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Cardiopulm Phys Ther J. 2010 December; 21(4): 29–34.
PMCID: PMC3004762

ABSTRACTS OF POSTER PRESENTATIONS

2010 December; 21(4): 29–34.

BREATHING EASIER AFTER BARIATRIC SURGERY

Background & Purpose: Bariatric surgery for the morbidly obese (MO) is undertaken for a variety of reasons (cosmesis; controlling DM, HTN, GERD, and/or OSA; and musculoskeletal unloading; to name a few) to improve life quality. The degree to which this restrictive lung condition of MO alters a person's effort perception and breathing mechanics as contributors to functional performance and life-quality has been given sparse attention. Therefore, the purpose of this Case Study was to document pre- to post-op changes in a person's life-quality scores, functional performance, dyspnea index, spirometry, ventilatory muscle pump forces, and chest excursion changes as more favorable body mass indexes (BMI) occurred. Case Description: institution review board approval and informed consent were obtained to study a 31 y.o. <♀> (70 inches tall and 275 pounds excess body weight at 424 pounds) with restrictive MO (BMI of 61.1 and a waist-to-hip ratio of 0.82) and the obstructive lung disease of Asthma(FEV1/FVC% of 0.69 and “triggers” of smoke, pollen, and cold air). A systems review revealed RA, a positive history for bilateral knee OA and right heel spur, HTN, hypercholesterolemia, and a positive family history for DM, CAD, HTN, and MO. Pre- and post-op Gastric band surgery values were obtained for life-quality (SF-36 inventory), functional performance (6-minute walk distance and velocity), spirometry (FEV1/FVC% and peak flow readings), ventilatory muscle pump forces (MIP and MEP), rib-cage excursion (<∑> axillary, xiphoid, and lower costal levels), and dyspnea scores (UCSD inventory) spanning four mid-west seasons in an urban setting. On 5 occasions (baseline pre-op, 3-, 6-, 9-, and 12-months post-op), all test results were obtained by the same PT clinician under similar indoor conditions and testing sequence. Outcomes: Clinically significant improvements from pre-op baseline were realized in life-quality (for roles physical, emotional, and general health), functional performance (from 1173 to 1632 feet and 2.2 to 3.1 mph), ventilatory muscle pump forces (1-year MEP was 15 percent greater and MIP equaled pre-op values), rib-cage excursion (from 11.0 cm to 18.0 cm), BMI (50.5% at 1-year), and dyspnea index (from 16 to 10). Less lower extremity joint pain while weight-bearing was also reported. Rescue medication (Proventil) was used only once, in the cold of winter, throughout all 12 months. A loss of 26% (72 pounds) of her weight excess approached a weight goal of 300 pounds to permit future tolerance of a planned pregnancy. Discussion: Following a 6-week period of post-op recovery in which no progressive physical activity was undertaken, daily caloric intake of 650–800 was the norm, below the 1200 calorie target set by her medical team. As daily activity advanced thereafter (pedometer readings from 3000 to 6000 steps), nutritional intake counseling became a top priority. Future interest is to determine whether breathing easier after bariatric surgery is the same for <♀> <♂> having “Android” versus “Gynoid” MO, with or without obstructive disease superimposed.

