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

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CSM 2023 Cardiovascular and Pulmonary Platform Abstracts

Cardiopulmonary Physical Therapy Journal 34(1):p a1-a12, January 2023. | DOI: 10.1097/CPT.0000000000000219
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Sabine Martina Gempel, Lawrence P. Cahalin, Yessenia Orozco, Thais Garcia, Jessica Firmeza, Christy Musino, Meryl I. Cohen

PURPOSE/HYPOTHESIS: Literature has reported some patients experience long-term impairments in pulmonary function following COVID-19 infection, with the most common abnormality being diffusing capacity for carbon monoxide (DLCO). Research on DLCO's association with other measures has been varied, with some studies demonstrating a significant association with older age, female gender, and disease severity, however these results are not consistent. In pulmonary patients, a DLCO of <40% or a drop in DLCO of >4 units is associated with increased morbidity and mortality, is an independent predictor of decreased exercise capacity, and predicts a more rapid decline in pulmonary function. In COPD patients, every 10% decrease in DLCO was associated with worsening quality of life (QOL), 6MWT, severe exacerbations, symptoms, and COPD assessment test (CAT) scores. CAT scores represent the general health status and include cough, sputum, energy, and ability to perform physical work. Daynes et al found an average of 52% of COVID-19 patients had high CAT scores (>10), which the GOLD guidelines suggest using as a cutoff to indicate symptomatic COPD. They found no significant association between CAT score and hospital length of stay or days on mechanical ventilation, but did find a moderately significant association to anxiety, depression, and self-reported physical activity levels. While a patient's pulmonary function test (PFT) may not be available to a clinician, the CAT is a quick and easy screening tool that can be performed in the clinic. The purpose of this study was to assess possible relationships between PFT measures and outcome assessments that can be performed in the clinic by a physical therapist (PT), which may aid in prognosis. NUMBER OF SUBJECTS: Sixteen subjects (8 male and 8 female with a mean age and BMI of 52 ± 16 and 32 ± 5, respectively) diagnosed with long-COVID and referred to pulmonary rehabilitation (PR). MATERIALS AND METHODS: Baseline PFT and CAT scores were obtained during the initial evaluation. Spearman's rho correlation analyses were performed. The 6MWT and DLCO were performed using standardized methods. RESULTS: The baseline CAT, DLCO, and 6MWT were 22.2 ± 6.7, 14.1 ± 7.3 and 292 ± 144 m, respectively. The CAT was significantly correlated to the DLCO (r-value of −0.63; P = .009) and 6MWT (r-value of −0.52; P = .04). CONCLUSIONS: Self-reported CAT scores were significantly correlated with DLCO and 6MWT in patients with long-COVID. CLINICAL RELEVANCE: DLCO is the most common PFT abnormality observed in patients with long-COVID and can provide useful information to the clinician regarding prognosis and possibly disease severity. However, PTs may not have access to a patient's PFT report. Alternatively, a CAT assessment is free and quick and can be easily performed in the clinic. We found CAT scores were significantly correlated to DLCO and 6MWT, which may allow clinicians to use CAT scores as a surrogate measure to aid in establishing a prognosis and/or understanding of disease severity in patients with long-COVID.


Elena Crooks, Morgan Beste, Kiara Hoxie, Abigail Morrison, Megan Alyse Johnson, Lauren Michelle Walters, Chiayo Gilbert, Douglas L. Weeks

