CSM 2023 Cardiovascular and Pulmonary Poster Abstracts : Cardiopulmonary Physical Therapy Journal

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CSM 2023 Cardiovascular and Pulmonary Poster Abstracts

Cardiopulmonary Physical Therapy Journal 34(1):p a13-a35, January 2023. | DOI: 10.1097/CPT.0000000000000220
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Daniel Ravelo, Dror Yair, Philip Wiese, Noris E. Perez, Kyle Patrick Burnett, Joshua James Currie, Johnny Owens, Lawrence P. Cahalin

BACKGROUND AND PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) often experience respiratory and peripheral muscle weakness which can further result in sarcopenia, an unexplained loss of skeletal muscle mass and strength, producing activity intolerance and poor functional performance (FP). No literature has examined the effects of blood flow restriction training (BFRT) on pulmonary function (PF) in patients with COPD and sarcopenia, but one previous case study compared low-load BFRT to low-intensity resistance training (LIRT) finding substantial gains from low-load BFRT compared to LIRT. This case study examined the effects of high-load resistance training (HLRT) and low-load BFRT on PF in a patient with COPD and sarcopenia. CASE DESCRIPTION: A 72-year-old Caucasian male, BMI = 29.6 with COPD (GOLD 2) and marked sarcopenia using European Working Group on Sarcopenia Guidelines. Interventions began with a preparatory week of 3 sessions of upper and lower extremity (UE and LE, respectively) HLRT at 50% of 1 rep max (1RM) obtained using standard methods, followed by 60 to 90 minutes of UE HLRT and LE HLRT 3x/week for 4 weeks at 80% of 1RM. A 2-week detraining period followed HLRT after which bilateral LE and UE BFRT was performed 3x/week for 4 weeks at 30% of 1RM with 60% LE limb occlusion pressure via the Delfi system (Vancouver, Canada) and 30-15-15-15 repetitions with 30-second rests between sets. Heart rate (HR) and oxygen saturation (SaO2) were continuously monitored with blood pressure (BP) and electrocardiography (ECG) taken before and after all interventions. PF measures included forced expiratory volume at 1-second (FEV1), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), sustained maximal inspiratory and expiratory pressure (SMIP and SMEP, respectively), inspiratory and expiratory duration (ID and ED, respectively), and inspiratory and expiratory fatigue index test (IFIT and EFIT, respectively) using American Thoracic Society methods. OUTCOMES: BFRT was performed safely without adverse event and without ECG or BP abnormalities with an average HR and SaO2 range of 68 to 104 bpm and 88% to 100%, respectively. BFRT improved PF more than HLRT including FEV1 (81 vs 71% of predicted), MIP (102 vs 95 cmH2O), SMIP (718 vs 701 PTU), ID (13.5 vs 12 sec), IFIT (32 vs 28), MEP (100 vs 91 cmH2O), SMEP (874 vs 697 PTU), ED (13 vs 9.5 sec), and EFIT (36 vs 22). DISCUSSION: BFRT was performed safely without adverse event and without ECG or BP abnormalities with an average HR and SaO2 range of 68 to 104 bpm and 88% to 100%, respectively. BFRT improved PF more than HLRT including FEV1 (81 vs 71% of predicted), MIP (102 vs 95 cmH2O), SMIP (718 vs 701 PTU), ID (13.5 vs 12 sec), IFIT (32 vs 28), MEP (100 vs 91 cmH2O), SMEP (874 vs 697 PTU), ED (13 vs 9.5 sec), and EFIT (36 vs 22).


Amy Michelle Wedge, Wiley Hoover, Ryan Douglas Wedge

BACKGROUND AND PURPOSE: Most people recover fully after COVID-19, yet approximately 1 in 13 adults are experiencing Long COVID (i.e., Post-Acute Sequelae SARS-CoV-2 Infection) symptoms in the United States1 and is expected to increase in prevalence as COVID-19 continues to be problem. Patients with Long COVID are characterized by exercise intolerance and 72% develop Post Exertional Malaise (PEM)2 which presents as severe chronic fatigue and an increase in all Long COVID related symptoms3,4. The purpose of this case report is to help physical therapists who are treating people with Long COVID who may develop PEM by describing a patient with Long COVID who had improved with physical therapy (PT) but plateaued after developing PEM. CASE DESCRIPTION: A 58-year-old Hispanic female who was diagnosed with SARS-CoV-2 in October 2020 with mild symptoms that did not require hospital admission or supplemental oxygen. She presented to outpatient PT 7 months later with ongoing complaints of fatigue, muscle weakness, difficulty walking, and completing activities of daily living. She was subsequently diagnosed with Post-Acute Sequelae SARS-CoV-2 Infection (i.e., Long COVID). The interventions focused on pacing, breathing strategies, and resistance, functional mobility, gait, and balance training. The primary outcome measures were the timed up and go (TUG), 30 sec sit-to-stand (30STS), 6-minute walk test (6MWT), and preferred and fast walking speeds (PWS and FWS) with the 10-meter walk test. The patient made significant progress with PT, however, started to plateau with complaints of severe fatigue crashes after exercise. In February 2022, the patient completed the DePaul Symptom Questionnaire-Post Exertional Malaise (DSQ-PEM) with a frequency and severity score indicating PEM. We are reporting outcomes from 5 months pre-PEM, and 3 months post-PEM. OUTCOMES: The patient made improvements pre-PEM: 54% (18.4–8.37 sec) with the TUG; 233% (3–10 repetitions) with the 30STS; 257% (364–1300 feet) with the 6MWT; 15% (0.8–0.92 m/s) with PWS; 30.8% (1.2–1.57 m/s) with FWS. After February 2022, there was a 7.3% (8.45–7.83 sec) improvement with TUG; 0% (9–9 repetitions) improvement with the 30STS; 9.0% (1250–1137 feet) decline with the 6MWT; 10% (0.77–0.85 m/s) improvement with PWS; 24.0% (1.71–1.3 m/s) decline with FWS. DISCUSSION: Our patient had a plateau and even a slight decline in functional gains which may have been associated with the onset of PEM, as evident by the change in outcome measures between the pre- and post-PEM phases. Physical therapists should use outcome measures, such as the DSQ-PEM5, along with functional measures when treating those with Long COVID and carefully adjust interventions based on individual presentation, because onset of PEM will change rehab recommendations6. Due to the many unknowns surrounding Long COVID and PEM, more research is needed to develop interventions that will improve function and quality of life.


Kimberly Klein Cleary, Ansel LaPier, Hunter Johnston, Emmanuelle McKinney

PURPOSE/HYPOTHESIS: Restricting lifting, pulling, and pushing to less than 10 lb (4.5 kg) is a common precaution during post-fracture bone ossification. However, such significant restrictions limit independence and can contribute to longer hospital lengths of stay and a greater need for assistance and rehabilitation after discharge. Previous research has shown patients do not accurately estimate upper extremity (UE) weight bearing (WB) force. Muscle force is directly related to motor unit recruitment, and direct in vivo measurement during complex movement patterns is not feasible. Therefore, Pectoralis Major (Pec) electromyography (EMG) may be a good indirect indicator of lateral anterior thoracic cage forces. The purpose of this study was to develop a regression model to predict UE WB force equivalent using Pec EMG and other variables to monitor patients recovering from thoracic surgery or trauma. NUMBER OF SUBJECTS: Subjects (n = 65) were a convenience sample of healthy adults (aged 18–40 or 60–85) recruited from a university community. Exclusion criteria were recent (<6 months) significant medical event, pain exacerbated with UE activities, and contraindications for exercise participation as outlined by the American College of Sports Medicine Guidelines. MATERIALS AND METHODS: This retrospective study used pooled data of a within-subjects protocol with repeated measures. Surface EMG was used to measure bilateral Pec activity, and UE WB force was measured using dynamometers via an instrumented walker. Data were collected simultaneously at 5, 10, 20, and 30 lb intervals. Subjects also completed functional outcome measures including the Timed Up and Go (TUG). Statistical analyses included Simple Linear Regression (SLR), Multivariate Linear Regression (MLR), and Random Forest Regression (RFR) modeling to predict anterior thoracic forces (P < .05). The Coefficient of Determination (R2) was used to assess the strength of the regression models. RESULTS: Using SLR, the highest R2 values were found when using EMG and all force data points, and when breaking the data into older (0.343) and younger (0.293) cohorts. MLR using Pec EMG and resting heart rate (HR), TUG, and body mass index (BMI) produced the most robust model for both the old (0.519) and young (0.402) cohorts. In the older cohort, the model was further improved with the addition of handgrip strength. The RFR analysis did not improve R2 (0.100) over the SLR, so further RFR modeling was not pursued. CONCLUSIONS: Pec EMG was the strongest predictor of UE WB force equivalent. Breaking the data into older and younger cohorts and adding HR, TUG, BMI and handgrip strength improved the model's predictive ability. Therefore, patients' anterior thoracic force can be reasonably estimated using Pec EMG. CLINICAL RELEVANCE: Accurately estimating force across the anterior thoracic cage would help patients recovering from injury to the ribs or sternum. EMG estimation of force would help patients titrate resumption of UE activities and return to optimal function. Ultimately, this technique may help patients transition to home safely, especially those who may not have access to follow-up services.


Jamie Lynn O'Brien, Alexandra Morvai, Kendall Sanders, Jessica Nicole Weeks, Caroline Wolford, Shelby Yahl

PURPOSE/HYPOTHESIS: Aerobic exercise training has been shown to improve function and cardiorespiratory fitness following stroke.1,2 Moderate to vigorous intensity exercise training has shown improvements in gait speed, balance, and executive function.3 Current clinical practice guidelines recommend the use of moderate to vigorous cardiovascular training in the treatment of individuals following stroke.4,5 However, studies indicate that physical therapists (PTs) often face barriers such as time, space, staffing and equipment to implementing intensity based rehabilitation.6,7 The purpose of this study is to determine the use of intensity utilized during physical therapy evaluation and treatment following stroke. NUMBER OF SUBJECTS: One hundred five physical therapists. MATERIALS AND METHODS: This study was conducted under the approval of the University of Findlay's Institutional Review Board. Surveys were sent via electronic communication to PTs through list serves, clinical affiliations, and social medial platforms to United States based PTs who evaluate or treat individuals with neurologic conditions for at least 20% of their current clinical practice. Exclusion criteria were those who are not PTs and those who do not practice in the United States. Surveys were analyzed for response frequency. Mann Whitney U and Kruskal-Wallace analyses were conducted to determine between group differences. RESULTS: Survey respondents primarily held Doctoral degrees (81%), were APTA members (73%), and had more than 5 years of clinical experience (79%). Eighty-six percent of respondents were aware of the CPG, with 76% of respondents reporting they had read the CPG and 50% reporting they had implemented the CPG findings into their clinical practice. However, only 37% of PT reported to spend more than 50% of their treatment at moderate intensity, while only 16% spent over half of their session at vigorous intensity. Board Certified PTs were more aware of the CPG than non-board certified clinicians (P = .002), however there were no other statistically significant differences between groups for the use of moderate or vigorous intensity training at evaluation or treatment. While 64% of PTs indicated that assessing intensity was essential during patient treatment, PTs did not consistently utilize vital signs (only 39%) or Heart rate maximum (11%) to measure intensity. CONCLUSIONS: Physical therapists are aware of current clinical practice guidelines for the use of moderate to vigorous exercise training following stroke. However, implementation of the clinical practice guidelines lags behind knowledge. Additionally, while larger numbers of PTs report using moderate to vigorous intensity exercise, many are not quantitatively measuring intensity, and thus actual exercise thresholds may differ from reported thresholds. CLINICAL RELEVANCE: The Academy of Neurologic Physical Therapy has instituted strong efforts to implement knowledge translation related to moderate to vigorous exercise training. This study aimed to identify current practice patterns among physical therapists who treat individuals with stroke.


Matthew Paul Hernandez, Angelina Nigro

PURPOSE/HYPOTHESIS: To assess a patient's confidence as it relates to their discharge home from the hospital after coronary artery bypass (CABG) surgery using a department developed confidence survey, the “Post CABG Confidence Assessment” (PCCA). The PCCA was administered to eligible patients on post operative day (POD) 4, or 5 and again on the day of the patient's discharge from the hospital. The PCCA aimed to assess the patient's confidence in multiple areas of concern related to home discharges including ADLs, IADLs, safety awareness, activity tolerance, functional mobility, medical understanding and family support. NUMBER OF SUBJECTS: Seventeen post CABG surgical patients. MATERIALS AND METHODS: Subjects completed 2 PCCAs, the first on POD#4 or #5 (depending on physical therapist's (PT) and patient's availability) and the second PCCA on the day the patient was discharged from the hospital (D/C day). The PCCA was administered by a licensed PT who followed an assessment administration procedure which was reviewed prior to administration. Score totals and changes in scores between first and second completed PCCAs were calculated for each patient. RESULTS: Significant changes (improvement) in Average PCCA Scores (P < .05) from POD#4/#5 to D/C day were found. Significant changes (improvement) in raw scores (P < .05) for patient's understanding of sternal precautions (question #8) from POD #4/#5 to D/C day. CONCLUSIONS: The present study revealed a positive trend of patient reported confidence in functional mobility, ADLs, falls, activity tolerance, understanding of medical condition and social support system upon discharge from hospital following CABG surgery. The present study revealed a positive trend of patient reported confidence specifically in question #8—“I confidently understand my sternal precautions.” The present study demonstrated no statistically significant differences of PCCA scores between any of the 3 surgical groups (elective, urgent or emergent). CLINICAL RELEVANCE: Our findings suggest that over the course of a usual hospital stay status post CABG procedure, patients may demonstrate an increased confidence in areas of ADLs, IADLs, safety awareness, activity tolerance, functional mobility, medical understanding and family support. These results suggest that patients post CABG procedure demonstrate an improved understanding of their sternal precautions over the course of their hospital stay.