2010 December; 21(4): 29–34.

THE USE OF EXERCISE AND A TELEHEALTH DEVICE TO PROMOTE SELF-EFFICACY IN INDIVIDUALS WITH TYPE II DIABETES

Purpose/Hypothesis: The purpose of this study was to examine the use of a structured exercise program and a Telehealth device to improve self-efficacy and exercise adherence in individuals with Type II diabetes. We hypothesized that this combination would significantly improve adherence to physical activity and self-efficacy in subjects with Type II diabetes. We also hypothesized that subjects would make improvements in the strength, aerobic and anthropometric measures used in this study. Number of Subjects: Six subjects with Type II diabetes were recruited from Nazareth College and surrounding community (2 male, 4 female, 63+6.65 y.o.). Three subjects were in an exercise plus Telehealth group (experimental group) and three subjects were in an exercise only group (control group). Materials/Methods: All participants participated in an eight week exercise program two times per week at Nazareth College. The Telehealth group had a monitor in their home which prompted them to do daily self management. Subjects were assessed throughout the study using the following measures: Self-Efficacy Scale for Diabetes, 10RM for eight major muscle groups, one mile walk test, and number of days per week physical activity was performed outside of exercise group. Exercise sessions included cardiovascular and strength training. All participants began with 20 minutes of aerobic exercise and progressed to 35 minutes by the end of study. Resistive exercises targeted eight major muscle groups in upper and lower extremities. Participants began their strength training program at 70% of their 10 RM and were progressed as tolerated. Additionally, subjects were encouraged to participate in at least two 30 minute sessions of aerobic exercise outside of structured exercise group, which they recorded in exercise journals. Results: Data was analyzed using a Repeated Measures test (p=.05) and a Spearman Rank Correlation. Between groups, the experimental group exercised significantly more days per week outside of the group exercise sessions than the control group. A trend toward significant findings included a correlation between time for one mile walk and times they reported they exercised per week (r=.7). Power analysis determined that only 41 subjects would be needed in order to find significant changes between groups for the self-efficacy scale used. Conclusions: This pilot study suggests that the use of an exercise program and a Telehealth device may help to improve individuals' adherence to exercise. Clinical Relevance:Clinically, these results may help physical therapists to determine ways to help motivate patients with Type II diabetes to begin an exercise program. Using phone or e-mail reminders, exercise logs, or mentorship programs may act as similar modes of increasing exercise compliance, as suggested by the results of our study. Limitations of this study include a small sample size, faulty pedometers, orthopedic conditions, non-random sample, and accuracy of RPE.

2010 December; 21(4): 29–34.

HEART RATE ACHIEVES STEADY STATE DURING UPPER EXTREMITY EXERCISE TUBING EXERCISE

Purpose/Hypothesis: To determine if: (1) steady state heart rate (HR) occurs when performing upper extremity exercise tube exercise (UTE); (2) HR response during UTE is reliable; and (3) steady-state HRs differs using different resistances (colors) during UTE. Number of Subjects:A convenience sample of 12 male and 12 female Doctorate of Physical Therapy students participated. Materials/Methods: After signing an informed consent, Body Mass Index (BMI), percent fat, arm length, mid-arm circumference, triceps skin fold, and chest circumference were collected. During UTE, subjects sat upright with elbows flexed 90°, arms adducted, with closed fists resting below the clavicles. Subjects held exercise-tube handles with tubing positioned at mid back under the axillary region. Subjects reciprocally extended upper extremities to 90° horizontal flexion at 30 rpm per arm for five minutes. Rate of perceived exertion (RPE) and HR were recorded every exercise minute. Three resistances (red, green, blue) of Thera-band® exercise tubing were randomly ordered in the protocol. The protocol consisted of a five minute bout, a ten minute rest, and a repeated five minute bout. One week of rest was allowed between color trials until all colors were completed. A one-way ANOVA (SPSS 17.0) was computed (Tukey post hoc) to calculate differences in HR between colors. A RMANOVA, split by color, was performed to determine differences between steady-state HRs and colors. Pearson correlations determined relationships between HR by test and by color. Significance was set at p ≤ 0.05. Results: Mean steady-state HR for red, green, and blue were: 87.1, 93.6 and 95.3 b/min, respectively. Based on group averages, subjects were exercising at 44.3%, 47.6% and 48.4% of their age-predicated max HR and at 12.2%, 18.5% and 19.0% of their max workload intensity, respectively. HR was significantly different until minute 3 for red and blue and minute 4 for green. Steady-state HR was significantly different between red and blue work during minutes 1–5 for and between green and red work during minutes 3–5, however, no differences were noted between green and blue. HR for tests 1 and 2 for minutes 4 and 5 were highly correlated (red r=.92, green r=.90, blue r=.92). Conclusions: UTE provided a reproducible steady-state stimulus perceived to be fairly light to somewhat hard on the Borg scale. Steady-state HR was achieved within minute 4 with all three colors. Red provided significantly lower HR than blue, while blue and green provided similar HR responses. Though, red and blue produced significantly different HR throughout exercise, red and green provided similar heart responses after 3 minutes of exercise. Clinical Relevance: Completely functional upper extremities allow for maximal independence. Arm cycle ergometers are expensive, difficult to calibrate, and are often unavailable in typical physical therapy settings. An inexpensive, readily available product (exercise tubing) allows the therapist, as well as the client, optimal flexibility in training the cardiovascular system and increasing muscular endurance.