PURPOSE/HYPOTHESIS: Sleep is vital for recovery following a cardiac event. Yet evidence is lacking on associations between sleep, cardiac pain and non-cardiac pain among individuals attending cardiac rehabilitation (CR). The purpose of this study was to describe the prevalence and severity of both cardiac and non-cardiac pain, and determine whether pain affects sleep quality in a sample of patients participating in an outpatient CR program. NUMBER OF SUBJECTS: One hundred subjects (67.3 ± 0.6 years, 68 male) completed the study. To be included in the study, subjects had to: be at least 18 years old, provide informed consent, have had a cardiac event and/or diagnosis in the last 6 months, and be attending CR. MATERIALS AND METHODS: Subjects completed a survey of demographics and clinical characteristics around time of admission to CR. Subjects reported cardiac-related pain (yes/no), other non-cardiac pain (yes/no), chronic pain (pain >3 months; yes/no), and rated average pain on a scale of 0 (no pain) to 10 (worst pain imaginable). Additionally, subjects completed the Pittsburgh Sleep Quality Index (PSQI) and the global PSQI score, a valid and reliable measure of sleep dysfunction, was calculated. Descriptive statistics and simple linear regression analyses were conducted using SPSS v27. RESULTS: Overall, 37.0% of subjects reported the presence of current cardiac pain, with a mean pain rating of 2.58 (±0.31). Additionally, 71.0% reported current non-cardiac pain, with a mean pain rating of 3.15 (±0.36), a pain severity significantly higher than cardiac pain severity (P < .01). Of those reporting non-cardiac pain, 85.7% reported experiencing chronic pain. Subjects with cardiac pain had poorer scores on the PSQI (10.65 ± 0.84) than subjects without cardiac pain (9.26 ± 0.66), but differences were not statistically significant (P = .20). Subjects with non-cardiac pain had significantly poorer scores on the PSQI (10.52 ± 0.62) than subjects without non-cardiac pain (7.52 ± 0.83; P < .01). Additionally, non-cardiac pain severity predicted PSQI scores (R2 = 0.17, B = 0.41, P < .001), but cardiac pain severity did not (P = .10). CONCLUSIONS: A striking number of individuals participating in CR reported cardiac and non-cardiac pain. The presence of pain negatively impacted sleep, with a greater effect associated with non-cardiac pain than cardiac pain. Non-cardiac pain severity predicted PSQI scores, where those with higher pain severities had significantly greater sleep disruptions. CLINICAL RELEVANCE: A large fraction of patients attending CR experience cardiac pain, and an even larger fraction of patients experience non-cardiac pain. Physical therapists should consider the high prevalence of non-cardiac pain and its ability to predict sleep quality in this patient population. Future work is needed to identify the impact of cardiac and non-cardiac pain on rehabilitation participation and functional outcomes. Furthermore, interventions to address non-cardiac pain and associated sleep disruptions should be implemented, and their impact on sleep quality and functional outcomes assessed.


Todd Eldon Davenport, Staci R. Stevens, Jared Stevens, Christopher R. Snell, Mark Van Ness

PURPOSE/HYPOTHESIS: Physical therapy practice depends on valid and reliable patient reported outcomes measures (PROMs). Post exertional malaise (PEM) and post exertional symptom exacerbation (PESE) are features of myalgic encephalomyelitis, Long Covid, and related conditions. They comprise a constellation of symptoms and signs including profound physical fatigue. Existing fatigue-specific instruments often are inappropriate to measure functional effects of accompanying symptoms and signs and demonstrate substantial floor effects. The purpose of this study was to determine the psychometric properties of a novel PROM for people living with PEM/PESE, the PEM/PESE Activity Questionnaire (PAQ). NUMBER OF SUBJECTS: 981 people living with PEM/PESE who completed a web-based questionnaire. MATERIALS AND METHODS: Respondents chose a function from a dropdown menu, consisting of the International Classification of Function core set for myalgic encephalomyelitis, and rated it on 2 different 0 to 10 scales. Each scale was anchored at 0 being “Completely unable to perform,” and 10 being “Can perform at the same level as a time I have good energy” and “Can perform at the same level as before I became ill,” respectively. Respondents also provided an estimate of effort intensiveness on a 0 to 10 scale, anchored at 0 being the activity took “No time, effort, and resources at all” and 10 being “All of my time, effort, and resources.” Respondents took the PAQ twice; they completed a demographic questionnaire after the first PAQ and before the second PAQ. Backward navigation was disabled so respondents could not view the first PAQ while completing the second PAQ. Descriptive statistics were calculated for the participants who completed versus did not complete the entire survey. Subgroup analyses by completion status and function were undertaken by chi-square analysis for binomial variables and one-way analysis of variance for continuous variables. Intraclass correlation coefficients were calculated for each scale to assess test-retest reliability. Floor effects were the proportion of participants reporting the lowest score. RESULTS: 981 surveys were available for analysis, including 675 complete surveys. All participants reported PEM/PESE. Respondents reported less frequent flu-like symptoms and pain, shorter recovery times after physical activity (i.e., less than 24 hours), and lower thresholds for physical and mental fatiguability than respondents who did not complete the survey (P < .001). Activities most frequently chosen for rating were “Carry out my normal routine,” “Prepare meals,” and “Maintain employment for financial reward.” Test-retest reliability was generally fair to excellent, depending on function and scale. Floor effects were noted in 9.2% to 24.7% of responses, also with notable variation based on function and scale. CONCLUSIONS: The PAQ provides valid, reliable, and sensitive outcome measure for people living with PEM/PESE. Survey completion may be limited by severity of PEM/PESE. CLINICAL RELEVANCE: Physical therapists could use the PAQ to assess illness severity and intervention efficacy for people living with PEM/PESE.


