Large therapeutic rolls (LTR) and balls are popular rehabilitation tools and have also been advertised as cardiovascular training devices. The aim of this study was to determine if individuals of varying fitness levels would reach aerobic training levels by evidence-based standards as described in American College of Sports Medicine (ACSM) publications.
Fourteen volunteers performed a maximal exercise test and on subsequent days, two submaximal exercise tests on the LTR (LTR-A and -B). LTR-A consisted of four 5-minute stages of exercise at progressive intensity levels. LTR-B included 20 minutes of continuous exercise. Oxygen consumption (VO2) and heart rate (HR) during exercise on the LTR were compared with ACSM recommended standards.
The average (range) peak intensity achieved during LTR-A was 66.8% (51.7-82.7%) of maximal VO2 reserve (VO2R) and 82.9% (70.7%-91.2%) of maximal heart rate (HRmax). During LTR-B, HR and VO2 of all participants was maintained at moderate exercise intensity and averaged 56% of VO2R and 78% of HRmax during the 20 minute exercise period.
These findings suggest that individuals with a wide range of aerobic fitness are able to reach and maintain aerobic training levels with appropriate exercise on a large therapeutic roll or ball.
large therapeutic roll; Swiss Ball; aerobic exercise; exercise intensity
Reduced cardiovascular fitness post-stroke may negatively impact recovery. There is little information regarding exercise testing performance and cardiorespiratory response to an aerobic exercise intervention in subacute stroke. The purpose of this study was to examine cardiorespiratory response in subacute stroke after an 8-week aerobic exercise intervention using a total body recumbent stepper (TBRS).
Nine individuals with mean age 61.2 (SD 4.7) years and mean 66.7 (SD 41.5) days post-stroke completed the exercise intervention. Participants had a mean Fugl-Meyer score of 100.3 (SD 29.3). Outcome measures were obtained at baseline and postintervention. A peak exercise test using a TBRS assessed oxygen consumption, heart rate, and minute ventilation. Participants completed an 8-week exercise intervention on a recumbent stepper 3 times per week at a prescribed heart rate intensity.
Submaximal VO2 was significantly lower from baseline to postintervention with a main effect of Study Visit (F1,8 = 8.5, p = 0.02). Heart rate was not significantly different pre- to postintervention. Minute ventilation exhibited no main effect of Study Visit or Test Minute.
Moderate-high intensity aerobic exercise in subacute stroke appears to be beneficial for improving cardiovascular outcomes during submaximal performance of an exercise test.
oxygen uptake; cerebrovascular accident; cardiovascular fitness; submaximal exercise
The purpose of the present pilot study was to provide a preliminary estimate of the minimum detectable difference (MDD) and minimum clinically important difference (MCID) of the six-minute walk test (6MWT) and daily activity in outpatients with chronic heart failure (CHF).
A convenience sample of 22 adults with stable New York Heart Association Functional Class II and III CHF performed two baseline 6MWTs separated by 30 minutes of rest. Subjects then wore a triaxial accelerometer for 7 days to monitor daily activity. After 7 weeks of usual care, subjects again wore the accelerometer for 7 days and then returned to the clinic to complete the Global Rating of Change Scale (GRS) with regard to their heart disease and perform another set of 6MWTs. For the 6MWT, the MDD was calculated using the two baseline 6MWT distances. For daily activity, the MDD was calculated using two methods: (1) day-to-day test-retest reliability during baseline monitoring, and (2) baseline to follow-up test-retest reliability in those who reported no change on the GRS. The MCID for the 6MWT and daily activity was calculated using the mean and 95% confidence interval (CI95%) for those subjects who reported ‘improvement’ on the GRS.
The MDD at the CI95% for the 6MWT was 32.4 meters. The MCID for the 6MWT was 30.1 (CI95% 20.8, 39.4) meters. The MDD for daily activity was 5,909 vector magnitude units (VMU·hr.−1) The MCID for daily activity was 1,337 VMU·hr.−1 There was good alignment of the MDD and MCID for the 6MWT, suggesting that clinically meaningful change is approximately 32 meters. However, the calculated MCID was substantially less than measurement error as represented by the MDD, indicating that the MCID was underestimated in this sample or that daily activity may be robust to change in overall disease status.
six-minute walk test; daily activity; heart failure; clinically meaningful change
To determine the opinions and attitudes toward exercise in people with chronic obstructive pulmonary disease (COPD) who had completed a randomised controlled trial of 12-months maintenance exercise.