2010 December; 21(4): 29–34.

CARDIOVASCULAR DISEASE PREVENTION AND HEALTH PROMOTION THROUGH AN INNOVATIVE SERVICE LEARNING PROJECT

Purpose: Heart disease is the leading cause of death in America and affects minority populations disproportionately. The Center for Disease Control and Prevention supports addressing modifiable risk factors through education and community awareness programs. Through a service learning project, doctor of physical therapy (DPT) students designed interactive educational activities that integrated current evidence on minority health and minority health disparities as it applies to persons with cardiovascular health concerns. The project met community needs while providing students with the knowledge and skills to create programs that serve the underserved populations. Description: DPT students created an educational series that consisted of 1 meeting per week for 4 weeks for students, faculty and staff at a HBCU (historically black colleges and universities). The students researched scholarly journal articles, formulated behavioral objectives, created innovative teaching strategies, developed assessment tools, analyzed data and reflected on their experience. On week 1, a 3-dimensional model of the heart was created and participants were “blood cells” who traveled through the chambers of the heart, passed through the valves, received oxygen from the lungs and transported oxygen to the body. Week 2, participants walked through a simulated artery with plague build-up. Education on minorities and heart disease was delivered by a power point presentation, heart and artery models, poster boards, and an interactive game. Week 3, students emphasized the benefits of exercise and demonstrated heart healthy activities that can be performed outside a gym. Week 4, participants were “detectives” who used items in the evidence room to assist them to solve cases requiring healthy lifestyle changes. Summary of Use: Participants completed an assessment after each session for a total of 419 assessment forms. Data analysis revealed that participants were able to recognize at least 2 modifiable risk factors, demonstrate one exercise/activity to promote heart healthiness, list one function of the heart and recognize 2 risks for heart disease in the minority populations. Participants reported that they felt more knowledgeable about the risks for heart disease and more equipped to be proactive in their own health care. Results were disseminated at the state-wide service learning conference. Importance to Members: Cardiovascular health care providers have a professional responsibility to educate the community regarding the risk factors for heart disease. Creative and interactive methods of instruction can promote change and stimulate internal motivation for people in the community to become more aware and proactive in their health care. Physical therapists can and should be leaders in the movement to increase cardiac awareness in the general public.

2010 December; 21(4): 29–34.

APPROPRIATENESS OF AQUATIC EXERCISE FOR WEIGHT LOSS AND FITNESS GAINS IN OVERWEIGHT AND OBESE PARTICIPANTS

Purpose/Hypothesis: The purpose of this study was to assess the feasibility and effectiveness of an aquatic exercise program on weight loss on cardiovascular fitness in an overweight and obese population. Number of Subjects: 7. Materials/Methods: Subjects were selected from a convenience sample at our University via a campus wide email solicitation and were students, staff, or faculty. Inclusion criteria consisted of BMI > 24.9 and no contraindications to exercise. Seven participants were eligible and randomly assigned to the aquatic group. Participants completed a body composition and fitness assessment prior to the start of the study, which was repeated at termination of the study. The fitness tests included field tests to assess VO2, flexibility and muscular endurance. The intervention consisted of hour long PT supervised aquatic exercise sessions 2x week for 6 weeks. Each session included 30 minutes of deep water running followed by 20 minutes of strength and flexibility training in the water. Participants wore flotation belts and HR monitors to assist with keeping running pace to match 75% of HR max. Subjects were also enrolled in a nutrition program that included a weekly lesson, on-line discussion boards, weighins, and food journaling. Results: The ages of the participants ranged from 25–60, and consisted of 1 male and 6 females. The BMI of participants ranged from 28.5–43.5 kg/m2. The compliance rates of the program were high, with only one subject dropping out due to time constraints of her job. The remainder of the 6 sub-jects all showed some improvement in body composition (either body mass or WHR) and in cardiovascular fitness as evidenced by decreased resting HR and BP and improved performance on fitness tests. In a post-intervention survey the participants stated the program was fun, engaging, and effective. They cited camaraderie and ability to exercise in a new way as positive influences to their participation. Conclusions: Despite the small sample size and variance in subjects, this study demonstrates that aquatic exercise is a viable option for weight loss and fitness gains in the overweight and obese population. Clinical Relevance: Most importantly this study illustrates the use of water as an alternative or adjunct exercise modality to land based exercise in those who are overweight and obese in their quest to improve body composition and fitness.