Nicholas Aaron Colby, Cristiane C. Meirelles, Timothy Mark Pace

PURPOSE/HYPOTHESIS: The AM-PAC basic mobility and the FSS-ICU both measure the functional ability of a patient in the acute setting, specifically in the ICU. While a few studies have analyzed the clinical utility of the AM-PAC or the FSS-ICU, there have been no studies comparing the 2 outcome measures simultaneously using the cardiovascular surgical population. The purpose of this study was to compare the degree of change in functional mobility demonstrated by the AM-PAC and the FSS-ICU in patients following open-heart cardiac surgery. It was hypothesized that the FSS-ICU would be able to detect smaller changes in functional mobility compared to the AM-PAC. NUMBER OF SUBJECTS: Twenty-four patients (mean age 59.0 ± 2.4 years) who underwent elective cardiac surgery via sternotomy were recruited for the study. Exclusion criteria included heart and lung transplants, emergency surgery, and post-operative stroke. MATERIALS AND METHODS: For each patient, an AM-PAC basic mobility and FSS-ICU measure were completed upon physical therapy (PT) evaluation and prior to discharge. Assessments were completed by both a physical therapist and physical therapist student who were trained in scoring measures. All calculations were completed and analyzed using MedCalc. RESULTS: Of patients included, 45% (11) underwent coronary artery bypass grafting (CABG), 25% (6) underwent a valve replacement, 17% (4) underwent a CABG and a valve replacement, and 13% (3) were congenital repairs. Upon hospital discharge, 92% (22) patients went home, and 8% (2) patients went to a skilled nursing facility. The scores for the AM-PAC and FSS-ICU at evaluation were 15.13 ± 2.25 and 16.54 ± 5.15 and the scores prior to discharge were 18.17 ± 0.87 and 25.79 ± 1.74, respectively. The average difference between evaluation and discharge (AM-PAC 3.04 ± 2.26, P < .0001; FSS-ICU 9.25 ± 4.89, P < .0001) were used to calculate 3 measures of responsiveness: standardized response mean, effect size using pooled standard deviation (Cohen's d), and effect size (ES) using baseline standard deviation. The AM-PAC had results of 1.35, 1.78, and 1.35, respectively. The FSS-ICU had results of 1.80, 2.49, and 1.89, respectively. The FSS-ICU had greater degrees of responsiveness across all 3 measures compared to the AM-PAC, but both outcome measures had a high effect according to Cohen's d interpretation. CONCLUSIONS: The FSS-ICU may be able to detect smaller changes in functional mobility due to its higher responsiveness compared to the AM-PAC. However, both measures can be used in the cardiac ICU to appropriately measure functional change in post-surgical patients. CLINICAL RELEVANCE: This is the first study that compared the FSS-ICU and the AM-PAC simultaneously within the same patient population. The FSS-ICU may be a better tool to measure functional mobility in lower-level patients, due to its ability to detect smaller changes in a patient's function. Future areas of research should explore the utility of the FSS-ICU across other ICU populations, including surgical and non-surgical patient populations in comparison with other outcome measures, such as the AM-PAC.


