not have a mechanical ventilator available, the ventilator circuit was connected to a laptop computer which was used to simulate a ventilator. It displayed typical data provided by a ventilator, to include ventilator setting (assist control, pressure support etc), respiratory rate, tidal volume, minute volume, fraction of inspired oxygen, and alarms (high pressure, low pressure, apnea, disconnect, high respiratory rate, etc). The ventilator data display was accomplished using PowerPoint™ (Microsoft Corporation, Redmond, Wash) slides that were designed to look like a ventilator display. These data were able to be changed as the simulation progressed by advancing the slides. Figure Figure11 is a photograph showing an example of the set-up in the simulation suite.

Student preparation

The students were given a brief orientation to the ICU simulation suite and the mannequin simulator, including information on additional equipment available (resuscitation bag, supplemental oxygen, suction device) and mannequin capability with respect to heart and lung sounds, pulses, joint mobility, etc. They were provided with pictures of the telemetry and ventilator screens to prepare them for what data was available and where it was located. Students were divided into groups of 5. Two students acted as clinicians, and the other 3 students silently observed and reflected on the provided questions (Table (Table2).2). The student clinicians were encouraged to verbalize as much of their decision-making as possible to allow the observers to compare their own decision-making with that of the student clinicians. The student clinicians were instructed to maintain a strict role-playing environment, and to interact with the mannequin as they would with an actual patient.

Table 2
Observer Questions for Reflection

Progression of the simulation

The simulation was divided into 3 stages, with each stage requiring students to assess the status of the “patient” and respond accordingly. Stage I began with the patient resting comfortably with pressure support ventilation and stable vital signs. As students became familiar with the environment, the patient's status, and the various devices attached to the patient, a ventilator disconnect alarm was created, requiring the students to assess the patient and respond appropriately.

Stage II began as the students prepared to mobilize the patient. A ventilator high-pressure alarm was then created, requiring students to perform suctioning of the patient and reassess the patient's status. It is appropriate to note at this point that a faculty member played the role of a nurse who was available to assist the students if asked. Thus, students could ask the “nurse” for assistance with this alarm and subsequent need for suctioning if desired.

Stage III began when the students began to sit the patient at the edge of the bed. At that point, a rise in respiratory rate, a rise in heart rate, a drop in oxygen saturation, and a drop in blood pressure was created in the “patient.” It should be noted that the students had the opportunity to ask the patient about symptoms of orthostatic hypotension, and a simulated response to the affirmative would be given by the facilitator. Additionally, it should be noted that current blood pressure values would only be displayed if the students activated the automated noninvasive blood pressure device. Thus, the scenario required students to actively seek out the patient's response to sitting. If they did not, then they would be forced to respond to the alarms of the ventilator (high respiratory rate) and the telemetry (oxygen desaturation and tachycardia). Throughout all 3 stages the heart rhythm was set to change to either atrial fibrillation and/or occasional premature ventricular contractions.

OUTCOMES

Student Performance

Student performance was not measured using any specific, reliable, and valid instrument as the simulation session was used as a laboratory activity. Furthermore, the use of the HFHS session as the subject of the present paper was not anticipated at the time. In general, however, students were able to mobilize the mannequin to a sitting position without compromising any of the monitoring or interventional devices (urinary catheter, chest tube, etc). Students were able to attend to and interpret relevant vital sign data, though some students were faster than others in recognizing changes that indicated a need for action (decreased oxygen saturation or blood pressure, etc). For example, some students performed blood pressure at 1-minute intervals and detected orthostatic hypotension immediately, whereas 1 student group had not yet performed a blood pressure within the 3-minute time period when the patient would develop syncope (the students were then told the patient was unresponsive). Psychomotor skill performance such as managing lines, leads, and tubes was notably awkward in many instances, which is consistent with novice performance. Response to ventilator alarms was generally appropriate but the speed of problem recognition was quite variable. Student reflection and self-evaluation at the completion of the simulation was surprisingly accurate.

Student Feedback

Informal feedback solicited from each student group immediately after the simulation was universally positive, especially regarding the opportunity to experience a realistic context for lines, leads, and tubes, as well as for making decisions in real-time. Students commented particularly about the realism of the environment and the stress and pressure associated with changes in “patient” status. Additional feedback was sought via email from 14 students who subsequently completed a 6-week clinical rotation in an acute care setting. Questions were based on the 5 main principles of simulation design21 (Table (Table3).3). Highly consistent feedback was received and is summarized in Table Table33.