Dawn Louise Osborne, Elizabeth S. Moore, Heidi H. Ewen, Anne Mejia-Downs

PURPOSE/HYPOTHESIS: The purpose of this study is to investigate whether an educational session on cardiovascular disease (CVD) prevalence, signs, symptoms, and risk factors in women affects PTs and PTAs' knowledge of CVD and attitudes toward female CV screening including their views on professional roles and responsibilities, self-efficacy, and confidence in performing these tasks. NUMBER OF SUBJECTS: Study participants will be physical therapy professionals licensed in the United States and recruited from a state-level conference meeting. Eligible PTs or PTAs must have a minimum of one-year professional licensed experience. A priori power analysis was performed with an estimated sample size of 105 for a moderate effect. MATERIALS AND METHODS: The study is a quasi-experimental, single group, pretest-posttest design. The study will explore whether a single educational session about CVD in women would impact physical therapy professionals' knowledge of CVD in women and their attitudes toward performing CVD screening. The study will be approved by the University of Indianapolis Institutional Review Board prior to participant recruitment. The intervention will be an educational session about CVD and health prevention in women. Session objectives will center on raising awareness of the prevalence and impact of the disease, identifying CV signs, symptoms, and risk factors of CVD specific to women, and explaining the role of physical therapy in this health condition. Domains of the Determinants of Implementation Behavior Questionnaire (DIBQ) will be used to measure PTs and PTAs' knowledge about CVD in women and their attitude toward screening and educating their female patients about CVD. The Capability-Opportunity-Motivation-Behavior Model will be applied to the DIBQ domains and capability, opportunity, and motivation will be used to determine the variable(s) or combination of variables that best influence physical therapy professionals' willingness to perform the behavior of cardiovascular screening and education for their female clientele.1RESULTS: Results are pending following data collection in October 2022. CONCLUSIONS: CVD for women is a public health concern, and lifestyle modification and early screening could have tremendous effects to reverse its projected path.2,3 Additional healthcare professionals working to screen and educate women and fellow professionals positively affect change. Also, research has shown that continuing education improves the probability of physical therapy professionals performing various cardiovascular screening practices.4,5,6CLINICAL RELEVANCE: The proposed study will provide education on a significant public health issue and investigate determinants of behavior of physical therapy professionals regarding their willingness to engage in screening, prevention, and health promotion patient education. The study will contribute to the information on an important public health issue in which the physical therapy profession can make a positive contribution.


Hailey Wagner, Kristen Merrill PT, DPT, Bradley Hojek, Zachary E. Walston

BACKGROUND AND PURPOSE: Twenty-five to 50% of individuals who contract COVID-19 develop postural orthostatic tachycardia syndrome (POTS).3 The underlying etiology remains undetermined, yet there is research to support several root causes. Mechanisms such as dysautonomia, hypovolemia and prolonged bed rest leading to cardiac atrophy provide some indications.2,3,4 Recent research suggests that a structured and supervised training program that includes both aerobic and resistance components, was found to improve oxygen uptake, increase cardiac size, and increase blood volume.1,5 The purpose of this case study is to describe the successful treatment of a 13-year-old female diagnosed with POTS following COVID-19 using aerobic and resistance training. CASE DESCRIPTION: A 13-year-old female student who was being treated for hypermobility, contracted COVID-19 during her plan of care. During this time, she developed symptoms of lightheadedness, headaches, fainting episodes, dizziness and heart palpitations. Her rheumatologist performed an active head up tilt test that was negative for orthostatic hypotension but positive for tachycardia, which indicated a diagnosis of POTS. She was prescribed fluidicortisone with a dose of 1 mg twice per day and returned to physical therapy. The interventions included 40 minutes of zone 2 aerobic training with a heart rate range of 151 to 171 beats per minute (BPM) on a recumbent bike and 20 minutes of resistance training of the lower extremities at rate of perceived exertion (RPE) of 7 to 8. The intensity of the aerobic training progressed to zone 3 and greater aerobic training with a heart rate of at least 171 BPM when the resting heart rate was stabilized. OUTCOMES: The patient completed 26 visits over 4 months. Following the completion of the program, the resting heart rate of the patient returned to 76 BPM from a starting rate of 127 BPM. Heart rate response to exercise was congruent with the subjective RPE reported by the patient without any reoccurring symptoms previously experienced. An active head up tilt test was performed in the clinic without a tachycardic response indicating she was no longer positive for POTS. The patient was able to resume her previous extracurricular activities, including soccer, without symptom provocation. DISCUSSION: The physiological rationale supporting this conclusion consists of a decreased compensatory tachycardic response to upright positions, improved oxygen uptake, increased blood volume and increased cardiac size. Although there was a successful outcome to this case, there are some limitations. Psychological components should be monitored as well as a greater importance of RPE due to due to the inability to accurately detect heart intensity in the diagnosis of POTS.4,1.


James William Bellew, Trent Cayot, Dawson W. LaBaw, Trevor J. Edgerton, Samuel Allen Somesan, Sofia Simpson, Edwin Joseph Northam

PURPOSE/HYPOTHESIS: Reactive hyperemia (RH) represents limb reperfusion following a short period of ischemia induced by arterial occlusion. Most neuromuscular electrical stimulation (NMES) training protocols are sufficient to induce brief arterial occlusion in stimulated muscles. NMES and blood flow restriction (BFR) training are 2 distinctly different methods used in rehabilitation to increase local muscular metabolic demand and muscular strength. Recent evidence has shown that RH increases following NMES, but the magnitude of increase is dependent on the NMES waveform used. To date, no study has examined waveform-dependent effects of NMES combined with concurrent BFR on RH. This study was designed to examine the effects of NMES + BFR on RH using 3 commonly used NMES waveforms. Based upon previous data suggesting waveform-specific effects on RH, the hypothesis was that NMES + BFR would also show waveform-specific effects on RH. NUMBER OF SUBJECTS: Fifteen healthy, recreationally active men and women (10 male; 6 female; 23 ± 1.1 years of age) without neurologic, cardiovascular, or musculoskeletal impairment (e.g. ligament or meniscal injuries) were examined. MATERIALS AND METHODS: A single-session balanced repeated measures design was used. Near-infrared spectroscopy (NIRS) was used to measure microvascular oxygenation (SmO2) and microvascular blood volume (total hemoglobin concentration, THb) of the quadriceps during 5-minute recovery periods following ten, 10-second NMES contractions using each of 3 waveforms combined with BFR at 60% limb occlusion pressure. Three commercially available NMES waveforms were used for muscle activation; Russian, biphasic pulsed, and burst modulated biphasic pulsed. Two-way, repeated measures ANOVA was used to examine if NMES waveform and/or recovery time (at 1, 2, 3, 4, 5 min) affected the SmO2 or THb responses. RESULTS: SmO2 increased reaching near baseline levels (−0.3 to 2.6 ∆BSL) during the end of the five-minute recovery. THb decreased after the first minute of recovery reaching a steady state (0.08–0.13 ∆BSL) by the fifth minute of recovery. No differences between NMES waveforms were observed for the SmO2 or THb recovery responses. CONCLUSIONS: Following NMES + BFR, a significant RH response was noted for all 3 NMES waveforms showing greater microvascular blood volume (higher THb) and that the blood was oxygenated to at least baseline levels indicating the greater blood volume was oxygenated. No difference in magnitude of RH response noted between waveforms. CLINICAL RELEVANCE: Several patient populations, including those with heart failure, COPD, PAD, endothelial dysfunction, and patients with critical illness are known to show compromised RH. The findings of this study provide novel and clinically relevant evidence suggesting that NMES combined with BFR is an effective intervention to induce acute RH and that, despite previous evidence examining NMES alone, there is not a waveform-specific response when NMES is combined with BFR.


Debra Rone McDowell, Lois Ann Stickley

PURPOSE/HYPOTHESIS: Measurements of patients' vital signs (VS) including blood pressure (BP), heart rate (HR), respiratory rate (RR), and oximetry (SpO2) are an essential aspect of a physical therapist (PT) examination and the clinical decision-making process. Previous studies have indicated that these screening methods are infrequently practiced by outpatient physical therapists (PTs). The purposes of this study were to analyze the frequency of VS measurements by PT students during their outpatient clinical experiences and to analyze the differences in frequencies between outpatient settings representing different areas of practice. NUMBER OF SUBJECTS: Participants included 39 Doctor of Physical Therapy third-year students completing full-time clinical experiences. Participation was voluntary and did not affect evaluations of students' clinical experiences. MATERIALS AND METHODS: Participants documented which VS were measured during patient visits. Frequencies of VS taken in relation to number of patients were calculated, and a Chi-Square Test of Independence was computed to determine association between settings and venues with type of VS measured. RESULTS: Eighteen forms were completed and represented 7184 patient visits in various settings: orthopedic/musculoskeletal (n = 4796, 66.76%), geriatrics (0%), adult neurology (0%), cardiopulmonary (n = 398, 5.54%), sports (n = 1453, 20.23%), and pediatrics (n = 537, 7.47%) and types of outpatient venues: private practice (n = 5205, 72.45%), hospital-based outpatient (n = 1134, 15.79%), and “other” (n = 845, 11.76%). The sports setting (n = 1581; 0%) had the lowest number of measured VS, followed by pediatrics (n = 578; 1.03%), orthopedic/musculoskeletal (n = 4876; 6.54%), and cardiopulmonary (n = 149; 65.59%). Among outpatient venues, private practice demonstrated the lowest number of measured VS (n = 5494; 2.97%), followed by “other” (n = 748; 18.61%), and hospital-based outpatient (n = 942; 23.66%). Heart rate (n = 237; 3.03%) was the most measured VS and there were no reports of RR measurements (n = 0; 0.00%). Chi-Square analysis showed a statistically significant correlation between HR (P = .019) and BP (P = .019) in the following settings: cardiopulmonary, pediatric, and orthopedic/musculoskeletal. No statistical significance was found for SpO2 (P = .2) in any setting. CONCLUSIONS: Patients with unstable VS and cardiovascular disease are prevalent across most PT outpatient settings. Despite VS measurement being important for screening in outpatient settings, it is widely under measured and is utilized less than 10% of the time throughout most outpatient settings, except for cardiopulmonary. These findings are inconsistent with expectations of VS assessment set by The Guide to Physical Therapist Practice 3.0 and demonstrate implications for patient detection and management of cardiovascular-related conditions. CLINICAL RELEVANCE: Regularly taking vital signs to screen patients, identify need for referral, and monitor response to interventions are critical. Failure to monitor VS increases risk for adverse events which could be prevented with routine screening.


Isaac Eduardo Pardo Gonzalez, Raymond Chung Poon, Samira Tabatabaiepur, Dror Yair, Justin Thomas Hara, Sabine Martina Gempel, Meryl I. Cohen, Lawrence P. Cahalin

BACKGROUND AND PURPOSE: Wim Hof Breathing (WHB) consists of 3 or more sets of 30 full inhalations and exhalations followed by breath-holding (BH) for certain periods of time. The proposed benefits of WHB include improvements in mental clarity and cognition, autonomic nervous system activity, and cardiorespiratory performance (CRP), but little empirical research has examined WHB. The purpose of this case series report is to describe the chronic effects of WHB on CRP. CASE DESCRIPTION: Five healthy college students (1 female and 4 males) with a mean ± SD age, height, and weight of 31 ± 5 years, 179 ± 9 cm, and 85 ± 17 kg, respectively, underwent measurements of heart rate (HR), systolic and diastolic blood pressure (SBP and DBP, respectively), respiratory rate (RR), oxygen saturation (SaO2), and end-tidal carbon dioxide (PetCO2) via the CardioTECH monitor (Edan Instruments, Inc., China) before, during, and after WHB (performed for 11 min in synchrony with the WHB for Beginners YouTube video (https://www.youtube.com/watch?v=0BNejY1e9ik) at baseline and after 4 weeks of daily WHB. Daily WHB consisted of 3 sets of 30 full inhalations and exhalations followed by BH for at least 30, 60, and 90 seconds after set 1, 2, and 3, respectively. HR and SaO2 were monitored via oximetry (FS20F Finger Oximeter) during daily WHB and were recorded via the ViHealth mobile app, providing WHB effects and adherence. Wilcoxon signed-rank tests compared CRP measurements before and after 4 weeks of daily WHB with statistical significance set at P < .05. OUTCOMES: Daily WHB was performed without adverse event and a high level of adherence (84 ± 10%) with a mean ± SD high and low HR and SaO2 of 132 ± 29 and 51 ± 11 bpm and 99 ± 1 and 46 ± 15%, respectively. Despite the only significant change in CRP after 4 weeks of daily WHB being a lower SaO2 after the 60 second BH (92 ± 9 vs 96 ± 5%; P = .04), several notable findings suggesting improved CRP were observed including a 1) lower HR throughout and after WHB, 2) lower minute 1 and 2 post-WHB RR (10 ± 1 vs 17 ± 9 br/min and 9 ± 4 vs 12 ± 5 br/min, respectively), 3) higher minute 1 and 2 post-WHB PetCO2 (30 ± 6 vs 28 ± 6 mm Hg and 29 ± 6 vs 27 ± 7, respectively), and 4) lower resting SBP and DBP (117 ± 13 vs 124 ± 11 mm Hg and 69 ± 5 vs 73 ± 5 mm Hg, respectively). Also, the maximal BH duration increased after 4 weeks of WHB (61 ± 17 vs 48 ± 10 seconds; P = .08). DISCUSSION: Four weeks of WHB produced a significantly lower SaO2 after the 60 second BH due likely to increased tolerance to BH and maximal BH duration. Although no other significant changes in CRP were found after 4 weeks of daily WHB, the lower HR throughout each WHB stage and the lower resting SBP and DBP suggest improved CRP. Furthermore, the lower RR and higher PetCO2 post-WHB after 4 weeks of daily WHB further supports improved CRP and tolerance to hyperventilation and hypoxia associated with WHB. Thus, WHB may be an important method to improve CRP and tolerance to hyperventilation and hypoxia in activities or sports in which such breathing effects are needed. Further examination of WHB on CRP appears warranted in view of a likely Type II error.