Daniel Christopher Dale, Deborah Michael Wendland, Tiffany Jean Haney

PURPOSE/HYPOTHESIS: The purpose of this study was to determine if the use of a task trainer in physical therapy education improves the self-efficacy and accuracy of students assessing blood pressure measurements. Hypothesis: Students having access to a low fidelity task trainer would demonstrate increased self-efficacy and accuracy in blood pressure assessment compared to students not having access to the task trainer. NUMBER OF SUBJECTS: Participants from consecutive cohorts of Doctor of Physical Therapy (DPT) students (38 students per cohort) participated. In total, 74 students completed the entirety of the study and were included in data collection. MATERIALS AND METHODS: Participants were divided into 2 groups: experimental and control. Both groups received traditional classroom instruction and lab practice for blood pressure assessment. The experimental group also had access to the Laerdal® Blood Pressure Training Arm during lab practice and open lab sessions. Student self-efficacy was assessed with a two-question survey given at 3 time points during training. Accuracy was assessed via a skills check of blood pressure measurement using high-fidelity manikins after all classroom instruction and lab practice. Data Analysis: Descriptive analysis was performed and t-tests were used to compare groups. RESULTS: Across both groups, students improved in their self-efficacy of blood pressure measurement performance (Mean change score: +34.22 points with trainer; +25.31 points control) and in confidence in their accuracy (Mean change score: +35.97 points with trainer; +29.54 points control). Variability was high and there was not a statistically significant difference between groups. When actual blood pressure assessment accuracy was measured, those who had access to the task trainer demonstrated an accuracy of 94.1 ± 7.8% while those who did not have access to the task trainer had an accuracy of 94.9 ± 6.4% (P = .77). Both groups demonstrated acceptable technique and accuracy. CONCLUSIONS: Both methods of teaching the assessment of blood pressure were equally effective in increasing student self-efficacy and accuracy. Given the effectiveness of both methods, the use of simulation to teach blood pressure assessment may have additional benefits to some students and improve efficiency of teaching, allowing faculty to be more attentive to student needs and techniques during the practice of these skills. CLINICAL RELEVANCE: The use of task trainers may be an effective method for teaching blood pressure assessment. Future studies should look to determine if improved student self-confidence, confidence in accuracy, and actual accuracy following the use of a task trainer correlates with improved accuracy and consistency of measurement in clinical education and clinical practice. Additionally, the use of a task trainer may better align with certain learning styles of students, and therefore can be used as an additional teaching method or strategy for students.


Sabine Martina Gempel, Lawrence P. Cahalin, Yessenia Orozco, Thais Garcia, Jessica Firmeza, Christy Musino, Meryl I. Cohen

PURPOSE/HYPOTHESIS: Some patients with COVID-19 have physical impairments that last well beyond the acute infection, termed long-COVID. An increasing number of patients experiencing ongoing symptoms are being referred to outpatient Pulmonary Rehabilitation (PR) with a growing understanding of their key limitations and the benefits of PR. Patients with long-COVID often present with significant inspiratory muscle weakness and functional limitations even months after infection and benefit from PR and IMT. The purpose of this study was to examine the impact of PR on inspiratory muscle performance (IMP) and several functional performance measures (FPM), as well as COPD Assessment Tool (CAT), quality of life (QOL) and depression (D) screening. NUMBER OF SUBJECTS: Eight patients (3 male and 5 female, age 51 ± 15, BMI 32 ± 6) diagnosed with long-COVID-19. MATERIALS AND METHODS: Twenty-two patients with long-COVID entered PR but only 8 patients successfully completed the program. The PR program included aerobic exercise, strength training, IMT, and education. Of the 22 patients who started PR, 64% dropped out due to a variety of reasons. IMP was examined via the PrO2 from residual volume providing the maximal inspiratory pressure (MIP) at 1 to 2 seconds of inspiration and the sustained maximal inspiratory pressure (SMIP) from MIP to total lung capacity. The 6-minute walk test (6MWT), timed-up-and-go (TUG), BERG balance test (BERG), 5x-sit-to-stand (5xSS), Patient Health Questionnaire (PHQ9), Ferrans & Powers QOL, and CAT were measured using standardized methods. Wilcoxon Signed Rank Tests were computed before and after PR with statistical significance set at P < .05. RESULTS: No significant difference in any outcome measure was found when comparing completers to non-completers of PR. Significant (P < .05) improvements in the SMIP (198.1 ± 61.5–286.8 ± 130.7 PTU), 6MWT (313 ± 103–451 ± 101 m), TUG (7.7 ± 2.3–6.2 ± 1.1 s), 5xSS (13.0 ± 3.2–10.5 ± 1.5 s) and QOL (21.2 ± 3.6–24.8 ± 2.4) were observed, while non-significant changes were observed in PHQ9 (7.3 ± 5.6–6.5 ± 5.1), BERG (52.7 ± 6.7–55.8 ± 0.4), MIP (69.9 ± 17.2–84.8 ± 27.7 cmH2O), and CAT (22.2 ± 7.7–19.8 ± 7.9) following PR. At baseline, SMIP but not MIP was significantly (P < .05) lower than predicted values (41 ± 11% and 76 ± 20%) but following PR the difference from predicted was no longer significant. CONCLUSIONS: Only 36% of patients with long-COVID who were referred to and initiated PR successfully completed the program. Following PR, patients demonstrated significant improvements in inspiratory muscle endurance, functional performance, and self-reported QOL, with non-significant improvements in balance and self-reported symptoms, confidence with activity, and depression. CLINICAL RELEVANCE: IMP and FPM are significantly impaired in patients with long-COVID. PR has been shown to significantly improve many respiratory, functional performance, and psychosocial outcome measures and should be considered as part of the plan of care for these patients. Furthermore, methods to improve adherence to PR in patients with long-COVID are needed.