Table 3
Questions and Response Themes for Student Feedback Following Acute Care Clinical Education Experience

DISCUSSION

The purpose of this article was to provide physical therapist educators with a brief introduction to the use of HFHS as a teaching intervention to assist students with applying didactic knowledge and practicing the procedural skills needed in the ICU setting to prepare them for acute care clinical education experiences. Based on a review of the literature, HFHS is being used with increasing frequency in health professional education, but has been described only once in the physical therapy literature. (Au: please reference) Based on our preliminary experience outlined in this paper, it appears that even 1 session using HFHS as a laboratory activity can have a substantial impact on students' perceptions and confidence prior to entering an acute care clinical experience. However, student feedback indicates that additional HFHS sessions would have provided even greater value in their preparation. Student perceptions and feedback described in this article qualitatively appear to be in close agreement with those described quantitatively by Geyer and Biearman.20

There are numerous other applications for HFHS not outlined in the present paper, most notably formative and summative evaluation. Our primary intent for using HFHS was to prepare students for acute care clinical education experiences that typically occur at some point after the cardiopulmonary and acute care content in the curriculum is presented. There is not currently an additional opportunity in our program to assess student learning outcomes to using HFHS for summative evaluation following completion of an acute care clinical experience. This formative and summative evaluation is completed by clinical instructors using the Clinical Performance Instrument.

One of the greatest criticisms of HFHS is its significant cost (average of $50,000 with a range of $30,000 to $185,000, depending on a variety of options) and therefore such cost may not be justified without clear benefit. Given the limited use of HFHS as described in this paper, new acquisition of HFHS resources would likely not be justified. However, HFHS resources were already available in our university as access and cost is shared by 2 colleges (Health Professions and Nursing). Thus, for physical therapist education programs that have access HFHS, we believe inclusion of HFHS is feasible. There is no evidence from any health profession that HFHS results in suboptimal or poorer learning outcomes, and there is some evidence that it may have a slight advantage over traditional educational interventions. For programs without access to HFHS resources, acquisition may likely only be justified if it would become a regular, integral component of several courses. Those programs with a heavy emphasis on problem-based learning might be ideally suited for this. Alternatively, a similar scenario could be designed using standardized patients (SPs). The SP programs can be feasible,22 and there is support in the physical therapy literature for using SPs to teach and/or evaluate orthopedic clinical examination skills,2325 medical referral decision-making skills for cardiovascular and pulmonary disease,26 communication skills,27 and core values.28 For the scenario described in the present paper, an SP in conjunction with a software program that allows for the display and manipulation of ICU monitoring data would be a lower cost alternative. However, realistic insertion of lines and tubes and simulation of heart sounds, lung sounds, and irregular pulses would not be possible. It should be noted that there are no studies that have compared HFHS to SPs with regard to which simulation modality is superior.

Recommendations for Future Study

Given the high costs associated with acquiring and maintaining HFHS resources, additional research is clearly needed regarding student preparation for clinical education experiences and, most importantly, preparation as clinicians. This may prove to be difficult because valid, reliable evaluation of physical therapist preparation and competency is somewhat ill-defined and not sufficiently standardized to evaluate the efficacy of a single teaching intervention for achieving an enhanced outcome. The licensure exam is standardized and allows for comparisons within and across programs, but as a paper-based examination with simplified clinical scenarios, would likely not be sufficiently sensitive for assessing the impact of HFHS. Thus, other mechanisms for evaluating the cost-to-benefit ratio of HFHS are greatly needed.

CONCLUSION

This paper is among the first in the physical therapy literature to describe the use of HFHS in a physical therapist educational program. In our experience, HFHS was well-received by students and was helpful in preparing students for acute care clinical education experiences. Given its high cost, the efficacy of HFHS should be further investigated.

ACKNOWLEDGEMENTS

The authors would like to express their gratitude to Tracey Schollmeyer, BSN, RN; Gerard Massey, MS; and Chris Swank, BS, MA for their assistance with coordinating and executing the simulation sessions.