Participants were eligible for recruitment to the maintenance exercise study if they had COPD and had completed an 8-week pulmonary rehabilitation program. They were randomized into an Intervention Group (IG) that consisted of once weekly, supervised hospital-based maintenance exercise plus home exercise for 12 months or a Control Group that undertook unsupervised home maintenance exercise for 12 months. At the end of the 12 months, participants completed a survey consisting of 23 questions using a visual analogue scale (VAS) of 100 mm.
Forty-eight participants completed the 12 month study and 36 participants (75%) completed the survey [IG mean (SD): age 65 (8) years, FEV1 58 (20) % predicted; CG: age 66 (8) years, FEV1 67 (17) % predicted]. No between group difference was found for the importance of exercise, the benefits of the program or the importance of support from the physiotherapist. However, the IG reported exercising more regularly, having more enjoyment of being involved in the maintenance exercise program, greater benefit in general well-being, and better physical fitness.
At the completion of the 12 month exercise study, the survey results showed that all participants reported positive attitudes towards both supervised and unsupervised maintenance exercise programs, with the IG reporting greater benefits.
COPD; survey; maintenance exercise program
The 5-Meter Walk Test (5MWT) has been recommended for use by the Society of Thoracic Surgeons as an outcome measure in the Adult Cardiac Surgery Database to predict frailty in individuals who are candidates for cardiac surgery. However, there are no published reports of performance on this test in the literature. Therefore, the purpose of this study was to provide descriptive analysis of the 5MWT for individuals who were candidates for cardiac surgery.
Retrospective analysis of 113 preoperative cardiac surgery candidates who underwent a 5MWT. Gait speed calculated from the test was completed as part of preoperative testing administered by physical therapists. Three trials were performed with up to a one minute rest between trials. Differences by trial, gender, use of assistive device, and gait or postural deviations were determined using t-tests.
Mean gait speed was 1.05 (SD 0.26) m/s for the subjects. There was a statistically significant increase in gait speed from trial 1 to trial 3 by 0.05 (0.08) m/s (p < 0.0001). There were no significant differences in gait speed between males and females. Participants using assistive devices displayed a significantly slower mean gait speed of 0.70 (0.27) than those who walked unaided, with a mean gait speed of 1.08 (0.24) m/s (p < 0.0001). Participants with noted gait or postural deviations also walked significantly slower (mean 0.84, SD 0.22) than those without deviations (mean 1.15, SD 0.21) (p < 0.0001).
Subjects displayed a slight increase in speed from trial 1 to trial 3, reinforcing a cited benefit of the shorter distance of the 5MWT that may limit fatigue. Although statistically significant, the increase in speed from trial 1 to 3 may not be clinically significant in relation to the intent of the test. Significantly slower gait speeds were noted when a subject had an observable gait or postural deviation or used an assistive device.
gait speed; cardiac surgery; CABG
There are limited data describing mobility interventions provided to patients with femoral catheters. The purpose of this study was to examine the incidence of femoral catheter related adverse effects during physical therapy (PT) sessions in a cardiovascular intensive care unit (ICU).
This was a prospective, observational study and included patients with at least one femoral catheter. Data were collected after each PT session.
There were 77 subjects with a total of 92 femoral catheters (50 arterial, 15 central venous, and 27 dialysis) treated. A total of 210 separate PT sessions occurred with 630 mobility activities including sitting on side of bed, standing at the bedside, transfers to stretcher chair or regular chair, and walking. There were no catheter related mechanical or thrombotic complications during any of the PT sessions.
Physical therapy sessions, including standing and walking were feasible and safe in cardiovascular ICU patients with femoral catheters who met the criteria for mobility interventions. The results from this study support the hypothesis that early mobilization in patients with femoral catheters is important to minimize functional decline and provide evidence that the presence of femoral catheters alone should not be a reason to limit progressive mobility interventions.
physical therapy; ICU; early mobilization; femoral catheter
The study purpose was to assess perceptions of physical therapists (PTs) regarding the role of physical therapy in cardiovascular disease (CVD) prevention.
A 25-item survey, validated by expert cardiovascular/pulmonary (CVP) PTs, was sent electronically to 2,673 PTs. Each item represented an element of clinical practice behavior: education of CVD/risk factors (EDCVD), administration of primary CVD prevention (PRECVD), identifying underlying CVD/risk factors (IDCVD), monitoring CV status in patients with CVD (MONCVD). Responses were assigned numeric values (strongly agree = 5 to strongly disagree = 1), and mean element scores were analyzed.