Matthew Marcus Walko, Taylor Nicole Heggan, Hannah Elizabeth Nestor, Elizabeth Schultz, Kara Wendling

BACKGROUND AND PURPOSE: Cancer and its sequelae cause cancer survivors to have health disparities, compared to their age-matched healthy peers, including reductions in overall fitness, ADL function, quality of life (QoL), and autonomic function. Interventions and resources, including physical therapy, can attenuate these disparities. Evidence shows that such interventions can improve outcomes in physical function and psychosocial measures. The purpose of this case study was to view the benefits of exercise for a cancer survivor and the effectiveness of telehealth and electronic supervision. Exercise-based interventions assist survivors in battling the side effects of cancer. CASE DESCRIPTION: The participant was a 49 year old female, 5 feet 7 inches tall, weighing 156 pounds. Medications included Anastrozole, Pentoxifyllin-E ER, Carvedilol, Rosuvastatin, and Candesartan. The patient was first diagnosed with melanoma at age 34, and was treated with surgery and chemotherapy. At the age of 48, our participant received her second cancer diagnosis of breast cancer stage 1B. She underwent double mastectomy and lymph node resection. Following her surgery and medication regimen, the patient noted reductions in her physical fitness, ADL performance, and quality of life (QOL). The participant was recruited via electronic survey in August 2021. Following informed consent, the patient completed 6MWT, 5x sit-to-stand test (5x STS), resting heart rate (RHR) and blood pressure (BP) measurements, and SF-36 via Zoom supervision. She then participated in a - week aerobic and strengthening program delivered via telehealth; her exercise prescription was based on her initial data and weekly updates, and exercise instruction was completed via original video posted to social media for ease of use and reference. Outcome measures were repeated at the conclusion of the program. OUTCOMES: The subject showed a 2 bpm decrease in resting RHR (68–66 beats per minute), 2 mm decrease in systolic BP (132–130) and 8 mm decrease in diastolic BP (88–80), an increase of 54 m (MCID 30.5 m) in her 6MWT distance (665–719), a 4.7 s (MCID 2.3 s) reduction in her 5x STS (12.96–8.26 s); she also recorded changes in SF-36 categories above the MCID: role limitations due to physical health (25% −100%, MCID 37%), pain (57.5% to 90%, MCID 27%), and general health (85% −100%, MCID 12%). DISCUSSION: This case study reinforces previous findings of supervised telehealth-based exercise programs promoting improvements in health, fitness and quality of life. The participant found the use of social media-based video exercise instruction to be helpful and easy to use, and reported high satisfaction with weekly telehealth check-ins.


Edwin Patrick Monroy

PURPOSE: To demonstrate how the use an audible handheld doppler ultrasound can help clinicians determine if compression can safely be applied to patients with lower extremity edema in setting of micro and macrovascular disease. DESCRIPTION: Much has changed in our understanding how edema is managed within our body but also when determining if compression is appropriate to apply in patients with an edematous limb. This includes those patients with infections, deep vein thrombosis, systemic edema, post op vascular bypass sites and peripheral arterial disease (PAD). Lack of access to an onsite vascular lab delays physical therapists from initiating compression to patients with peripheral edema, especially when training is limited to taking an ankle brachial index (ABI). Patients with mixed disease and diabetes have inaccurate ABIs due to the calcification within the arterial vessel walls that develop. This discussion will include research showing how using an audible handheld doppler on the pedal arteries is comparable to taking ABIs with toe pressures and how hearing for a biphasic and triphasic waveform can help a clinician determine that inelastic compression can safely be applied for these patient populations. Patient cases showing how to perform and appropriately hear for these waveforms will be shown along with tips on applying compression based on the materials available to therapists in their respective settings. SUMMARY OF USE: Physical therapists utilization of a handheld doppler ultrasound across all settings can help reduce delays in care, provide information for earlier referrals to a vascular physician and ultimately make a significant impact on a patient's health in a system that undervalues preventive care. IMPORTANCE TO MEMBERS: Physical therapists come across patients with peripheral edema in all settings that can be acute or chronic in nature and many times unrelated to what they are being seen for. Understanding when and how to intervene is crucial to prevention of not only integument/vascular issues but also with respect to a patient's functional mobility. Ultimately, by elevating our practice we can better serve our patients across all settings.


Claire Elise Child, Maddalena Di Piazza, Mikayla Minton, Jose Ugas, Avry Freaney, Marion Paetznick, Soraya Bailey, Mary Beth Brown

PURPOSE/HYPOTHESIS: Commercially-available pulse oximeters offer a noninvasive and rapid approximation of arterial blood oxygen saturation. Measurement error due to motion artifact is a known challenge of pulse oximetry. Despite evidence that exercise training is safe and effective for ILD, exercise remains a far underutilized therapy. Patients with ILD may limit their participation in exercise because they do not trust pulse oximetry devices during movement. The purpose of this study was to characterize the felt needs and preferences of persons with ILD regarding pulse oximetry monitoring devices during home exercise. NUMBER OF SUBJECTS: Sixty-four persons with lymphangioleiomyomatosis (LAM) and 29 persons with pulmonary fibrosis (PF). MATERIALS AND METHODS: We conducted a rapid user needs assessment using mixed quantitative and qualitative methods. An anonymous, web-based survey was distributed via the official email list serves and social media groups of disease-specific advocacy foundations for LAM and PF. We then completed 30 to 60 minute semi-structured interviews to gain further insight into pulse oximetry user needs. Study procedures were approved by the University of Washington Institutional Review Board. RESULTS: A total of 93 survey responses were collected (n = 64 persons with LAM, n = 29 persons with PF) and 19 semi-structured interviews were completed (n = 16 persons with LAM, n = 3 persons with PF) between November 2021 and February 2022. Participants owned on average 3 ± 2 (range 1–9) different pulse oximetry devices, including medical grade, over-the-counter, and wrist-wearable or smartphone-based oximeters, with prices ranging from about $20 to $1000. Nearly all participants regularly monitor pulse oximetry outside of clinic settings. Interestingly, 13.7% reported monitoring pulse oximetry only when they are physically active. Challenges reported include that devices do not give readings unless users are at rest, and it is awkward to keep a fingertip pulse oximeter on for long periods of time. From the qualitative interviews, additional user challenges were thematically analyzed and included frustrations with the inability to find devices that generate readings during exercise, fears about the health implications of low or dropped oximetry readings during exercise, and mistrust relying on values to guide titration of supplemental oxygen. CONCLUSIONS: These results show that current commercially-available pulse oximeters largely do not meet the needs and preferences of persons with ILD that are at an increased risk for exercise desaturation. Several challenges and opportunities were identified to improve the user experience associated with pulse oximetry use during exercise. These findings motivate the need for further design and engineering innovations to improve the accuracy and user experience of pulse oximeters for patients at risk for exercise desaturation. CLINICAL RELEVANCE: Patients with ILD may benefit from additional education about the functionality and accuracy of their pulse oximetry devices during exercise. Design innovations towards more exercise-friendly pulse oximetry devices may promote increased exercise participation by persons with ILD.


Matthew Marcus Walko, Kodee Lynn Bair, Jenna Kathryn Lysakowski, Shelby Nicole Hoke, Julia Elizabeth Seltzer, Luke Boulden Tamberino

PURPOSE/HYPOTHESIS: It is known that anxiety can negatively impact autonomic nervous system function, as evidenced by decreased parasympathetic measures of heart rate variability (HRV), including the standard deviation of normal to normal (SDNN) and root mean square of successive differences (RMSSD) measures. It is also known that screen time via the use of smartphone devices, particularly to consume social media, can cause anxiety. We investigated the link among smartphone screen time (ST), social media (SM) use, anxiety, and measures of HRV. Additionally, we hypothesized that subjects' aerobic fitness could offset the effects of ST, SM and anxiety on HRV measures. NUMBER OF SUBJECTS: Thirty eight (38) college-aged students (21 female, 17 male, 0 identifying as non-binary), mean age 23.05 (±2.525). MATERIALS AND METHODS: Subjects enabled their smartphones' internal apps to monitor their ST and SM for a period of 7 consecutive days. On day 8, subjects' free-breathing resting 5-minute 1-lead ECG was obtained using the KardiaMobile 6L device, and HRV measures were calculated using Kubios HRV Premium Software. Subjects total ST and total SM were recorded. Subjects also completed the generalized anxiety disorder 7-item scale (GAD-7) and a one-mile submaximal run/walk test to estimate maximal VO2 (VO2 max). RESULTS: ST (mean 1835 min per week, ± 755) and SM (mean 710 minutes per week ± 461) were not significantly correlated with HRV measures (SDNN mean 51.95 ± 27.30; RMSSD mean 53.35 ± 36.47), including SM and SDNN (r = .079, P = .637) or SM and RMSSD (r = .084, P = .618); correlations of GAD-7 (mean 5.08 ± 4.79) and ST (r = .310, P = .058) and SM and GAD-7 (r = .308, P = .060) approached significance. As anticipated, VO2 max (mean 43.01 ml.kg/min ± 7.93) showed a statistically significant negative correlation with GAD-7 (r = −.340, P = .037); however, there was no correlation between VO2 max and ST or SM usage. CONCLUSIONS: Smartphone use, as measured by weekly ST and consumption of SM, does not significantly influence measures of resting cardiac autonomic function as determined by measures of heart rate variability (SDNN and RMSSD). CLINICAL RELEVANCE: Despite links between ST and SM consumption and anxiety, and links between anxiety and resting HRV measures, we found no statistically significant correlation directly linking ST or SM with resting HRV measures. This relationship was not impacted by subjects' aerobic fitness. Our evidence indicates that ST and use of SM may not have the negative impacts on cardiac autonomic function that past literature predicts. Researchers will complete further investigation on this topic.


Katy N. Blessing, Ryan Lee Dawson, Raven Alexis Giles, Kierra N. Henderson, Nancy Maria Kuhn, Lauren Marie Strohman, Mitchell D. Terry, Julie Marie Skrzat

PURPOSE/HYPOTHESIS: To investigate if there is an association between physical therapy (PT) frequency and discharge disposition in patients admitted to a cardiac service (CS). We hypothesized that there will be an association between patients who receive >0.57 PT visits and discharge home. NUMBER OF SUBJECTS: Thirty-seven Inclusion criteria included ≥18 years of age, PT consult, admitted to the cardiac service, and AMPAC score between 12 to 17 at PT initial evaluation. Exclusion criteria included vulnerable populations. MATERIALS AND METHODS: A retrospective chart review was conducted over a 3-month period. Subjects were stratified by frequency of PT visits: ≥0.57 or <0.57 with the cutoff determined as 4 visits over 7 days. Discharge dispositions included home with or without home PT services, skilled nursing facility (SNF), inpatient rehab (IP), or other. Statistical analyses included demographic and descriptive statistics, Chi-square analysis, and odds ratio. RESULTS: Thirty-seven subjects were included (mean age = 79 years, 12 females). The top 3 admitting diagnoses were valvular disorders (27%), heart failure (16%), and myocardial infarctions (16%). Thirteen subjects received ≥0.57 PT visits throughout their hospitalization. The frequency of discharge dispositions was as follows: home = 59.46%, SNF = 24.32%, IP = 13.51%, and other = 2.70%. There was no significant association between PT frequency and discharge location (X2 = 0.48, P = .79). An odds ratio demonstrated that patients were 1.43 times more likely to be discharged home if they received ≥0.57 PT visits. There was a statistically significant difference in AMPAC score between PT initial evaluation and last PT visit (P = .0018). CONCLUSIONS: There was no statistically significant association between PT frequency and discharge disposition. This could be due to a small sample size with an uneven distribution between frequency groups and discharge locations. However, patients were 1.43 times more likely to be discharged home if they received ≥0.57 PT visits. CLINICAL RELEVANCE: Prioritizing patients on a PT caseload and allocating staffing resources remains a challenge in the acute care setting. This study builds upon previously published literature examining PT frequency and discharge disposition; however, it is unique in isolating patients admitted to the CS with a primary diagnosis being a cardiac pathology. Future studies should consider a larger sample size to discriminate amongst discharge locations and focus PT interventions to improve score to optimize discharge to home.


Timothy Gray, Emily Borders, Haotian Cai, Barbara Gordon, Tor Olson, Kate Traylor, Lawrence Ho, Claire Elise Child, Mary Beth Brown

PURPOSE/HYPOTHESIS: Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease characterized by thickening of the lung interstitium resulting in impaired gas exchange and reduced exercise capacity. The purpose of this cross-sectional study was to compare performance in maximal and submaximal exercise testing, and how testing variables relate to clinical indicators of disease severity and health-related quality of life (HRQL). NUMBER OF SUBJECTS: Fifteen adults with IPF (age 67.1 ± 9 years, range 46–79, 4 female) stable on antifibrotic therapy and enrolled in a randomized controlled trial (NCT04838275). MATERIALS AND METHODS: Subjects completed 1) 6-minute walk test (6MWT) with supplemental oxygen (O2) use permitted, 2) cardiopulmonary exercise test (CPET) using Balke (or modified Balke) treadmill protocol without supplemental O2, 3) pulmonary function tests (PFTs), and 4) the St. George's Respiratory Questionnaire for IPF (SGRQ-I). Relationships were analyzed using Pearson correlations. Data are presented as mean ± SD. RESULTS: In 6MWT, a distance of 462 ± 68 m (89 ± 14 %predicted) was achieved with a nadir (lowest value of) SpO2 of 91 ± 5%. Four subjects used supplemental O2 (range 2-6LPM) during 6MWT. In CPET, subjects achieved 24 ± 5 mL/kg/min VO2max, 8.6 ± 4 min time to VO2max, and 7 ± 1.4 peak METs, with a nadir SpO2 of 84 ± 5%. 6MWT distance positively correlated to VO2max (r = 0.53, P = .04) and time to VO2max (r = 0.58, P = .02). Less 6MWT distance was observed for patients with worse lung function in PFTs including for FEV1 (L) (r = 0.71, P = .003), FVC (L) (r = 0.56, P = .04), and DLCO (mL/min/mm Hg, corrected for hemoglobin) (r = 0.69, P = .007). Interestingly, all SGRQ-I total and domain scores inversely related to 6MWT and CPET capacity and effort variables. Less patient-reported impairment on SGRQ-I was observed in patients with greater 6MWT distance (r = −0.71, P = .003). Participants with more impairment in the Activities domain of the SGRQ-I also reported more dyspnea during 6MWT (r = 0.61, P = .02), higher supplemental O2 use during 6MWT (r = 0.58, P = .02), and lower CPET nadir SpO2 (r = −0.57, P = .03), with lower % predicted DLCO (r = −0.66, P = .01). CONCLUSIONS: In adults with IPF that are stable on antifibrotics, multiple relationships exist between 6MWT and CPET capacity and effort variables, as well as clinical measures of disease severity and HRQL. The 6MWT relates to VO2max via CPET, risk for exercise desaturation in CPET, disease severity via PFTs, and HRQL. Strong correlations between SGRQ-I scores and pulmonary function suggest that patient-reported symptoms and impact on quality of life are important indirect indicators of disease severity. CLINICAL RELEVANCE: The 6MWT is widely used in clinical practice as a measure of submaximal exercise capacity and for prescription of home supplemental O2 for IPF. Strong correlations with CPET and PFTs support the use of 6MWT for measuring function and dyspnea in patients with IPF. The SGRQ-I is another low-resource instrument that informs disease-specific impact on HRQL.