REFERENCES

1. Patel VL, Kaufman DR. Clinical reasoning and biomedical knowledge: implications for teaching. In: Higgs J, editor. Clinical Reasoning in the Health Professions. Boston: Mass Butterworth Heinemann; 2006.
2. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspectives. 2005;26:96–103. [PubMed]
3. Povenmire HK, Roscoe SN. Evaluation of ground-based flight trainers in routine primary flight training. Human Factors. 1971;13:109–116.
4. Huff EM, Nagel DC. Psychological aspects of aeronautical flight simulation. Am Psychol. 1975;30:426–439.
5. Trollip SR. The evaluation of a complex computer-based flight procedures trainer. Human Factors. 1979;21:47–54.
6. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63:763–770. [PubMed]
7. Gaba DM. Improving anesthiologist's performance by simulating reality. Anesthesiology. 1992;76:491–494. [PubMed]
8. Hravnak M, Beach M, Tuite P. Simulator technology as a tool for education in cardiac care. J Cardiac Nurs. 2007;22:16–24. [PubMed]
9. Henneman EA, Cunningham H, Roche JP, Curnin ME. Human patient simulation: teaching students to provide safe care. Nurse Educator. 2007;32:212–217. [PubMed]
10. Fox-Ribichaud AE, Nimmo GR. Education and simulation techniques for improving reliability of care. Curr Opin Crit Care. 2007;13:737–741. [PubMed]
11. Hunt EA, Nelson KL, Shilkofski NA. Simulation in medicine: addressing patient safety and improving the interface between healthcare providers and medical technology. Biomed Instrum Technol. 2006;40:399–404. [PubMed]
12. Lighthall GK, Barr J. The use of clinical simulation systems to train critical care physicians. J Intensive Care Med. 2007;22:257–269. [PubMed]
13. Rosenthal ME, Adachi M, Ribaudo V, Mueck JT, Schneider RF, Mayo PH. Achieving housestaff competence in emergency airway management using scenario-based training: comparison of attending vs housetaff trainers. Chest. 2006;129:1453–1458. [PubMed]
14. Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. Qual Saf Health Care. 2004;13:395–397. [PMC free article] [PubMed]
15. Tan GM, Ti LK, Suresh S, Ho BS, Lee TL. Teaching first-year medical students physiology: does the human patient simulator allow for more effective teaching? Singapore Med J. 2002;43:238–242. [PubMed]
16. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fi delity medical sim-Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005;27:10–28. [PubMed]
17. Colucci SL, Craney TL, Edinger JR, et al. Efficacy of human patient simulator in skills validation for practicing nurse anesthetists [abstract] AANA J. 2007;75:362.
18. Cannon MR, Walker JR. An effective approach to highfidelity simulation in anesthesia: integrating curricula [abstract] AANA J. 2007;75:363.
19. Lasater K. High fidelity simulation and the development of clinical judgment: students' experiences. J Nurs Ed. 2007;46:269–276. [PubMed]
20. Geyer MJ, Biearman B. Use of human patient simulation in acute care physical therapy education [abstract]. American Physical Therapy Association's Combined Section Meeting 2008.
21. Jeffries PR, Rizzolo MA. Designing and implementing models for the innovative use of simulation to teach care of ill adults and children: a national, multi-site, multimethod study. National League for Nursing. 2006
22. Black B, Marcoux BC. Feasibility of using standardized patients in a physical therapist educational program: a pilot study. J Phys Ther Educ. 2002;16:49–56.
23. Ladyshewsky R, Baker R, Jones M, Nelson Evaluating clinical performance in physical therapy with simulated patients. J Phys Ther Educ. 2000;14:31–37.
24. Ladyshewsky R, Baker R, Jones M, Nelson L. Reliability and validity of an extended simulated patient case: a tool for evaluation and research in physiotherapy. Physiother Theory Pract. 2000;16:15–25.
25. Wessel J, Williams R, Finch E, Gemus M. Reliability and validity of an objective structured clinical examination for physical therapy students. J Allied Health. 2003;32:266–269. [PubMed]
26. Boissonnault W, Morgan B, Buelow J. A comparison of two strategies for teaching medical screening and patient referral in a physical therapist professional degree pro gram. J Phys Ther Educ. 2006;20:28–36.
27. Ladyshewsky R, Gotjamanos E. Communication skill development in health professional education: the use of standardized patients in combination with a peer assessment strategy. J Allied Health. 1997;26:177–186. [PubMed]
28. Hayward LM, Blackmer B, Markowski A. Standardized patients and communities of practice: a realistic strategy for integrating the core values in a physical therapist edu cation program. J Phys Ther Educ. 2006;20:29–37.

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