Most of the 516 respondents were APTA Section members (34% CVP Section, 42% other Section membership) and worked in academia (53%). Items showing a high (> 95%) level of agreement included patient education of smoking (97%) and monitoring exercise intensity (99%), assessing exercise benefits (99%), clinically identifying obesity (97%) and hypertension (97%), and monitoring CV response to exercise (99%). Items failing to reach 80% overall agreement were patient education of CVD medications (79%) and blood chemistry (72%), and assessing CVD family history (75%), patient BMI (60%), and body composition (33%). Identifying underlying CVD (77.2%) was the only practice behavior failing to reach 80% agreement. Outpatient PTs agreed significantly less to all elements vs. academics, and to IDCVD vs. all PTs except home health.
Physical therapists support most CVD prevention behaviors, but not given elements of patient education and identifying underlying CVD/risk factors.
cardiovascular disease; primary disease prevention; secondary disease prevention
The purpose of this study is to report cardiorespiratory fitness levels among adults with diabetes and report differences by demographic (eg, body mass index) and behavioral (eg, physical activity) variables.
Data from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) were used in the analyses. Cardiorespiratory fitness was assessed using a non-exercise prediction equation and through a submaximal treadmill-based test using heart rate extrapolation. Participants completed a questionnaire to assess various demographic and behavior variables. Seventy eight participants met inclusion criteria and constituted the analyzed sample.
The majority (55.1%) of participants were estimated as having low or moderate cardiorespiratory fitness. Results showed that for both methods normal weight individuals had greater cardiorespiratory fitness than obese individuals, and for the non-exercise prediction equation, participants who sat during the day and did not walk very much had lower cardiorespiratory fitness (mean = 26.1 mL/kg/min [95% CI: 18.9-33.4]) than those doing heavy work or carrying heavy loads (mean = 34.6 mL/kg/min [95% CI: 30.2-39.1]).
These results suggest that obese and inactive adults with diabetes may be at an increased risk for morbidities and mortality associated with low cardiorespiratory fitness. Physical therapists are encouraged to apply evidence-based principles for exercise prescription and physical activity counseling to help patients with diabetes regulate their blood glucose control and improve cardiorespiratory fitness.
obesity; physical activity; physical therapy
For patients with end-stage heart failure awaiting transplantation, lack of donor organs has created an increased need for alternatives such as left ventricular assist device (LVAD) implantation. The purpose of this study is to determine safe and effective exercise parameters for physical therapy in the acute care setting.
A systematic literature review was conducted according to PRISMA guidelines using Sackett's Levels of Evidence to rate the evidence. Multiple databases were searched with inclusion criteria of: available in English, inpatient care up to 6 months postoperatively, description of intervention type and exercise parameters. Exclusion criteria: no defined exercise parameters, outpatient treatment, infection post VAD, or palliative or hospice care post VAD.
Six studies out of 1,291 articles met inclusion criteria. Common exercise parameters used were the Borg Rating of Perceived Exertion scale 11-13 (6-20 scale) or > 4 (0-10 scale), Dyspnea scale > 2 (0-4 scale) and > 5 (0-10 scale), mean arterial pressure (MAP) 70-95 mmHg, and LVAD flow > 3L/min. Levels of evidence ranged from case controlled to expert opinion.
Current evidence on inpatient exercise parameters for patient's status post LVAD implantation is not sufficient to suggest definitive guidelines; however, these exercise parameters provide a reference for patient care.
ventricular assist device; physical therapy; exercise
The ankle brachial index (ABI) is a valid and reliable measurement of lower extremity circulation and can be used as a screening tool for peripheral arterial disease (PAD), but the usage pattern in physical therapy practice is virtually unknown.
This study was performed to describe the phenomenon of using the ABI in outpatient physical therapy practice.
Nine participants from 3 different outpatient physical therapy clinics were provided with a hand held Doppler and education on how to accurately perform an ABI. Over a 3-month period, participants performed the ABI on any patient presenting with age > 50 with at least two risk factors for PAD. Immediately following the 3-month data collection period, two focus group interviews were performed to examine the therapist's experience using the ABI. Transcripts were analyzed to identify facilitators and barriers to implementation.
Facilitators identified include familiarity, ease of use, accuracy, and confidence with results. Barriers included flow and routine disruption, patient did not want/refused, and issues related to direct access.
Although some barriers to use of the ABI in an outpatient clinical setting need to be considered, most participants found the experience of using the ABI positive and feasible.
ankle brachial index; peripheral arterial disease; physical therapy
Following a cardiac event patients are at risk for deficits in mobility and function. However, measures of physical performance are not commonly used and have not been extensively studied in patients enrolled in cardiac rehabilitation. The purpose of this study was to determine the reliability and the minimal detectable change (MDC) of gait speed, 5 times sit to stand (5 STS) and hand grip strength for individuals enrolled in cardiac rehabilitation.