2010 December; 21(4): 29–34.

CHANGES IN BODY COMPOSITION, FITNESS LEVELS AND CARDIAC RISK FACTORS FOLLOWING A 10 WEEK EXERCISE AND NUTRITION PROGRAM FOR OVERWEIGHT/OBESE CHILDREN

Purpose/Hypothesis: Childhood obesity studies traditionally use body mass index (BMI) as the primary outcome measure. BMI is a statistical measure of weight classification based on weight and height, however it does not reflect % body fat or distribution of adiposity, and is influenced by linear growth. Fitness levels, body composition, and cardiometabolic factors may be more accurate indicators of program effectiveness. Purpose: To evaluate the effect of an exercise and nutrition intervention administered to overweight and obese children, ages 8–17, by examining body composition, fitness levels, cardio-metabolic factors, quality of life, and BMI. Hypotheses: Children randomized to the intervention will show improved levels of body composition, fitness, cardio-metabolic factors, and quality of life (QOL), following a ten week exercise and nutrition program and as compared to a matched, waitlist control group. These changes may be maintained over a 10 week home exercise program (HEP). Number of Subjects: n=48 Materials/Methods: The influence of a twice weekly, 10 week exercise and nutrition intervention plus a 10 week HEP was examined in 48 children (treatment group:n=24, WLC group:n=24). Body composition (dual-energy, X-ray absorptiometry), fitness levels (flexibility [sit and reach], agility [“t” test], muscle endurance [push ups and sit ups], strength [hand held dynamometer], cardiovascular endurance [6 min walk test]), and cardiometabolic risk factors (BP, HR, total cholesterol, and HgA1c) were made at baseline, following a 10 week intervention and following a 10 week home program. QOL was assessed using the Impact of Weight on Quality of Life Scale (IWQOL). Results: Upon completion of the program, there were no differences between groups. Within groups and across time, body composition improved with significant changes in % body fat (−2.1%) and % lean tissue (+1.9%) noted (p<.05). Fitness levels also improved significantly (p<.05) and improvement was noted in cardiovascular endurance (p=.07). Cardiometabolic risk factors remained stable. There was no significant difference in scores for QOL however the domain of body esteem approached significance (p=0.07) following the exercise intervention. Conclusions: A 10 week exercise and nutrition intervention can influence body composition and fitness levels. In this study, % lean tissue increased while growth and BMI remained stable. This increase in % lean tissue was accompanied by an increase in strength and muscle endurance. These changes coincided with a stable BMI. Notably, improvements were maintained or enhanced over a 10 week home program phase, indicating adoption of a healthy lifestyle change. Clinical Relevance: Fitness measures may be better indicators of program effectiveness, and physical therapists are well suited to measure and monitor fitness levels when working with overweight and obese children. Stability of BMI may be a better goal for this population.

2010 December; 21(4): 29–34.

THE EFFECT OF VENTILATORY STRATEGIES ON SIT-TO-STAND TRANSFERS IN THE GERIATRIC POPULATION: A PILOT STUDY

Purpose/Hypothesis: Many older adults have difficulty rising from chairs, particularly lower or softer surfaces. The use of ventilatory strategies has been described to enhance the ability to complete motor tasks. The purpose of this study was to investigate whether instructing elderly individuals to use ventilatory strategies (inhalation with upward eye gaze) with sit-to-stand transfers would improve the ability to rise from a chair. Number of Subjects: A sample of convenience was recruited from two independent living facilities. Twenty-two subjects (17 female, 5 male) with the mean age of 85.7 years completed pre- and post-testing. Materials/Methods: After baseline testing, subjects were educated on how to incorporate ventilatory strategies with basic sit-to-stand transfers and were instructed to practice daily. Baseline measures included Timed Up and Go (TUG), items 2–4 of the Tinetti Performance-Oriented Mobility Assessment (POMA), and timed five-time sit-to-stand from a standard chair with arms, a standard chair without arms, and a recliner. Qualitative descriptions of arm, leg and head position, overall movement, and attempts required to rise during each sit-to-stand trial were also documented. One week after initial instruction, subjects returned to demonstrate and review the previously learned ventilatory strategies and were re-instructed as needed. Two weeks following initial baseline testing and instruction, subjects were reassessed. Results: The pre- and post-test scores for TUG, items 2–4 POMA, and time to complete the five-time sitto-stand for each chair were analyzed with a paired t-test. No statistically significant differences were found. Conclusions: Although the results of this pilot study did not show statistically significant improvements, ventilatory strategies in clinical practice and in published case studies have been very beneficial in enhancing transitional movements. Based upon these preliminary results, modifications will be made to the current study design. Rather than using a sample of convenience, a larger number of targeted participants with more uniform transfer deficits will be sought and the study will include a control group. The educational method will be modified including increased practice. In addition, the subjects will be allowed to practice the strategy with feedback for a greater length of time. Clinical Relevance: Ventilatory strategies are simple, easily taught techniques that can be used with older adults to enhance functional movements. Improved transitions from sit-to-stand can allow elderly individuals to maintain independence and improve quality of life.