Michael Ross Ainbinder, Peter Andrew Altenburger, Elizabeth Anne Staats, Valerie Ann Strunk, Amy J. Bayliss

PURPOSE/HYPOTHESIS: The COVID-19 pandemic has taken a toll on the psychological resilience of healthcare workers across the world but has also had a significant impact on healthcare professionals in training. The pandemic has required educators to adapt how they teach but also to take into consideration innovative learning activities to increase students' resiliency. The purpose of this study was to assess the impact of high-fidelity human simulation (HFHS) sessions on acute care confidence in a critical care setting in physical therapy students' who rate their resiliency at low levels. NUMBER OF SUBJECTS: Eighty-one DPT students. MATERIALS AND METHODS: One week prior to the HFHS sessions each subject completed the Acute Care Confidence Survey (ACCS) and the Brief Resiliency Scale (BRS). All subjects participated in 2 HFHS sessions in a 3-member team and were given objectives and a case history 1 week prior to each HFHS experience. The HFHS used the Laerdal's SimMan 3G manikin equipped with an oxygen delivery system, lines and tubes and a monitor displaying vitals. The format for each simulation lab included a 15-minute pre-brief session, a 20-minute SimMan encounter and an immediate 15-minute debrief session. Following the completion of the HFHS learning experience each student completed a second ACCS. RESULTS: A Kruskal-Wallis test was used to compare confidence score across low, normal, and high resilience groups. Low and normal resiliency level students had significantly lower confidence in manual skills prior to simulation (P < .05) compared to their high resiliency counterparts. Following simulation, all resiliency groups demonstrated confidence improvement that resulted in no significant differences between the groups. A Wilcoxon Signed Ranks Test revealed significant improvement in all confidence scores for each group following simulation. CONCLUSIONS: Resiliency levels did not impact students' ability to gain confidence from simulation training. HFHS when graded has been shown to increase stress and decrease confidence in students. These HFHS learning activity exposures were not graded which may have allowed those students with lower resiliency to learn in a less stressful environment and still develop confidence. A positive change in student confidence may be more related to a graded exposure to an acute care setting that allows skill development in a low stress environment. CLINICAL RELEVANCE: The simulation sessions increased student confidence by providing a realistic clinical environment and expectations, with confidence being less impacted by a student's resiliency. This low stake learning environment provided a valuable opportunity for students to improve clinical confidence regardless of their self-rated resiliency level.


Justin Thomas Hara, Samira Tabatabaiepur, Raymond Chung Poon, Dror Yair, Isaac Eduardo Pardo Gonzalez, Sabine Martina Gempel, Meryl I. Cohen, Lawrence P. Cahalin

BACKGROUND AND PURPOSE: Wim Hof Breathing (WHB) has been described as power breathing during which 3 or more sets of 30 full inhalations and exhalations are followed by breath-holding for certain periods of time. The proposed benefits of WHB include stress reduction, greater focus and mental clarity, and improvements in the autonomic nervous system (ANS), cognition, cardiorespiratory system (CRS), and metabolic/physical performance, but little empirical research has examined the effects of WHB. The purpose of this case series report is to describe the acute effects of WHB on the CRS. CASE DESCRIPTION: Five healthy college students (1 female and 4 males) with a mean ± SD age, height, and weight of 31 ± 5 years, 179 ± 9 cm, and 85 ± 17 kg, respectively, underwent measurements of heart rate (HR), systolic and diastolic blood pressure (SBP and DBP, respectively), respiratory rate (RR), oxygen saturation (SaO2), and end-tidal carbon dioxide (PetCO2) via the CardioTECH monitor (Edan Instruments, Inc., China) before, during, and after WHB. WHB was performed for 11 min in synchrony with the WHB for Beginners YouTube video (https://www.youtube.com/watch?v=0BNejY1e9ik). WHB consisted of 3 sets of 30 vital capacity breaths followed by expiratory breath-holding for 30, 60, and 90 seconds (or until the breath could no longer be held) immediately followed by 15 second inspiratory breath holds after each respective set. Wilcoxon signed-rank tests compared CRS measurements before, during, and after WHB with statistical significance set at P < .05. OUTCOMES: WHB was performed without adverse event and produced a significant (P = .04) increase in HR and RR from baseline during all 3 of the 30 full inhalations and exhalations (70 ± 9–94 ± 15 bpm and 10 ± 3–16 ± 1 br/min, respectively) and a significant (P = .04) decrease in PetCO2 from baseline during all 3 of the 30 full inhalations and exhalations (35 ± 8–20 ± 6 mm Hg). The SaO2 decreased during all 3 breath holds, but was significantly (P = .04) less than baseline only after the 90 second breath-hold (99 ± 1–85 ± 11%). After WHB all outcome measures returned to baseline by minute 2 post-WHB except for PetCO2 which was significantly (P = .04) less than baseline (27 ± 7 vs 35 ± 8 mm Hg). SBP was unchanged and DBP increased minimally during WHB (124 ± 11 and 124 ± 19 mm Hg and 73 ± 5 and 76 ± 8 mm Hg, respectively). DISCUSSION: WHB produced significant acute effects on the CRS including HR, RR, PetCO2, and SaO2 all of which returned to baseline by minute 2 post-WHB except for PetCO2. The acute effect of WHB on SBP and DBP was minimal. The significant acute effects of increasing HR and RR and decreasing PetCO2 and SaO2 is likely to elicit a variety of physiological responses the most prominent of which is stimulation of the sympathetic nervous system which has the potential to produce some of the proposed benefits of WHB. One study examining the effects of WHB on the CRS found results similar to ours, but further examination of the acute and chronic effects of WHB on the CRS, other systems, and functional performance appears warranted.


Tanya Kinney LaPier, Brianna Hunting, Amy Penner, Sean Sibley

PURPOSE/HYPOTHESIS: Median sternotomy is commonly performed to access the heart during cardiac surgeries. Sternal precautions are often implemented following median sternotomy with the goal of reducing complications but restricting arm activity may contribute to loss of patient function. There is little data on how upper body functional activity resumption occurs in patients after hospital discharge following median sternotomy. We developed a technique using multiple accelerometers to distinguish between specific, purposeful arm movements and total, whole-body arm movements. The purpose of this pilot study was to evaluate the concurrent validity of a tri-accelerometer technique to measure arm movement during upper body activity using established self-report outcome measures. NUMBER OF SUBJECTS: This study included 17 volunteers (65–80 years old) who were able to perform arm activities without pain or limited functional range of motion and who had not experienced a major medical problem (e.g. myocardial infarction) in the past 6 months. MATERIALS AND METHODS: We used ActiGraph GT9X Link Activity Monitors and placed them on each wrist and at the waist of study participants for 4 consecutive days. Step count data obtained from the waist monitor (gait VMC) was used to determine periods walking during which UE movement was assumed to be arm swing. This allowed determination of both total and specific arm movement not associated with gait (total – gait VMC). Study participants also completed a series of self-report outcome measures including the International Physical Activity Questionnaire (IPAQ), Heart Surgery Activity Questionnaire (HSAQ), and RAND Short Form Health Survey (SF-36). Pearson Correlations were calculated between the vector magnitude counts (VMC) from the activity monitors and the IPAQ, SF-36, and H-SAQ scores (P < .05). RESULTS: The total and total minus gait VMC data obtained was significantly correlated (r > 0.42) with total walk, total moderate physical activity + walk, and total physical activity categories of the IPAQ. Our tri-accelerometer technique to measure arm movement during upper body activity resulted in data that was inversely related to SF-36 scores. The activity monitor VMC values were not significantly correlated with the total H-SAQ frequency or difficulty scores. CONCLUSIONS: The strength of the relationship between scores on the IPAQ and the VMC obtained with our tri-accelerometer technique were moderate, which supports its concurrent validity. Unexpectedly, SF-36 subscale scores were inversely related to the activity monitor VMC perhaps due to the relatively high functional level of our study participants. We only used H-SAQ total frequency and total scores which may not be sensitive enough indicators of daily arm activity. CLINICAL RELEVANCE: An objective method to understand the trajectory of recovering following median sternotomy and evaluate prognostic indicators of and interventions to prevent loss of upper body function would be clinically useful. Future studies are needed to determine the utility and validity of our tri-accelerometer technique in patient populations.


Katy N. Blessing, Katelin Gorski, Amanda Fink, Elizabeth A. Wetzler

BACKGROUND AND PURPOSE: As the number of individuals with end stage heart failure grows, so does the need for alternative treatments1. Left ventricular assist devices (LVADs) are mechanical circulatory support systems that allow blood to bypass the malfunctioning ventricles to maintain optimal blood flow.1 The placement of LVADs can lead to several complications, one of the most common being right heart failure (RHF).1,2,3 Severe cases are addressed with the use of a temporary right ventricular assist device (RVAD).2 This case study describes the role that physical therapy (PT) plays in treating newly implanted LVAD patients with the presence of a temporary RVAD by promoting early mobility to increase functional capabilities and advance to the next level of care. CASE DESCRIPTION: Case One is a 69 y/o male who was admitted to the Cardiac Intensive Care Unit (CICU) with hyponatremia and left heart failure (LHF). Ejection fraction (EF) on admission was 25% and LVAD evaluation was initiated. Patient was implanted with LVAD on hospital day 21. Post-operative course was complicated by volume overload due to RHF. RVAD was placed on hospital day 25 and PT evaluation was completed on hospital day 26. Case Two is a 53 y/o male who was admitted to the advanced heart failure service with shortness of breath. At this time, EF was noted to be 20% and patient was milrinone dependent. Patient began to decompensate and was implanted with LVAD on hospital day 17. During procedure, RHF was discovered to be extremely poor and RVAD was placed in the operating room. Once patient was medically stable, PT evaluation was completed on hospital day 20. Treatment program for both patients consisted of bed mobility, transfer training, balance training, muscle strengthening, LVAD management tasks, and assisted cough/deep breathing techniques. For each therapy session, the treatment team present consisted of physical and/or occupational therapist, cardiac rehabilitation therapist, bedside nurse, and perfusionist. OUTCOMES: Case One received 29 post LVAD PT sessions during acute care stay. Of these, 9 sessions were completed in the presence of the RVAD. Patient’s AM-PAC scored improved from 7/24 to 17/24 during hospital course. Patient was discharged to the acute inpatient rehabilitation center on hospital day 56. Case Two received 23 post LVAD PT sessions during acute care stay. Fifteen sessions were completed in the presence of the RVAD. Improvement from 6/24 to 24/24 was documented from PT initial evaluation to final PT session. The progression in functional status allowed this patient to be discharged directly home with home PT on hospital day 45. DISCUSSION: Early mobility following LVAD implant is essential to optimize respiratory function, decrease risk of DVT/PE, decrease the risk of ICU acquired neuropathy/myopathy, improve functional mobility and independence.4,5,6 This case study demonstrates that physical therapy can be safely implemented following LVAD implant when complicated by RHF/RVAD placement when the appropriate multidisciplinary team approach is utilized.


Kelly Harbron, Miriam Rose Rafferty, Kristen Hohl, Sandra A. Billinger

BACKGROUND AND PURPOSE: Submaximal graded exercise testing (GXTsubmax) is rarely used during inpatient (IP) rehabilitation, and there is little research supporting its use. Lack of exercise testing limits optimal exercise prescription using target heart rate (HR) zones, which are important for high intensity gait training and rehabilitation. The purpose of this study was to help determine whether GXTsubmax was (1) safe, (2) feasible and (3) able to inform a target training HR zone in people with medically complex diagnoses. CASE DESCRIPTION: Nine patients in IP rehabilitation were identified via therapist referral and chart review (7 males; mean age ± standard deviation 57 ± 13 years). Diagnoses were stroke (n = 2), COVID rehab (n = 4), limb loss (n = 2), and oncology (n = 1). All participants were considered medically complex with significant cardiac and pulmonary disease comorbidities. They received medical clearance to participate in the GXTsubmax. We used the total body recumbent stepper submaximal exercise test (TBRS submax) for the exercise test. Oxygen saturation, heart rate, rate of perceived exertion (RPE) and blood pressure were monitored. Termination criteria included reaching one of the following: 85% HR Max, RPE 17, SpO2 drop <90%, patient requests to stop, or end of test. A target HR zone was chosen through comprehensive performance analysis including HR and RPE. HR zones were identified that correlated with Borg RPE zones 11 to 15/20. Once these HR zones were determined, we compared them to calculated target HR zones using Karvonen's Formula (Moderate exercise intensity 40%–60% HRR) and estimated peak VO2. OUTCOMES: Nine patients completed 1 or 2 tests during their length of stay, resulting in 15 tests analyzed. There were no serious adverse events. Two tests were terminated at the end of the first stage (3 minutes), 7 tests by the end of the second stage (5–6 minutes), 3 tests by the end of the third stage (7–9 minutes), and 3 tests made it to the fourth stage (11–12 minutes). Reasons for termination were: 11 (73%) reached the RPE 17, 1 SpO2 was 89%, 1 reached 85% HR max, and 2 completed the test. The total duration for set up and completion was less than 30 minutes. Physical therapists (n = 3) reported the TBRS submax was feasible, billable, and provided a valuable opportunity for patient education on exercise intensity. Based on RPE and patient performance, therapists suggested a lower initial target power (15 watts vs 30 watts) and reduce the stepwise workload changes to accommodate complex patients. Seven participants required an extrapolated target HR range because of the brevity of their GXTsubmax. Target HR zone identified based on the GXTsubmax was more than 10% below the target HR derived from Karvonen's Formula for 7 participants. DISCUSSION: This study suggests the TBRS submax is safe and feasible in IP rehabilitation. Our experience suggests a reduction in both initial watts across stages is needed in complex patients. Future studies should determine whether the target heart rate zones through the TBRS submax are appropriate in IP rehabilitation and contribute to prognosis, quality of life, and discharge planning.