Suh-Jen Lin, Cooper I. Overton, Nicole Jelley, Kayley D. Cowin, Katherine Froehlich-Grobe

PURPOSE/HYPOTHESIS: Individuals with spinal cord injuries (SCI) often are at risk of physical inactivity and cardiovascular comorbidities, due to impaired overall muscle function, transportation issues, and difficulties accessing exercise facilities. It is important for those with SCI to maintain regular physical activity for improving muscle strength, function, and overall quality of life. Investigators tested whether a 16-week virtually delivered and group-based program to teach self-management skills for exercise could help people adopt a regular exercise regimen. The purpose of this study, conducted as a secondary analysis of data on subjects with SCI randomized to a wait list control or enrolled in the “Workout on Wheels Internet Intervention (WOWii)” program, was to examine the outcomes of breathing strength and lung function after the 16-week program. It was hypothesized that there would be significant improvements in breathing strength and lung function among the intervention group compared to the control group of the WOWii study. NUMBER OF SUBJECTS: There were 24 subjects tested on breathing strength and lung function, 17 of whom returned following 16 weeks for post-intervention evaluation (age: 43 ± 10 years, Body Mass Index: 26.3 ± 1.2 kg/m^2, Time since injury [years]: 12 ± 1.9, ASIA category: A [n = 7], B [n = 5], C [n = 1], D [n = 4]), with 11 in the intervention group and 6 in the control group. Institutional Review Board approval on this part of the study protocol was obtained. MATERIALS AND METHODS: The WOWii database were extracted for demographics and the following outcome variables: maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax), lung function (e.g., FEV1, FEV1/FVC, and forced expiratory flow (FEF)). Descriptive statistical analysis and two-way (group, time) ANOVA were conducted with SPSS version 25.0. RESULTS: Intervention group PImax (cmH2O) pre: 81.7 ± 32 (SD), post: 86 ± 30; Control group PImax (cmH2O) pre: 110 ± 22.6, post: 106 ± 20 (P > .05). Intervention group PEmax (cmH2O) pre: 69.3 ± 6.3, post: 68.9 ± 7; Control group PEmax (CmH2O) pre:81.5 ± 24.6, post: 91 ± 19.4 (P > .05). Intervention group FEF (%pred) pre: 47.8% ± 21%, post: 56% ± 17%. Control group FEF (%pred) pre: 56% ± 29%, post 70% ± 25% (P > .05). The lack of significant differences observed in these outcomes could be attributed to the small sample size, large variabilities in the outcome variables due to mixed levels of injury (thoracic vs cervical; complete vs incomplete), and possibly the limitation of web-based exercise without supervision. CONCLUSIONS: Our findings could provide data to calculate effect sizes of selective outcome variables to estimate the sample sizes in future studies. CLINICAL RELEVANCE: The virtually delivered 16-week intervention maybe help individuals with SCI address barriers to exercise and support them in exercising more regularly, though this study did not indicate that their exercise participation significantly improved breathing strength or lung function.