Forty-nine individuals enrolled in phase II or III cardiac rehabilitation participated in the study. Gait speed, 5 STS, and hand grip strength were measured over two sessions held on the same day. Intraclass correlation coefficient was used to determine reliability and MDC95 was calculated to measure responsiveness.
All 3 measures showed high reliability (ICC for gait speed = 0.96, 5 STS = 0.87, right hand grip strength = 0.97, left hand grip strength = 0.97). The MDC95 for gait speed was 0.16 meters/second, 3.12 seconds for 5 STS, 5.2 kilograms for right and 5.1 kilograms for left hand grip strength.
Gait speed, 5 STS, and hand grip strength are reliable and responsive measures for patients in cardiac rehabilitation. Findings support their use in clinical practice and future cardiac rehabilitation studies.
cardiac rehabilitation; gait speed; sit to stand
Physical therapists (PTs) have a unique opportunity to intervene in the area of health promotion. However, no instrument has been validated to measure PTs’ views on health promotion in physical therapy practice. The purpose of this study was to evaluate the content validity and test-retest reliability of a health promotion survey designed for PTs.
An expert panel of PTs assessed the content validity of “The Role of Health Promotion in Physical Therapy Survey” and provided suggestions for revision. Item content validity was assessed using the content validity ratio (CVR) as well as the modified kappa statistic. Therapists then participated in the test-retest reliability assessment of the revised health promotion survey, which was assessed using a weighted kappa statistic.
Based on feedback from the expert panelists, significant revisions were made to the original survey. The expert panel reached at least a majority consensus agreement for all items in the revised survey and the survey-CVR improved from 0.44 to 0.66. Only one item on the revised survey had substantial test-retest agreement, with 55% of the items having moderate agreement and 43% poor agreement.
All items on the revised health promotion survey demonstrated at least fair validity, but few items had reasonable test-retest reliability. Further modifications should be made to strengthen the validity and improve the reliability of this survey.
health promotion; physical therapy; validity; reliability
Cystic fibrosis (CF) is a disease that requires intensive multidisciplinary care, including care by physical therapists (PTs). People with CF are now living well into adulthood, necessitating a transfer of care from the pediatric setting to an adult one. Physical therapists play a large role in the care of the person with CF; however, there is little known about the PT role in transition of care.
To explore transition issues for people with CF from the perspective of PTs.
An 18-question online survey was sent to PTs via an electronic CF listserv. Questions were derived from an analysis of transition literature in CF and other chronic childhood conditions. Physical therapists who reported treating people with CF gave their opinions on issues impacting transition from their perspective as well as their perception of patient and parent concerns. Descriptive statistics were used for data analysis.
A total of 26 PTs completed the survey. A majority, 61.5%, reported that there was a transition program at their facility, with 42.3% involving physical therapy. Common themes for patients and parents included feeling uncertain about: knowledge of the adult physician, acquiring pulmonary infections in the adult setting, and pace of the adult clinic. Physical therapists were concerned about adherence with airway clearance and exercise following transfer to the adult clinic.
The role of PT in transition programs is quite varied. Physical therapists should address common concerns of their patients and families to improve the transition process and possibly impact adherence to the PT plan of care.
transition of care; cystic fibrosis; physical therapy
The primary purpose of this study was to investigate 6-minute walk test (6MWT) performance in young children who were normal weight (NW) and overweight (OW).
Seventy children, 5-9 years of age, participated in this study. The 6MWT was performed on an indoor walkway. Heart rate (HR), blood pressure (BP), and oxygen saturation (SaO2) were measured. A self-reported physical activity questionnaire was completed by a parent/guardian. Data were analyzed with independent t tests, ANOVA, correlation analyses, and logistic regression.
The systolic BP values were higher in the children who were OW compared with their NW peers (resting mean 104.1 (8.9) mmHg vs. 97.5 (7.8) mmHg, P < 0.05; post-6WMT: mean 118.4 (10.78) mmHg vs. 109.9 (9.1) mmHg, P < 0.05). The SaO2 values were lower in the children who were OW compared to their NW counterparts (resting: mean 97.2 (1.1) % vs. 98.0 (1.0) %, P < 0.05; post-6WMT: mean 96.8 (1.0) % vs. 97.7 (1.0) %, P < 0.05).