Darrell V. Hardin, Simon Young Un, Neil Mistry, Michael Hernandez, Benjamin Robert Langford, Noris Perez, Kyle Patrick Burnett, Joshua James Currie, Lawrence P. Cahalin

BACKGROUND AND PURPOSE: Very few studies have compared the cardiorespiratory response (CRR) of resistance training (RT) and aerobic exercise (AE) with blood flow restriction (BFR) in health or disease. A better understanding of the CRR associated with RT and AE with BFR appears needed to administer safe and effective exercise. The purpose of this case series was to compare the CRR during RT and AE with BFR performed at the same intensity and limb occlusion pressure (LOP) in healthy adults hypothesizing that AE with BFR would elicit a greater CRR than RT with BFR. CASE DESCRIPTION: Four healthy adults with a mean ± SD age, height, and weight of 28 ± 6 years, 178 ± 9 cm, and 89 ± 19 kg, respectively underwent bilateral lower extremity RT and AE with BFR (Delfi Medical Innovations, Inc., Vancouver, BC) at the same LOP (80%) and intensity (60%–70% of age-predicted maximal heart rate) separated by at least 1.5 hours of rest. RT was performed via squats using a chair that provided a 90-degree angle at the hip to touch and rise with a 1-to-1 stand to squat ratio at a rate of 50 bpm with the standard number of repetitions of 30/15/15/15 employed and a 30 second rest between sets with cuffs inflated throughout. AE was performed with a calibrated Monark 828E cycle ergometer without resistance for 10 minutes with the revolutions/min maintained between 50 to 60. CRR was measured with the CardioTECH monitor (Edan Instruments, Inc., China) and the Borg rating of perceived exertion (RPE) 6 to 20 scale and 0 to 10 pain scale quantified exertion and pain. OUTCOMES: RT and AE with BFR produced an almost identical CRR with a mean ± SD peak heart rate, systolic blood pressure, diastolic blood pressure, respiratory rate, oxygen saturation, end-tidal carbon dioxide, RPE, and pain level of 131 ± 30 versus 125 ± 13 bpm, 148 ± 22 versus 145 ± 13 mm Hg, 77 ± 12 versus 83 ± 9 mm Hg, 36 ± 9 versus 37 ± 6 br/min, 98 ± 1 versus 99 ± 1, 34 ± 1 versus 35 ± 3 mm Hg, 14 ± 3 versus 13 ± 1, and 6.5 ± 1 versus 6.0 ± 2, respectively. DISCUSSION: The almost identical CRR observed during both RT and AE was surprising considering the different modes of exercise and metabolic cost associated with AE versus RT. However, the intensity of exercise and LOP during both modes of BFR exercise were the same suggesting that BFR exercise produces a similar CRR despite the mode of exercise. Further investigation of the CRR during BFR RT versus AE appears warranted in view of the almost identical CRR and the purpose of RT which is to elicit skeletal muscle strength and hypertrophy while the goal of AE is to elicit improved aerobic capacity and oxygen consumption. A better understanding of the CRR during RT and AT with BFR is likely to facilitate improved exercise training that is performed safely in both health and disease.


Sara Kathryn Arena, Christopher Wilson, Lori Elizabeth Boright, Emily Esper, Caitlin Kovary, Carly Pawlitz, Olivia Webster

PURPOSE/HYPOTHESIS: Evidence for the effectiveness of prevention-focused programming among older adults utilizing direct access referrals from community centers to physical therapists (PTs) has been reported. However, the outcomes of cognitive and cardiovascular screenings administered to older adults prior to enrollment in PT-led prevention programming is limited. Therefore, the purpose of this study is to describe rationale for participation exclusion or need for medical clearance among older adults prior to participating in a PT direct consumer access prevention-focused exercise program. NUMBER OF SUBJECTS: Research records from 214 community dwelling older adults. MATERIALS AND METHODS: After securing ethics board approval, a retrospective descriptive analysis of data obtained during a prior randomized controlled trial (RCT) was analyzed. Two unique data sets emerged from the RCT: Group-S was screened for study inclusion criteria but ultimately not enrolled and Group-E was enrolled and participated in the preventative exercise programming. Participant demographics including a confirmed Alzheimer's diagnosis or recent hospitalization, outcomes of cognitive screenings (Mini-Cog, Trail Making Test Part B), outcomes of a cardiovascular screening (American College of Sports Medicine Exercise (ACSM) Preparticipation Health Screening), and the ethics board record of adverse or medical events was extracted from the RCT records. Descriptive statistics were generated for demographic and outcome variables and inferential statistics were analyzed using the Chi-squared tests with significance determined at P < .05. RESULTS: Records from 70 individuals in Group-S and 144 individuals in Group-E were available for analysis. 18.6% (n = 13) in Group-S were not enrolled due to medical instability or potential safety considerations. Specific rationale for non-inclusion was as follows: 11.4% (n = 8) did not pass a cognitive screening and/or had a confirmed Alzheimer's diagnosis, 4.3% (n = 3) had a recent hospitalization, and 2.9% (n = 2) were told it was unsafe to exercise by their medical provider. A significant relationship was identified between not passing the Mini-Cog and advancing age (P = .02). The ACSM Preparticipation Health Screening identified 40% (n = 58) of Group-E participants as needing medical clearance prior to initiating the exercise programming. No adverse or medical events related to program participation were reported. CONCLUSIONS: A PT-led prevention-focused program utilizing direct access referrals from community senior centers offers a safe option for older adults to participate in individualized exercise that may reduce falls and health related risks. CLINICAL RELEVANCE: Cognition and cardiovascular screenings are effective in identifying medical clearance needs of older adults prior to engagement in PT-led prevention focused health care services. Furthermore, a PT direct access referral mechanism is an opportunity to bridge a gap between public health and medical care delivery options for older adults.


Magno F. Formiga, Ronikelson Rodrigues, Chayenne Chylld César Lopes, Eliene Maria Soares Monteiro Yano, Carlos Daniel Nunes de Sousa, Lawrence P. Cahalin, Rafael Mesquita

PURPOSE/HYPOTHESIS: Cigarette smoking is the most common risk factor for chronic obstructive pulmonary disease (COPD). Yet, despite often having COPD-like symptoms even before they've been diagnosed with the lung condition, many active smokers tend to have low awareness toward the disease, which remains highly underdiagnosed. The Fagerström Test for Nicotine Dependence (FTND) is a screening instrument for assessing the intensity of physical addiction to nicotine. We hypothesized that subjects with higher nicotine dependence but with no current diagnosis of lung disease would experience more symptomatology as assessed by the COPD Assessment Test (CAT). NUMBER OF SUBJECTS: Twenty-four (17 females). MATERIALS AND METHODS: A convenience sample of active smokers (mean ± SD age = 55.24 ± 11.05 years and BMI = 27.46 ± 5.77 kg/m2) with no known diagnosed pulmonary disease were assessed using the FTND, which provides both yes/no and multiple-choice items that are summed to a total score ranging from 0 to 10 reflecting levels of nicotine dependence. For this experiment, the participants were classified into 2 groups based on the intensity of their physical addiction to nicotine: low to moderate dependence (i.e., FTND scores of 0–7) and high dependence (i.e., FTND scores of 8–10). Subjects also completed the CAT, which consists of 8 items and has a scoring range of 0 to 40, with higher scores indicating greater impact of COPD-related symptoms on health status. RESULTS: The mean ± SD pack-years of smoking, FTND and CAT scores of the entire sample were 48.3 ± 30.08, 6.16 ± 2.88 and 18.46 ± 9.33, respectively. A one-tailed Mann-Whitney U test revealed that CAT scores were significantly increased in active smokers whose nicotine dependence was high (mean rank: 15.45) when compared to the low to moderate dependence group (mean rank: 10.39), U = 40.5, P = .04. Moreover, Spearman's correlation analysis indicated that there was a significant association between a high level of nicotine addiction and worse symptomatology as assessed by the CAT (rs = 0.36, P = .04). CONCLUSIONS: Many smokers are not aware of the risks of tobacco use and often fail to make the connection between cigarettes and the signs of growing dependence and smoking-related symptomatology. We found that active smokers with no current diagnosed lung disease experience several COPD-like symptoms that significantly impair their health status. The FTND was able to distinguish between individuals experiencing different levels of respiratory and physical symptoms which likely resulted from an already established but not yet detected obstructive lung disorder. CLINICAL RELEVANCE: With worrying smoking prevalence rates and environmental factors likely to further contribute to the development of lung diseases worldwide, physical therapy-led screening efforts to promote awareness, appropriate health care referral and identification of COPD among current smokers are warranted.


Leslie Marie Smith, Sindhuja Muralidharan, Amy M. Yorke

PURPOSE/HYPOTHESIS: To investigate the frequency of clinicians taking blood pressure (BP) in an outpatient (OP) clinic before and after a series of webinars focused on the clinical importance of taking BP measurements. NUMBER OF SUBJECTS: A convenient sample of 20 physical or occupational therapists at a hospital-based health system working primarily at outpatient clinics were asked to participate in this study. MATERIALS AND METHODS: This observational case control study consists of 2 phases. In Phase I, the researchers explored the attitudes, behaviors, beliefs, and barriers towards BP monitoring using an eighteen-item survey. After the survey, de-identified patient data from the electronic medical records (EMR) was analyzed to determine the frequency of BP measurements documented. In Phase II, webinars were developed for clinicians to understand the importance of BP measurement for the management of hypertension (HTN). After the webinars, another EMR review was completed to determine frequency of BP documented and patients with HTN and other cardiovascular diseases or risk factors. RESULTS: The results of the survey showed that one third (33%) of the participants agreed that BP should be taken on all patients during initial evaluation or reevaluation, and 100% reported rarely or occasionally taking BP. A review of 408 de-identified adult patient's EMR showed that there was a 0% frequency of BP monitoring. The average patient age was 57 years, 22.2% of the patients had diagnosed HTN and 38.1% had cardiovascular diseases. For Phase II, 8 clinicians (n = 8) participated in the post-test for the webinar education series. Three months following the webinars, 251 de-identified patient's EMR were reviewed, and there was a 16% improvement in frequency of monitoring BP. The average age was 59 years, 24.7% had diagnosed HTN and a total of 34.3% had a cardiovascular risk factor. CONCLUSIONS: Use of webinars increased the frequency of BP monitoring by 16%. The study demonstrated that providing education on HTN and BP monitoring is feasible to improve frequency of BP being taken in OP therapy clinics. Future studies may consider using knowledge translation (KT) for a structured technique for greater improvement in taking BP.1. CLINICAL RELEVANCE: HTN is a prevalent and preventable risk factor for several medical conditions that can lead to death. Nearly half of the patients are diagnosed with HTN or pre-HTN within the OP therapy clinics. Despite one third of the participants agreeing that BP should be taken during initial evaluation or reevaluation in Phase I, no therapist demonstrated the behavior when about a quarter of the patients were diagnosed with HTN and one-third of the patients had a cardiovascular disease or a risk factor. In Phase II, a webinar educational series on BP management improved the frequency of BP measurement. KT is a helpful intervention that could be incorporated for future studies with the aim to improve the frequency of BP monitoring.


Sara Milgrom, Ashley Lynn Lynn Marie Williams, Anne Keenan, Meredith Brown, Kate Kayton, Michele Megurdichian, Stephen Paul Bailey

PURPOSE/HYPOTHESIS: Individuals with Long COVID experience a variety of symptoms (cardiopulmonary, neurological, musculoskeletal, and psychological) for 12 weeks or more after being infected with COVID-19. Preliminary evidence suggests exercise to be beneficial in alleviating short-term COVID-19 symptoms. The purpose of this investigation is to assess the impact of a progressive therapeutic exercise program on individuals with Long COVID. NUMBER OF SUBJECTS: Ten participants (8 females, 2 males) with Long COVID (age = 49 ± 5 yrs, mass = 89 ± 6 kg, BMI = 30.2 ± 1.9 kg/m2) were enrolled in the study. MATERIALS AND METHODS: Before and after the intervention participants were assessed for 6-minute walk distance (6MWD), 5-times sit to stand (5XSTS), gait speed, grip strength, perceived quality of life (SF-12), and general fatigue (visual analog fatigue scale, VAFS). Participants then completed a progressive, individualized exercise program (∼8 weeks) designed to improve cardiovascular fitness, muscle strength, and endurance. Modes of exercise used to facilitate improvement in cardiorespiratory fitness included the treadmill, NuStep, semi-recumbent bike, semi-recumbent elliptical, and stand-up elliptical. Heart rate (HR), blood pressure (BP), O2 saturation, and rating of perceived exertion (RPE) were regularly monitored during aerobic exercise. Dumbbell exercises targeted at large muscle groups were used to challenge muscular strength and endurance. Progression of exercise intensity and duration was based on symptom response to exercise. Paired t-tests were used to evaluate changes in outcome measures following the intervention. RESULTS: 6MWD (pre = 469 ± 19 m, post = 529 ± 18 m, P = .001), 5XSTS (pre = 11.4 ± 1.1 s, post = 9.4 ± 0.9 s, P = .012), gait speed (pre = 1.24 ± 0.05m/s, post = 1.35 ± 0.07m/s, P = .029), and right (pre = 69.8 ± 4.2lbs, post = 73.6 ± 4.4lbs; P = .041) and left (pre = 64.7 ± 3.5lbs, post = 68.8 ± 3.1lbs; P = .041) grip strength improved following the intervention. Similarly, both the physical component (pre = 44.4 ± 3.1, post = 50.7 ± 2.4, P = .006) and mental component (pre = 43.9 ± 2.9, post = 51.4 ± 2.0, P = .007) of SF-12 improved, while VAFS (pre = 4.8 ± 0.5, post = 2.8 ± 0.6, P = .005) was reduced following the intervention. CONCLUSIONS: A progressive individualized exercise program can be effective at improving physical function and perceived quality of life in Long COVID patients. CLINICAL RELEVANCE: Many physicians are referring patients out to be treated for Physical Therapy, but there is currently limited reference of evidence-based practice to treat these individuals and some concern that exercise may exacerbate symptoms. The majority of APTA clinical guidelines for COVID-19 focus on short-term COVID-19 symptoms and do not address treatment methods for Long COVID symptoms. While functional status has been demonstrated to be negatively impacted in Long COVID patients, little guidance is available for treatment strategies in this population. This investigation provides physical therapists with a generalized strategy to improve physical function and quality of life in Long COVID patients.