2010 December; 21(4): 29–34.

CARDIOVASCULAR RISK FACTORS AND PHYSICAL PERFORMANCE PROFILE OF AGING FEMALES WITH DIABETES ENROLLED IN A PUBLIC HEALTH CLASS

Purpose/Hypothesis: Many older adults with physical impairments and/or functional limitations enroll in Diabetes Management Classes typically directed by Diabetes Nurse Educators in medically underserved areas through the local Public Health Department. The purpose of this study was to identify the cardiovascular disease (CVD) risk factors and physical performance profile of older white (W) and African-American (AA) females with type 2 diabetes (T2D) in these classes. These individuals may benefit from specific physical therapy intervention yet are often not referred by their primary care physician. Number of Subjects: Subjects were recruited from Diabetes Management Classes offered in medically underserved areas through the local Public Health Department. Thirty-eight females with T2D age 55 years or older (mean = 66.8 ± 8.5 yrs) volunteered. Twenty-two subjects were AA and 16 subjects were W. Materials/Methods: Subjects completed informed consent and a health risk questionnaire. Vital signs, height, weight, and waist circumference were recorded and body mass index was calculated. Supervised by physical therapists and physical therapist students, subjects completed the Modified Physical Performance Test (MPPT), the Six Minute Walk Test for distance (6MWD), gait speed, and the Timed Up and Go test. Chi-square analyses were used to compare the frequency of CVD risk factors and other health problems between AA and W subjects. T-tests were used to compare physical performance test means for AA and W subjects. Statistical significance was set at p < 0.05. Results: The CVD risk factor/health status and physical performance profiles of the AA and W females were not significantly different except for years with diabetes (5.2 ± 3.6 yrs for W and 10.2 ± 8.0 yrs for AA) and waist circumference (38.3 ± 4.7 inches for W and 42.3 ± 4.8 inches for AA); therefore risk factors and physical performance profile are reported in aggregate. Eighty-four percent had a sedentary lifestyle; 92% had hypertension, 94.7 % reported family history of heart disease, 81.5% had hypercholesterolemia, 13.5% were smokers, and 73.7% were obese. Other comorbid conditions included osteoarthritis (92%), peripheral neuropathy (57.8%) and chronic obstructive lung disease (21.1%). Nearly half (42%) used an assistive device for gait. Subjects demonstrated below normal 6MWD (351.8 ± 93.8yds) and an MPPT mean score (27.4) suggesting mild frailty. Conclusions: Aging AA and W females with T2D residing in medically underserved communities had similar CVD risk factors and physical performance profiles. Aging females with T2D in medically underserved areas had well below average physical performance scores in the 6MWD and MPPT. Clinical Relevance: Aging females in medically underserved areas have many CVD risk factors and lower physical performance scores. These data suggest physical therapy intervention would be beneficial in this population.