The children who were OW had higher systolic BP and lower SaO2 levels at rest and post-6WMT. More research is needed to determine if these differences contribute to children who are OW having difficulty performing exercise.
obesity; children; exercise capacity
One potential complication after cardiothoracic surgery involves mediastinitis, which may lead to a sternectomy. A sternectomy involves partial or total debridement of the sternum to remove infected bone. Little evidence regarding functional outcomes following sternectomy exists in literature. The purpose of this case series is to report the demographics of 6 patients admitted to a long term acute care hospital (LTACH) treated for sternectomy after open heart surgery, along with presenting length of stay (LOS) data, analyzing functional outcomes, and describing the physical therapy (PT) interventions used with these patients to obtain the reported functional outcomes.
Medical charts were reviewed retrospectively. Information in four main areas were extrapolated from the chart and further analyzed: patient demographics, length of hospital stay (acute care and LTACH), admission and discharge FIM scores, and information about the PT interventions (both numerical and descriptive).
Patients included 5 males and 1 female with an age range of 65-78 years old (mean 70 years old, SD 4.8 years). Patients had a total mean acute care LOS of 26.33 (12.26) days and total mean LTACH LOS of 27.67 (11.74) days. Median total FIM score at admission was 80.00 [range 58.00-94.00], while the median total FIM score at discharge increased significantly to 106.50 [range 86.00-116.00] (p = 0.031). Total mean FIM score change during LTACH stay (efficiency) was 25.17 (3.25), and FIM score change per day (efficacy) was 1.23 (0.46). Median motor score had a significant increase from admission to discharge (p = 0.031). Median cognitive score did not significantly change from admission to discharge (p = 0.125). PT interventions used with this patient population were presented and described, with a mean number of PT sessions in LTACH of 27.33 (15.38) (range = 10-46).
Although patients required an increased acute care LOS and an additional stay on LTACH, all 6 patients were discharged home following a course of multi-disciplinary inpatient rehabilitation on a LTACH unit. Patients are able to make significant functional gains during rehabilitation following sternectomy, as evidenced by increases in FIM score.
sternectomy; FIM; mediastinitis
The purpose of this study was to compare an Exercise Training Group (EX) with an Attention-Control Group (AT-C) to more specifically assess the impact of exercise training on individuals with heart failure (HF).
Forty-two individuals with HF were randomized to AT-C or EX that met with the same frequency and format of investigator interaction. Baseline, 12- and 24-week measurements of B-type naturetic peptide (BNP), 6-minute walk test (6-MWT), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were obtained.
BNP tended to increase in the AT-C while remaining stable in the EX over time. A clinically significant increase in 6-MWT was demonstrated by the EX but not the AT-C. The EX achieved a clinically significant change on the KCCQ at 12 weeks, with further improvement by 24 weeks, while the AT-C demonstrated a clinically significant change at 24 weeks.
Attention alone was inadequate to positively impact BNP levels or 6-MWT distances, but did have a positive impact on quality of life after 24 weeks. Although exercise offers enhanced benefits, individuals with HF unable to participate in an exercise program may still gain quality of life benefits from participation in a peer-support group that discusses topics pertinent to HF.
heart failure; attention; exercise
The purpose of the present review was to use existing, published data to provide an estimate of the amount of change in six-minute walk test distance (Δ6MWT) that represents a clinically meaningful change in individuals with chronic heart failure (CHF).
The present review included two separate literature searches of the CINAHL and Medline databases for articles that: (1) reported the intraclass correlation coefficient (ICC) of the 6MWT in individuals with CHF, and (2) used the 6MWT along with either aerobic capacity or health-related quality of life (HRQL) as study endpoints in randomized controlled trials (RCTs) of exercise-based intervention for individuals with CHF. The ICCs were used to calculate the minimum detectable difference (MDD) at the 95% confidence interval for each included study. The Δ6MWT associated with aerobic capacity and HRQL within-group effect sizes for the intervention and control groups in each included RCT was analyzed using receiver operating characteristic (ROC) curves.
Thirteen articles reported the ICC for the 6MWT. The mean (standard deviation) MDD calculated based on these data was 43.1(16.8) m. Eighteen RCTs measured the 6MWT and either aerobic capacity and/or HRQL. A Δ6MWT of 40–45 m was associated with at least moderate aerobic capacity and HRQL effect sizes in the intervention groups. The Δ6MWT thresholds that discriminated between intervention and control groups using ROC curves revealed the following sensitivity/specificity for the respective thresholds: 19 m, 94.4/83.3%, 32 m, 83.3/94.4%, and 48 m 44.4/100% (AUC = .935, p = .009, CI95% .855, 1.015).
A Δ6MWT of approximately 45 m appears to exceed measurement error and be associated with significant changes in either aerobic capacity and/or HRQL.
heart failure; six-minute walk test; clinically meaningful change; minimum detectable difference