Neeti Pathare, Helen Harrod Clark, Kara Marks

PURPOSE/HYPOTHESIS: Given the economic and health impact of COVID-19, it is critical to develop optimal inpatient programs to prevent its long term sequalae.1,2 Current guidelines advocate the use of pulmonary rehabilitation (PR) in patients with COVID-19.3 However, there is a lack of concrete information on PR in an inpatient setting for COVID-19. Therefore, we synthesized literature on the safety, feasibility and efficacy of inpatient PR on pulmonary outcomes and quality of life (QoL) in individuals with COVID-19. We hypothesized that inpatient PR would improve outcomes in this population. NUMBER OF SUBJECTS: The pooled sample consisted of 718 participants (F = 35.2%, age = 36–71 y). MATERIALS AND METHODS: Using PubMed, Web of Science, Cochrane Library and Embase, 3 researchers screened 474 articles for eligibility with the search terms: (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19 *) AND (respiratory or pulmonary) AND (physical therapy or physiotherapy or rehabilitation). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used. Nine articles were finalized using the inclusion criteria: publication date >2019, age >18 y, inpatient setting, and English language. Subsequently, reviewers extracted relevant information and appraised using the Physiotherapy Evidence Database (PEDro) score. RESULTS: Studies were mainly retrospective (retrospective chart review = 5, prospective observational = 4); and had PEDro score of 4/10. Inpatient PR ranged from 2 to 12 weeks. The primary outcomes included six-minute walk distance (6MWD), pulmonary function and QoL. Within group analyses (n = 9) showed that inpatient PR improved 6MWD statistically and clinically (mean improvement 111–204.7 m). In all the studies (n = 3) that offered comparisons with a no PR group (n = 3), inpatient PR offered a statistically significantly benefit in this population. Further analysis showed improvements in exercise capacity were in a dose–response fashion and were related to disease severity (n = 2). Within group changes were noted in FEV1 and FVC values (n = 3). For QoL data (n = 6), within group improvements were noted only in 3 studies. Inpatient PR was reported to be safe by all studies that reported adverse events (n = 4). CONCLUSIONS: Current review suggests that inpatient PR was safe, feasible and induced large improvements in exercise capacity in individuals with COVID-19. These findings concur with data on the use of PR in chronic pulmonary diseases.4 This is important as exercise capacity is regarded as a strong predictor of cardiovascular mortality.5 The divergent results on pulmonary function and QoL may be due to the heterogeneity of PR duration, QoL measures and disease severity.6,7 Limitations included retrospective designs, small sample size and variance in protocols. Future research should be directed on improving methodological rigor of studies. CLINICAL RELEVANCE: Our study provides valuable evidence that inpatient PR is safe and may accelerate improvement in exercise capacity in individuals with COVID-19.


Tracy Galada, June Katherine Maloney, Heather Brossman, Benjamin I. Binder-Markey

PURPOSE: Up to 60% of mechanically ventilated (MV) patients develop diaphragmatic weakness and ventilator induced diaphragm dysfunction (VIDD).1,2 Additionally, following prolonged MV (>72 hours) as many as 80% of patients have difficulty weaning, resulting in adverse clinical outcomes and poor prognosis.3 However, current physical therapy standards of care do not recognize or treat the diaphragm as a primary limiting factor in recovery. The purpose of this scoping review is to summarize reported muscle adaptations of the diaphragm in critically ill patients following prolonged MV. We define VIDD, clarify characteristic features, and identify leading proposed theories of VIDD development. Finally, this review highlights the need for PTs to quantify impairment-level diaphragmatic deficits to apply the most effective therapeutic interventions post-MV. DESCRIPTION: The diaphragm is a thin muscle (2-4mm thick) that sits at the interface of the thoracic and abdominal cavities and serves as the primary muscle of inspiration. Following prolonged MV the diaphragm undergoes structural changes such as atrophy, reduced cross-sectional area, reduced force generating capacities, and impaired length tension relationships, which collectively contribute to VIDD.4 Subsequently, these changes play a major role in impaired and delayed weaning, extubation, and recovery processes of these individuals. However VIDD is inconsistently defined, current definitions include: ≥10% change in diaphragm thickness, ≥30% change in diaphragm thickening fraction, excursion <10 mm, and transdiaphragmatic pressure <11 cm H2O during bilateral phrenic nerve stimulation. Within the literature we identified 3 pathways by which VIDD develops following prolonged MV. These pathways are 1) under- or over-assistance during MV due to a lack of diaphragm protective ventilation strategies that modify MV settings to levels of support that optimize patient effort and diaphragm use.5 2) Decreased neural activity of the diaphragm due to learned disuse or neurologic involvement.6 3) Inability of established and proposed indices that predict readiness to successfully wean and extubate to assess inspiratory muscle strength and performance and accurately reflect diaphragm function causing poorly timed weaning and a diaphragm that is dysfunctional.7SUMMARY OF USE: PTs' understanding of VIDD and means of quantifying diaphragm dysfunction are crucial to driving patients' rehabilitative successes. PTs are equipped with the fundamental skills and knowledge to treat VIDD for they can evaluate and treat maladaptive breathing patterns and inspiratory muscle dysfunction with muscle training devices and exercise-mediated interventions. Diaphragm dysfunction should be part of a routine PT examination along the continuum of care, especially following MV. IMPORTANCE TO MEMBERS: This review is a call to action for PTs and interdisciplinary teams to establish objective measures to evaluate all components of the ventilatory pump in patients post-MV through routine clinical assessments for early diagnosis and treatment of VIDD.


Raquel Elise Arce

PURPOSE/HYPOTHESIS: To provide information on the patient characteristics, physical therapy rehabilitation course, and functional outcomes in patients who underwent a left ventricular assist device (LVAD) implantation. NUMBER OF SUBJECTS: 21. MATERIALS AND METHODS: From September 1, 2020, through May 1, 2022, 21 patients with an LVAD implantation were identified for inclusion. Patients were referred to physical therapy by the cardiothoracic surgery or heart failure teams at Keck Medical Center of USC. Data collection included the Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Inpatient Basic Mobility Short Form based on the functional status documented at each physical therapy encounter. RESULTS: The median age was 60 years, with 52% female. Length of stay from the date of LVAD implant to discharge ranged from 11 to 209 days. The median (interquartile range) acute hospitalization length of stay with an LVAD implant was 28 (42.5) days. Fifteen patients were discharged home with family and/or caregiver support, 5 discharged to an inpatient rehabilitation unit, and 1 expired during the hospitalization course. Mobility was initiated at a minimum of 2 days postoperative. Physical therapy interventions included the following: (1) stretching and range of motion; (2) bed mobility; (3) static and dynamic sitting and standing balance; (4) transfers; (5) pre-gait in the room; forward and backward gait with various assistive devices; (6) gait in the hallway; (7) neurologic reeducation; (8) therapeutic exercise for upper extremities and lower extremities in supine, sitting and standing positions; (9) education and prescription of a home exercise program with an emphasis on phase I cardiac rehabilitation parameters. The overall AM-PAC 6-Clicks Basic Mobility Scores improved from the initial physical therapy evaluation to discharge with an average change of score of 9. Initial AM-PAC 6-Clicks Basic Mobility raw scores ranged from 6 to 18 and final raw scores ranged from 6 to 24. CONCLUSIONS: Patients with an LVAD implantation receiving physical therapy interventions demonstrated improvement in their functional mobility by the time of discharge. Acknowledging that patients with LVAD implantations typically present with low levels of functional mobility post-operatively suggests that the utilization of the initial AM-PAC 6-Clicks Basic Mobility was not the best predictor of discharge disposition for the patients reviewed. The final inpatient AM-PAC 6-Clicks Basic Mobility score was more predictive of discharge disposition in our patient population. CLINICAL RELEVANCE: Patients who are post-LVAD implantation were able to make significant functional improvements from initial evaluation to discharge as demonstrated by the change in the AM-PAC 6-Clicks Basic Mobility score. The results of this analysis facilitated discussion regarding the timing of physical therapy evaluations, the use of the AM-PAC 6-Clicks Basic Mobility score for monitoring progress, and improving the plan of care for patients post-LVAD implantation.


Christa Bauer Gilley, Kathryn H. Reeves

PURPOSE/HYPOTHESIS: To assess maximum mobility achieved by the critically ill patient who is supported on axillary Impella in anticipation of bridge to left ventricular assistive device (LVAD) with a focus on outcome measures utilized to assess patient's function. NUMBER OF SUBJECTS: 37 subjects. MATERIALS AND METHODS: We retrospectively reviewed charts of adult patients who underwent surgical implantation of axillary Impella 5.0 proceeded by LVAD placement surviving to hospital discharge (February 2017 to January 2022). Patient demographics were collected and analyzed. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility tool was chosen to assess patient's functional status at different points during admission while supported on mechanical circulatory support. RESULTS: All patients included in this study participated in physical therapy while supported on Impella followed by LVAD. The median length of stay (LOS) prior to Impella placement was 9.8 days. Patients were supported on Impella for a median of 18.9 days. INTERMACS score profiles at the time of LVAD were obtained; INTERMACS 1 32% (n = 8), INTERMACS 2 60% (n = 22) and INTERMACS 3 8% (n = 3). Total LOS for all patients bridged with Impella to LVAD was a median of 63.35 days, with a post LVAD LOS at 28 days. Patients with INTERMACS 1 score had a total LOS 79.8 days, with a post LVAD LOS 37.6 days. Those with INTERMACS score 2 to 3 had a total LOS of 55.4 days with a post LVAD LOS 23.3 days. When comparing groups this was statistically significant (P value of 0.01 and 0.013, respectively). When analyzing discharge destination, 6 (50%) of the INTERMACS 1 group required inpatient rehab and 6 (50%) were discharged home. Patients with INTERMACS 2 to 3 had a greater likelihood of being discharged home (P = .012). AM-PAC Scores were obtained at several points throughout LOS. Immediately post Impella median score was 12 with an increase to 18.4. Scores dropped to a median of 15.7 on post-op LVAD day 7, increasing by day 14 (18.3), and further increasing at discharge (20.7). A statistical difference (P = .005) was noted on scores post-op day 7 and 14. CONCLUSIONS: When physical therapy is provided to critically ill patients supported on Impella as a bridge to a LVAD therapy is safe and effective. No adverse events were noted during physical therapy sessions. This study verifies that patients with the most profound degree of critical illness based on INTERMACS scores can safety participate in physical therapy while maximizing functional activities based on AMPAC scores prior to LVAD placement. CLINICAL RELEVANCE: Surgical implantation of a LVAD is a major cardiothoracic surgery. Patients undergoing such surgery benefit from a physical therapy program prior to LVAD to maximize cardiopulmonary endurance and strength to assist with discharge home, despite a patient's level of critical illness. Development of a mobility protocol for the patient supported on Impella is of benefit to maximize safety.


Natalie Gabrielle Anzures, Alexis Mielke

BACKGROUND AND PURPOSE: Individuals who contract severe COVID-19 are likely to have pulmonary function impairment and in some severe instances develop irreversible lung injury. In certain cases, a lung transplantation can be a life-saving treatment option. Typically, individuals who receive a lung transplant discharge to the community from the acute care hospital. In some cases where functional mobility concerns persist, such as poor endurance and decreased exercise capacity, patients discharge to the acute rehabilitation setting as a bridge to the community. There is a paucity of background information on treatment of individuals with lung transplantation in the acute rehabilitation setting and even less information on lung transplantation status-post COVID-19 diagnosis. The purpose of this case series is to highlight unique concerns of this specific population in the acute rehabilitation setting. CASE DESCRIPTION: Nine patients (Males = 8, Females = 1) who received a bilateral lung transplant status-post severe COVID-19 illness were admitted to the acute rehabilitation unit between 2021 to 2022. Average age was 48 years old (SD = 10). Patients were noted to have prolonged acute care stays due to various complications prior to transition to acute rehabilitation. Each patient was treated by a multidisciplinary team over the duration of their stay and received a total of 3 hours of therapy per day 5 days per week. All patients were independent with their functional mobility prior to COVID-19 illness. OUTCOMES: The average length of stay for these patients was 19 days (SD = 9) in the acute rehabilitation setting. Patients showed statistically significant changes in functional outcomes as measured by Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) scores of Sit to Stand, Chair/Bed-to-Chair Transfer, Walk 10 ft, Walk 50 ft with 2 turns, and Walk 150 ft from initial evaluation to discharge. Patients also demonstrated statistically significant improvements in gait speed as measured by the 10 Meter Walk Test (10MWT). Seven out of the 9 patients were recommended to have supervision and/or caregiver assist post-discharge. No patients required supplemental oxygen upon discharge. All patients were recommended home health services after discharge due to their immunocompromised status and ongoing COVID-19 pandemic. DISCUSSION: This case series highlights that individuals who received a bilateral lung transplant status-post COVID-19 illness and required additional hospitalization at the acute rehabilitation level have unique mobility concerns. After the acute rehabilitation stay, patients were able to demonstrate notable improvements in functional mobility with intensive therapy. However, patients required a prolonged length of stay and had increased caregiver burden upon discharge. Future research may involve case-matched controls to compare individuals status-post lung transplantation due to a chronic premorbid condition versus individuals status-post lung transplantation due to an acute COVID-19 diagnosis.