2010 December; 21(4): 29–34.

ANALYSIS OF PRE-OPERATIVE PHYSICAL PERFORMANCE IN BARIATRIC SURGICAL PATIENTS: IMPLICATIONS FOR CLINICAL PRACTICE GUIDELINES

Purpose/Hypothesis: Limited evidence exists to guide physical therapists in the clinical interpretation of physical performance measures for obese clients. Prior to elective bariatric surgery, patients are commonly evaluated for sub-maximal exercise capacity using a six-minute walk test (6MWT). The goals of this study were to: 1) examine the predictive value of a pre-operative 6MWT on bariatric surgical outcomes, and 2) develop clinical guidelines for evidence-based evaluation of exercise capacity for obese patients. Number of Subjects: 180 Materials/Methods: Patient data was retrospectively analyzed from physical therapy preoperative evaluations and a bariatric surgical database from a university hospital. Pearson correlation coefficients were used to determine association between pertinent variables. Linear regression and logistic regression were used to analyze continuous and dichotomous outcome measures, respectively. Clinicians and faculty collaboratively discussed literature and study results to develop guidelines for incorporation of available evidence into the evaluation process. Results: Patients who had bariatric surgery were middle-aged (mean = 45.6 years, SD = 10.2) and predominately (80%) female. Distance completed during the 6-minute walk ranged from 30.48 – 731.5 meters (mean = 417.4, SD = 107.9). The immediate post 6MWT heart rate was relatively low. On average, patients' heart rates were 57.8% (SD = 9.32) of age-predicted maximum post 6MWT. Combined with gait speed, this translated into a low physiological cost index (PCI) of 1.68 beats/meter (SD = 1.50). Performance on the 6MWT was not associated with post-operative surgical outcomes (i.e. number of complications, length of stay, or readmissions). Conclusions: Performance on the 6MWT did not predict surgical outcomes of obese patients receiving gastric bypass or banding. Post hoc discussions with clinicians who performed the assessments suggested to the investigators that patients in this cohort may not have consistently walked “as far as possible” during the 6MWT. In addition, the absence of a subjective measure of exertion and lack of information on types, dosages, and compliance with prescribed medications may have contributed to the inability to predict surgical outcome. Clinical Relevance: For physical assessment of preoperative patients, it is imperative that standardized clinical guidelines be developed and disseminated in order to improve the quality of physical therapy evaluations. Given the lack of literature available for guidance when working with this patient population, we suggest that 1) protocol instruction be consistent with the American Thoracic Society Guidelines 2) the Borg Rating of Perceived Exertion be used, and 3) documentation of cardiac medications be included in the evaluation.

2010 December; 21(4): 29–34.

EXERCISE INTENSITY AND TRAINING ADAPTATIONS FOLLOWING PARTICIPATION IN A WORKPLACE WELLNESS PROGRAM: A DESCRIPTIVE STUDY

Purpose/Hypothesis: Current evidence suggests worksite wellness programs do not commonly increase physical activity, improve aerobic fitness, or decrease cardiovascular risk factors. Limited evidence exists on the exercise training stimulus performed in these programs; therefore, this study measured exercise training intensity during a 12-week worksite wellness program and then assessed the participants' training adaptations. Number of Subjects: 22 subjects from a university wellness program agreed to participate in this study. Materials/Methods: Informed consent was signed and institutional approval was received prior to starting the study. Participants received exercise training guidelines and wellness education. Exercise load (intensity, frequency, duration) was measured with Polar RS400 heart rate monitors. Pre- and post-intervention tests included: cardiopulmonary fitness (Rockport 1-mile walk test), body composition (body fat percentage, weight, height), serum measures (lipid profile, C-reactive protein, fasting glucose) and resting vitals (heart rate, blood pressure). Analyses: Paired t-test and Pearson product moment were used to assess the data using SPSS 14.0. Results: There were no significant improvements in participants' anthropometric and physiological measures over the course of the study. Participants trained in the targeted heart rate zone (>50% maximum heart rate [HRmax]) a median of 73 minutes per week and at a frequency of less than 2 times per week. There was no correlation between total time spent in the target zone and any of the measures of interest. Conclusions: The participants' exercise frequency and duration in the target heart rate zone were insufficient to meet the American College of Sports Medicine (ACSM) guidelines of exercise participation necessary to make fitness gains. Although a cause and effect relationship cannot be inferred from this study, the lack of training load might be responsible in part for the lack of improvements in the participants' anthropometric and physiological measures. Clinical Relevance: The exercise stimulus in this unsupervised worksite was insufficient to meet ACSM guidelines for training adaptations. Further studies are needed to explore the possibility that a lack of exercise intensity, frequency, and/or guidance may contribute to the modest improvements seen in unsupervised wellness and exercise programs. This information is important to maximize the benefits of such programs.


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