Clare Louise Nicholson, Joshua Kurt Johnson

PURPOSE/HYPOTHESIS: The optimal physical therapy (PT) treatment frequency for patients undergoing lung transplant is not clear, so practice patterns are variable. “Lungs 4 Life” (L4L) is a focused initiative at one hospital to standardize PT visit frequency (6 per week) for patients in the intensive care unit (ICU) due to lung transplant. We aimed to examine changes in actual visit patterns and observed patient outcomes associated with the implementation of L4L. NUMBER OF SUBJECTS: Patient records were included for those treated by a PT while hospitalized for a lung transplant. Episodes occurring between June 2020 and May 2022 were identified then separated into a L4L cohort (December 2021-May 2022) and a historical control (HC) cohort (June 2020-November 2021). Consistent with clinical guidelines for L4L eligibility, patients with AM-PAC 6-Clicks mobility (6-Clicks) scores </ = 18 and JH-HLM performance </ = 6 were included. MATERIALS AND METHODS: This was a retrospective cohort study. We tested for differences between the HC and L4L cohorts in the proportion of days with a visit in the ICU (number of visits divided by ICU length of stay, in days) and mean duration of each visit in the ICU using linear regression. We tested for differences between the cohorts in hospital length of stay and 6-Clicks score at hospital discharge using inverse probability of treatment weighting. In all analyses, we adjusted for age, gender, mortality risk, pre-hospital level of function, and initial 6-Clicks score. RESULTS: The L4L cohort included 46 patients; the HC included 106. Those in the L4L cohort were younger (mean ± SD age = 55.1 ± 13.0 years) than in the HC (59.9 ± 10.2 years) and had greater mortality risk (87.0% vs 54.7% graded as “extreme”). The mean proportion of days with a visit in the ICU was 44.8 ± 17.5% in the L4L cohort versus 29.8 ± 15.4% in the HC, and visits were 38.7 ± 5.2 versus 33.0 ± 8.0 minutes. The median [IQR] ICU length of stay in the L4L cohort was 24.6 [10.0, 50.4] compared to 10.5 [4.8, 26.2] days in the HC. Mean 6-Clicks scores at hospital discharge in the L4L cohort were 17.8 ± 6.7 and 20.8 ± 4.4 in the HC. In adjusted analyses, compared to the HC, the L4L cohort had: higher proportion of ICU days with a visit (r = 15.7, 95% confidence interval [CI]: 9.2, 22.2), longer visits (r = 5.6, 95% CI: 2.1, 9.1), longer ICU length of stay (r = 18.9, 95% CI: 4.9, 32.9), and non-different 6-Clicks scores at hospital discharge (r = −0.3, 95% CI: −2.5, 1.8). CONCLUSIONS: Implementation of the L4L initiative increased the frequency and duration of PT visits for patients in the ICU, but was associated with a longer ICU length of stay and no difference in functional status at hospital discharge. CLINICAL RELEVANCE: Increasing the volume of PT treatment is possible with focused effort, even for very ill patients with a lung transplant. Identifying the patient outcomes most affected by this change, and methods by which they can be improved, requires additional exploration.


Clayton Daniel Powers, Todd Eldon Davenport

BACKGROUND AND PURPOSE: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of autonomic dysfunction affecting blood circulation characterized by excessive tachycardia and orthostatic intolerance.1 Patients who develop POTS experience symptoms affecting multiple bodily functions that, in turn, severely limit functioning.2,3 One of the main non-pharmacological interventions recommended for POTS management is aerobic exercise to improve cardiovascular function4; however, some POTS patients may not tolerate aerobic exercise due to post-exertional malaise (PEM).5,6 For these patients, a pacing approach may be more appropriate.5 This case report describes the effect of pacing in the context of a pragmatic multimodal approach applied to a person living with POTS and vasovagal syncope. CASE DESCRIPTION: A 16-year old female diagnosed with POTS and vasovagal syncope presented to physical therapy with goals to tolerate a full day of school and participation in band again. At her initial evaluation, she was attending 6 hours of school followed by 1 to 2 days recovering at home due to PEM. She experienced 5 syncope episodes/day and was only able to tolerate 3 hours of upright activity with feet on the floor/day on non-school days and 6 hours of upright activity on school days. Her Chronic Fatigue Syndrome Symptom Scale (CFSSS) total was 49/80. Her Dizziness Handicap Inventory (DHI) was 72%. Orthostatic vitals during tilt table testing were 68bpm heart rate (HR) and 102/55 blood pressure (BP) in supine and 127bpm HR and 96/67 BP after 7 minutes in 70° head-up tilt before patient experienced a syncope episode and testing was terminated. The patient was advised on lifestyle modifications for orthostatic intolerance management (e.g., wear compression, increase electrolyte and fluid intake). Other interventions included pacing using a heart rate monitor to alert the patient to lower her heart rate to avoid exceeding calculated ventilatory anaerobic threshold based on age, education on recognizing immediate and delayed signs of PEM, dietary advice, instruction in diaphragmatic breathing and recumbent strengthening exercises. OUTCOMES: After 6 visits over the span of 3 months, the patient's DHI improved from 72/100 to 44/100 and CFSSS improved from 49/80 to 10/80. Her hours of upright activity with feet on the floor improved from 3 hours to 11 hours on non-school days and 6 hours to 8 hours on school days. By her seventh visit, 4 months from initial evaluation, her syncope episodes improved from 5 episodes/day to 1 episode/week. Her rating of perceived function improved from 20% to 45%. She was able to stand for 30 minutes while playing mallets during a school concert without PEM the next day. She experienced more good days than bad days, and was able to attend a half-day of school without significant PEM the next day. DISCUSSION: The patient described in this case is an example of a subset of POTS patients that experience PEM as part of their symptomology. She appeared to benefit from a pacing approach to manage her symptoms and functioning instead of an aerobic exercise-based approach.


Diane M. Wrisley, Eder Alejandro Garavito, Ashley Poole

PURPOSE/HYPOTHESIS: Patients with cardiorespiratory dysfunction, such as COPD, have postural instability and increased risk of falls compared to age matched controls. Given that COVID-19 is defined as a respiratory condition, it could be presumed that these patients may demonstrate the same balance deficits. Ninety percent of patients with a history of COVID-19 report at least one neurological symptom, and these neurological symptoms could potentially result in alterations in balance. The act of maintaining upright posture or balance depends on both sensory and motor responses. It has been previously demonstrated that people post-COVID have motor and sensory balance deficits including vestibular dysfunction after leaving the acute care institution. The purpose of this study was to determine and characterize balance in patients “COVID recovered” (off airborne isolation but not discharged from the hospital). NUMBER OF SUBJECTS: Twenty-five subjects were recruited. Mean age was 55.6 ± 11.3 years, 17 males, 8 females, mean length of time since diagnosed with COVID-19 was 34 ± 15 days. All subjects had a primary or secondary diagnosis of COVID- 19 during hospitalization and were considered “COVID recovered” (off-airborne isolation but not discharged from the hospital) and were receiving care in an acute inpatient hospital. MATERIALS AND METHODS: Following consent, subjects completed the Activity-specific Balance Confidence Scale (ABC), a questionnaire about symptoms of dizziness, the Timed “Up & Go” (TUG) and the modified Clinical Test of Sensory Interaction and Balance (mCTSIB). Subjects had vital signs monitored before, during, and after the examination. RESULTS: There were no differences in clinical test scores based on age (<65 or ≥65) or order of testing. Using age appropriate normative scores, all subjects had abnormal scores on the TUG indicating difficulty with motor balance, 88% had abnormal scores on the ABC indicating low confidence in performing balance activities, and 48% of the subjects had abnormal scores on Condition 4 of the mCTSIB indicating difficulty using vestibular information for balance. There was no correlation between the clinical test scores and age, length of time with COVID-19, or O2 changes during testing. Surprisingly, there was no correlation between the scores on the clinical balance tests. CONCLUSIONS: Both young and older adults present with motor and sensory balance deficits acutely following a COVID-19 infection. Subjects have low perceptions of their ability to balance that may impact their function as they are discharged. CLINICAL RELEVANCE: People acutely post-COVID-19 may have balance deficits. These deficits may be due to immobility and deconditioning. It is recommended that people acutely post COVID-19 receive education and interventions to increase mobility, improve balance, and specifically receive activities that stimulate the vestibular system. It is also recommended that people acutely post-COVID-19 have these balance deficits and perceptions of balance function be considered in discharge planning.


Kristin St. John Moreno, Caitlyn Paige Ferguson, Vanessa Annette Garcia, Samuel Montalvo, Alvaro N. Gurovich

PURPOSE/HYPOTHESIS: In 2020, COVID-19 became a global pandemic affecting multiple aspects of everyday life.1-4 Since COVID-19 was a highly transmissible disease, in-person classes were moved online,5,6 gyms were closed,1-3 and social interactions were limited.4 While some data exist on the impact COVID-19 has had on students,5,6 there is a need for further research to examine the compounding effects of the graduate level workload and the COVID-19 pandemic on physical therapy students. The purpose of this study is to understand how COVID-19 affects the cardiovascular (CV) and mental health of Doctor of Physical Therapy (DPT) students as they progress through the program. We hypothesize that students would have better health outcomes in their second year, when the COVID-19 restrictions lessen, compared to their first year, when COVID restrictions were at their peak. NUMBER OF SUBJECTS: 16 students from the University of Texas at El Paso's DPT Class of 2023 were recruited via in-class presentation and email. MATERIALS AND METHODS: Data collection occurred over the time period of a year and a half with a total of 3 visits (Oct 2020, June 2021, and April 2022). Primary outcome measures included cardiovascular fitness level via VO2max, arterial stiffness via Pulse Wave Velocity (PWV), and endothelial function via Venous Occlusion Plethysmography (VOP). Secondary outcome measures included Perceived Stress Survey (PSS), International Physical Activity Questionnaire (IPAQ), and Dietary Screening Questionnaire (DSQ). A repeated-measures analysis of variance (RM-ANOVA) and Cohen's d for standardized effect size were utilized. Significance was set prior at an α level of 0.05. RESULTS: VO2max increased from visit 1 to visit 2 (P = .02, d = 0.63) and then decreased from visit 2 to visit 3 (P < .01, d = 0.85), with no change between visits 1 and 3 (P > .05). Endothelial function increased from visit 1 to visit 3 (P < .01, d = 0.89) and from visit 2 to visit 3 (P = .02, d = 0.65), with no differences between visits 1 and 2. Overall, there were no significant differences observed for PWV, PSS, METs, sitting time, sweetened beverages, and added sugar (P > .05) between visits. CONCLUSIONS: The DPT Class of 2023 started their graduate education in the beginning of the COVID pandemic, with an already limited physical freedom. COVID restrictions were lessen in early 2021, ∼4 months before visit 2. It appears that those 4 months were enough time to improve VO2max but not endothelial function. Interestingly, VO2max decreased back to baseline after the second year, with an increase in endothelial function. These changes could be attributed to an increase in time spent at school during the second year and increased travel time due to classes moving from virtual to in person, which could impact cardiopulmonary fitness but not endothelial function. CLINICAL RELEVANCE: Results from this study can help DPT programs throughout the nation understand the importance of developing strategies to support their students during times of crisis to reduce the risk of CV and mental health diseases in the future.


Lila Buls Wollman, Ralph Fregosi, PhD

PURPOSE/HYPOTHESIS: Nicotine is one of the most addictive substances known, and it is estimated that 50.6 million US adults use nicotine in some form. It is well known that smoking, the most common form of nicotine exposure, alters lung structure and function. In contrast, the impact of chronic nicotine exposure during adulthood on neural structures involved in the motor control of breathing is relatively unknown-even though nicotine is well known to elicit neural plasticity in multiple neural circuits. Here, we test the hypothesis that chronic nicotine exposure alters the ventilatory response to hypoxia, which is a critical respiratory chemoreflex that enhances breathing and limits arterial O2 desaturation. NUMBER OF SUBJECTS: Preliminary data was collected from adult female Sprague- Dawley rats in 3 groups: Control (n-4), nicotine exposed (n = 4), and nicotine withdrawal (n = 4). MATERIALS AND METHODS: Rats were exposed to 2% saccharin water alone (Control), or saccharin water plus 200 mg/mL (−) nicotine bitatrtate dihydrate (nicotine exposed) for 4 weeks. To elicit nicotine withdrawal, nicotine-exposed rats are then switched saccharin water for 48 hours. All animals were studied 48 hours after the water switch in the withdrawal group. Using whole body plethysmography, restful breathing was recorded for approximately 5 min, after which the animal was challenged with a 5- minute episode of hypoxia (10% O2/balance nitrogen). Tidal volume and frequency were calculated and averaged over 3 stable periods of baseline breathing, and during a stable period of the last minute of the hypoxic episode. Tidal volume and frequency were multiplied together to calculate minute ventilation and values were normalized to both VO2 and VCO2. Tidal volume, frequency and minute ventilation during hypoxia are reported as baseline and compared between groups using a one-way ANOVA with Tukey's post-hoc test. RESULTS: Four weeks of chronic nicotine exposure through drinking water had no effect on the ventilatory response to a brief, 5- minute episode of hypoxia (10%) (Minute ventilation: One-way ANOVA, Control vs Nicotine Exposure; P = .6533). In contrast, nicotine exposed rats show a significantly blunted ventilatory response to hypoxia following 48 hours of nicotine withdrawal (Control vs Nicotine Withdrawal, P = .0447). The reduced ventilatory response was due to a blunted increase in tidal volume (Amplitude: One-way ANOVA, Control vs Nicotine Withdrawal; P = .007), with a normal frequency response (Control versus Nicotine Withdrawal; P = .2518. CONCLUSIONS: These data indicate that chronic nicotine exposure in adulthood can elicit neural plasticity in the respiratory motor network. CLINICAL RELEVANCE: This has important clinical ramifications, as hypoxia is a commonly encountered medical complication, and withdrawal symptoms are often observed in hospitalized patients as it is common for them to abstain from smoking during periods of worsening health or in preparation for surgery. Hence, a patient in the perioperative period or one who is critically ill, who already has an impaired HVR due to medications or disease, may be more severely affected if they are also in nicotine withdrawal.


Deborah Jane Hoekstra

THEORY/BODY: Evidence based practice (EBP) is a pillar of physical therapy practice. However, implementation of EBP especially at the hospital level can be daunting and eluding for many physical therapists (PT). We will describe the process of our own EBP initiative for our patient post lung transplantation using the Iowa Model of Evidence-Based Practice. The Iowa Model is a widely used framework for the implementation of EBP. It is an application-oriented guide giving the steps to help identify issues, research solutions and implement changes. Our purpose is to explain use of the Iowa Model in an improvement initiative at a single institution. This will support increased understanding of and confidence in using this tool to create change. The Iowa Model consists of several steps. The first is identification of a trigger or the problem where a solution is warranted. After deciding if the trigger is a priority to the organization (2), this problem is framed into a question. The third step is formulation of a team that will develop, evaluate, and implement the EBP change. Next, you must gather and analyze the research related to the desired practice change, followed by (5) critique and synthesis of the research discovered during the literature search. If there is satisfactory evidence, or if you hope to add to the lacking body of evidence, you will then (6) design and plot practice change, (7) integrate and sustain change, and (8) disseminate results. The Iowa Model and our project begin with identification of the issue: patients in pulmonary rehabilitation at a single institution were not allowed to use their arms for functional transfers or upper extremity exercises for 8 weeks after lung transplantation surgery. This brought about the clinical question: will reducing restrictions on patients after lung transplantation be safe and lead to improved outcomes? A PT resident primarily worked with her mentor, identifying other stakeholders to make a team to evaluate the current evidence. Evidence was then assembled, appraised and synthesized. Once completed, the resident and team worked together to design and plot the practice change: formulation of new clamshell precautions, as well as a new exercise protocol for patients post lung transplant in inpatient and outpatient settings. Once this plan was finalized, change was integrated through education to necessary providers and units. Change was sustained with check-ins and tracking patients to assess efficacy and completion of the protocol, with continued education or review as necessary. This project is still ongoing, but results will be disseminated as the final step of the Iowa Model. The Iowa Model provides a framework for evaluating and implementing EBP that is very applicable in inpatient and outpatient pulmonary rehabilitation settings.


Christa Bauer Gilley, Jason Fred Radfar

Theory/Body: Our project was aimed at changing the culture surrounding mobilization of the patient supported on ECMO therapies. It is well known that critically ill patients benefit from early mobilization. Culture around mobilizing patients supported on ECMO at our facility has been historically conservative and progressive mobility was met with resistance. Our goal was to initiate a culture change to one in which progressive mobility was not just accepted but became an expectation for the critically ill. Thus, utilizing a multidisciplinary approach in designing and implementing a standardized formal protocol for mobilization of patients supported on VA/VV ECMO. This initiative required a multidisciplinary team of stakeholders and influencers to promote acceptance and willingness (buy-in) from nursing leadership, staff nurses, perfusion, pulmonary critical care team and ICU lead physicians. Our team created a protocol with the following goals: 1) increase early and progressive mobilization of patients supported on ECMO 2) decrease time of eligibility to transplant listing of patients supported on ECMO 3) improve outcomes of patients supported on ECMO to include; earlier decannulation, decreased hospital length of stay and discharge to home or rehab versus skilled nursing facility or LTACH 4) change nursing culture to one where early and progressive mobilization is the expectation for patients supported on ECMO 5) increase confidence among healthcare staff regarding early and progressive mobility of the critically ill patient. For every ECMO patient on our unit, bedside nursing staff completes a daily checklist. The purpose of this list was to create ownership from nursing to allow them investment in the process. Checklist was created and vetted by all teams to allow input and to cultivate a multidisciplinary approach. Each team's voice was honored which allowed them the feeling of ownership in the process. The bedside nurse and physical therapist reviewed the patients' case daily. Once the patient passes the suggested guidelines for mobility the multidisciplinary team, led by the physical therapist and consisting of the bedside nurse, perfusionist and respiratory therapist, initiates mobility per physical therapy protocol. If patients do not pass the safety checklist by nursing, a multidisciplinary conversation occurs to determine the appropriateness (risk/benefit) of mobilizing the patient, and session is either initiated or deferred. A specialized team and protocol are imperative to successful mobility for this patient population. This initiative created influencers who consisted of team leads targeted to implement change. Culture change has occurred and patients receiving ECMO support are mobilized daily without hesitation. Our future plans include modification of nursing checklists and physical therapy protocol, creation of post mobilization procedures to collect and analyze data, and the development and implementation of an ECMO competency for our PT/OT rehabilitation staff to ensure a high level of training and clinical competence.


Deanna Moore McIntire, Chad M. Aldridge, Marc K. Burkard

PURPOSE/HYPOTHESIS: We sought to investigate the impact of preoperative frailty on hospital resource utilization in patients receiving elective cardiothoracic surgery. NUMBER OF SUBJECTS: 541 patients, 65.6% males, with a median age of 67.0 years old. MATERIALS AND METHODS: This study conducted a retrospective analysis on patients following elective cardiothoracic surgery including coronary artery bypass graft, aortic valve replacement, mitral valve replacement and/or aortic or multiple cardiac valve procedures, from January 2019 to December 2020. The Fried Frailty Index (FFI) used 5 associated risk factors (grip strength, gait speed, weight loss, exhaustion, and activity tolerance) to measure preoperative frailty and score patients as Robust (0), Prefrail (1 or 2) or Frail (3 or more risk factors). Kruskal-Wallis Rank Sum and Chi-squared tests compared differences among continuous and categorical variables by Frailty group. Log-normal linear and logistic regressions estimated the dose-response of frailty on hospital metrics of length of stay (LOS), intensive care unit (ICU) hours, ventilator hours, discharged home and 30-day readmissions adjusting for age, sex, and elective procedure. RESULTS: Of the 541 patients, 241 (45%) scored Robust, 257 (48%) Pre-frail, and 43 (8%) Frail on the FFI. The Frail group had longer median (interquartile range [IQR]) LOS at 8 days (7–12), ICU hours at 91.70 (49.70–126.35), and ventilator hours at 5.72 (3.65–11.85) compared to the Pre-frail group at 7 days (5–9; P < .001), ICU hours at 69.80 (40.40–116.50; P = .046) and ventilator hours at 5.25 (3.57–8.87; P < .001), and the Robust group at 6 days (5–7; P < .001), ICU hours at 46.15 (25.70–97.69; P < .001), and ventilator hours at 3.97 (2.78–6.13; P = .468). Only 67.4% of the Frail group versus 77.8% of the Pre-frail and 88.6% of the Robust groups discharged to home, P < .001. The Frail group had more readmissions in 30 days at 23.3% versus 11.6% of the Pre-frail and 6.4% of the Robust groups, P = .002. CONCLUSIONS: Preoperative frailty testing can identify patients who utilize more postoperative resources. This study shows that patients who score Frail or Pre-frail (55.5%), use more postoperative resources with longer LOS, ICU hours, and ventilator hours; less discharges to home and more 30-day readmissions after elective cardiothoracic surgeries. Targeting patients that would benefit from a prehabilitation program to improve preoperative frailty status and guide perioperative planning can save hospital resources and improve postoperative outcomes. The large proportion of Pre-Frail and Frail patients in this study strengthens the relevancy and importance of prehabilitation research. CLINICAL RELEVANCE: Frailty testing for preoperative risk stratification can enhance prediction of cardiothoracic surgical outcomes. Because one can modify frailty, we recommend research into the effect and cost-benefit of prehabilitation for elective cardiothoracic surgeries. Physical therapists have the expertise to measure frailty and develop prehabilitation programs for this population.


Samantha Evelyn Nerpel, Magno F. Formiga, Lawrence P. Cahalin

PURPOSE/HYPOTHESIS: Heart failure (HF), a progressive condition where the heart is unable to provide the body with an adequate supply of blood, accounts for 8.5% of cardiovascular deaths in the United States. Remote ischemic conditioning (RIC) is a protocol that applies a temporary ischemic state to an extremity via vessel occlusion using a cuff, then releases the occlusion to produce a variety of physiologic responses to potentially improve cardiovascular function and elicit other associated benefits. Studies have explored the impact that RIC can have in HF, but a systematic review has not yet been performed. Thus, we sought to examine the available RIC literature to report on the methods and effects of RIC on cardiac function (CF), quality of life (QOL), and inflammatory markers (IM) in patients with HF. NUMBER OF SUBJECTS: 149 HF subjects, 31 control. MATERIALS AND METHODS: A literature search was performed in PubMed and the Cochrane database through July 2022. The search strategy was conducted in English and included a mix of terms for the key concepts RIC and HF. A study had to meet the following criteria to be included: (a) the study was original research conducted in adults with a diagnosis of HF, (b) study participants underwent RIC, (c) post-intervention measures of CF, QOL or IM were provided. Studies had to be peer-reviewed and published prior to the search to be eligible for inclusion. Study quality was assessed using the PEDro scale. RESULTS: Seven published reports out of 231 identified records were considered eligible with a total of 180 subjects (163 males). The average PEDro scale was 7.43 with a range of 6 to 9. The outcome measures of interest included measurements of CF (LVEF%, BP, HR), QOL (NYHA functional class, MLHFQ), and IM (BNP, IL-6, CRP). Three studies applied short-term RIC (2 studies with 1 acute RIC session, 1 study with 1 week of twice daily RIC) and 4 studies applied long-term RIC (4–6 weeks in duration). The protocol of RIC application varied between studies with 3 studies not providing the occlusion pressure used during RIC. Chronic RIC application was found to significantly improve CF, QOL, and heart rate variability and demonstrated a moderate improvement on IM. Short-term RIC had minimal effect in subjects with HF. CONCLUSIONS: HF is associated with poor CF, reduced QOL, and increased IM. The results of this systematic review suggest that chronic RIC has the potential to improve CF, IM, and QOL while acute RIC appeared to have minimal effect on the above measures. The application of RIC varied widely between studies, with almost half of the studies not providing the occlusion pressure used in the protocol. Further investigation of RIC using standardized methods in patients with HF appear warranted. CLINICAL RELEVANCE: Chronic RIC may be a useful adjunct treatment, which could easily be provided by a physical therapist, in the management of HF. Chronic RIC has the potential to improve CF, QOL, IM, and possibly skeletal muscle which could further improve the health of patients with HF.


Molly A. Hickey, Abigail Ferrara, Chase A. Pecoraro, Victoria Lukashevich, Zack Leader

PURPOSE/HYPOTHESIS: It has been nearly 20 years since The World Health Organization (WHO) released the Global Strategy for Diet, Physical Activity and Health, reporting that over 70% of deaths each year result from noncommunicable diseases. Evidence is strong that for patients who have these conditions, promotion of physical activity (PA) guidelines should be included in usual care. Evidence is also strong that adhering to these guidelines may mitigate sequelae of other conditions common to physical therapy (PT) practice. Unfortunately, evidence likewise exists that many PTs are not including PA promotion in the regular management of patients. The purpose of this study was to explore literature published since the WHO released PA guidelines, to identify outcomes associated with PA counseling specifically provided by PTs regardless of reason for referral. NUMBER OF SUBJECTS: n/a. MATERIALS AND METHODS: PRISMA guidelines were used for conducting the review. A broad scoping search was first performed to determine if there was sufficient volume of studies published on PT provision of “non-treatment” health promotion and/or wellness advice, and further, if there was a sufficient subset of studies related specifically to outcomes related to reduction of non-communicable disease risk or morbidity. Of all categories identified as most impactful on risk and morbidity, studies addressing PA guidelines appeared to be the most available. A refined search was then conducted. Fifteen studies met inclusion criteria and were subjected to full text review. RESULTS: Heterogeneity of methods for patient recruitment and assignment across retained studies prompted the use of a 3-stage process to assess for quality, including randomization/blinding of reviewers and the use of 2 different instruments for quality/risk of bias. This resulted in the elimination of 6 studies due to poor quality; The studies retained included 6 randomized controlled trials and 3 quasi-experimental designs. Six of the studies were rated as high quality, and 3 as moderate quality. A meta-analysis was not possible due to study variability, so a descriptive synthesis of the results was used to identify themes and relationships. All retained studies demonstrated positive results related to physical therapist-led PA guidance in conjunction with usual care. Themes emerged on the effects of health coaching, motivational interviewing, individualized programs, deliberate use of behavior change theory, and the use of wearable devices. Eight of 9 studies were conducted outside of the United States (US). Subjects were skewed toward older white females. CONCLUSIONS: Our review suggests that there has been insufficient activity in practice implementation of PA guideline promotion by physical therapists, particularly in the U.S. The underlying causes are multi-factorial, and exist at the individual organization, and system levels. There are avenues available to harness what is already known to develop future research studies to inform better alignment of competencies to address these critical prevailing healthcare priorities. CLINICAL RELEVANCE: The window is closing on our opportunity to elevate practice to meet these needs. The time is now.


Ana Ilijeska PT, DPT, Karlie Jordan Gross, Kim Stravrolakes PT, MA, MS, Clare C. Bassile

BACKGROUND AND PURPOSE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a widespread virus that led to the acute respiratory disease named coronavirus disease 2019 (COVID-19).1 Similarly to SARS-COV in 2002, many individuals post COVID-19 are experiencing persistent respiratory impairments and decreased exercise capacity limiting their ability to complete activities of daily living (ADLs) and affecting their quality of life (QOL).2,3 Post COVID-19 patients are demonstrating decreased pulmonary function as measured on pulmonary function tests (PFTs) with 39% of individuals having reduced diffusion capacity, 15% having restrictive patterns, and 7% having obstructive patterns.4 Pulmonary rehabilitation has demonstrated the ability to improve exercise capacity, QOL, fatigue level, and strengthen respiratory musculature to improve pulmonary function.5 The purpose of this case study is to demonstrate the positive impact pulmonary rehabilitation has on aerobic capacity, PFTs, exertional dyspnea, and QOL in an individual post long COVID-19. CASE DESCRIPTION: Patient is a 44 year-old female presenting to pulmonary rehabilitation post hospitalization for COVID-19. Patient was hospitalized for over one-month secondary to developing acute hypoxemic respiratory failure on 2 accounts requiring high flow nasal cannula, steroids, and ICU management. Post hospitalization, patient continued to have decreased pulmonary function as measured on PFTs, dyspnea with ADLs, desaturation below 90% on room air with stair negotiation and brisk walking, and required 2 liters per minute (L/min) of supplemental oxygen for management. Patient underwent a 3-month outpatient pulmonary rehabilitation program consisting of aerobic treadmill training, upper (UE) and lower extremity (LE) strength training, functional mobility training (step-up and sit to stand), and patient education (energy conservation, breathing techniques, vital sign monitoring, and exercise intensity progression). OUTCOMES: At discharge, patient demonstrated significant improvement in exercise capacity as she improved by 610 ft (46.9% improvement from initial evaluation [IE]) on the 6-min walk test (6MWT). Subjectively, patient noted decreased shortness of breath (7/10 (IE) to 3/10 on the Modified Borg Dyspnea Scale) while performing the 6MWT. Patient demonstrated improvements in PFTs as her FVC and FEV1 reached normal based upon the percent predicted method6 (FVC: 72.7% to 90% of predicted, FEV1: 77.8% to 95.2% of predicted), and DLCO improved from 45% to 70.3% of predicted. In the subjective questionnaires, patient had significant improvement on the UCSD Shortness of Breath questionnaire (6 unit improvement, MCID: 57), and clinical improvement noted on the Duke Health Profile questionnaire with a decrease in disability score (100 (IE) to 0) and depression score (50 (IE) to 40). DISCUSSION: This case study demonstrates that pulmonary rehabilitation is a safe and effective exercise program that results in improvements in exercise capacity, pulmonary function, exertional dyspnea, and QOL in individuals recovering from long COVID-19.

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