Kelly M. Lindenberg, Nancy Kulikowski Shipe, Michaela Kendall, Matthew Austin Kohlmann, Scot King, Courtney M. Nunley, Joshua E. Roberts, Ashley McDowell

PURPOSE/HYPOTHESIS: Kinesiology Tape (KT) has been used clinically to improve posture, mobility, and muscle strength. Limited research has investigated the effect of KT on respiratory function, including rib mobility or diaphragm activity. The purpose of our study was to explore the effects of taping methods on posture and breathing mechanics in healthy individuals. NUMBER OF SUBJECTS: 75 adult subjects were recruited via convenience sampling from the university population. MATERIALS AND METHODS: The study utilized a randomized block design. Subjects were randomly assigned to one of 3 groups: KT, sham tape (ST), or control (C). Subjects were blinded to group assignment. Data collection occurred over two sessions, 48-hours apart. Baseline measurements were taken including chest wall expansion (CWE) measured with a digital tape measure at the sternal angle (SA) and xiphoid process (Xi), diaphragm performance through measurement of maximal inspiratory pressure (MIP), and posture measured via left and right (L, R) tragus (TWD) and acromion (AWD) to wall distances. Next, KT or sham cover roll tape was applied to the upper back and neck, or no tape was applied to each subject based on group assignment. Ten minutes later, the same measurements were repeated on all subjects. Subjects continued to wear the tape for 48 hours and returned to participate in a final round of the same measurements. Mixed measures ANOVAs were used to determine the influence of tape at baseline (pre), immediately post-taping (post1), and 48 hours post-taping (post2) between the ST, KT, and C groups. Post hoc analyses utilized Tukey method. RESULTS: AWD-L data yielded a significant (sig) time*group interaction (P = .042). Post hoc showed sig difference in KT pre-post1 (P = .001), and in C pre-post1 (P = .016) and post1-post2 (P = .006). TWD-R data yielded sig between-group effects (P = .038). Post hoc showed that KT was sig different from ST pre (P = .016) and post2 (P = .012) and approached sig at post1 (P = .051). CWE-Xi data yielded a sig within-subject effect for time only (P = .001). Post hoc showed sig difference pre-post1 (P = .004) and post1-post2 (P = .006). MIP data yielded a sig within-subject effect for time only (P < .001). Post hoc showed sig diff pre-post1 (P = .007), pre-post2 (P < .001), and post1-post2 (P < .001). All other data yielded non-sig results. CONCLUSIONS: KT had a limited and inconsistent impact on posture measures where only AWD-L decreased immediately post-taping, but this was not seen 48 hours later. Taping did not impact CWE at the sternal angle. There was an evident training effect for CWE-Xi and MIP, where all groups saw a consistent increase in both measures at pre, post1, and post2. CLINICAL RELEVANCE: This method of KT application is not supported as an intervention for improving posture or enhancing inspiratory breathing mechanics in healthy adults. Further investigation of KT in other populations is needed.


Steven Matthew Laslovich, Mitchell J. Rauh, Bent Alvar, PhD, CSCS,*D, TSAC-F,*D, FNSCA, Matthew Allison, MD, MPH

PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of a 12-week in-home self-monitored, self-directed lifestyle based physical activity program (LBPA) on changes in endothelial reactivity, sedentary behaviors, and both standing and stepping activities in individuals with asymptomatic peripheral arterial disease (APAD). NUMBER OF SUBJECTS: Participants (n = 38) with APAD (ages 52–87) were randomized to an attention control (AC) or a LBPA and sedentary reduction (PASR) group employing an interactive online 3-month program. MATERIALS AND METHODS: Participants were screened for asymptomatic peripheral arterial disease by the ankle brachial index (<0.9), no limitations participating in daily bout-oriented walking sessions, and no self-reported lower extremity claudication symptoms. Following randomization, the ActivPal™ monitor was utilized to measure postural and stepping parameters for 7 consecutive days after baseline and then repeated 12 weeks later. At baseline, and again at 12 weeks, endothelial function was evaluated by peripheral arterial tonometry (PAT) using the EndoPAT™ system. This system measures the vasodilator function in the microvasculature of the fingertip during reactive hyperemia (PAT-RHI). RESULTS: The PASR group significantly decreased daily sitting/lying time (−0.80 ± 0.87 vs 0.18 ± 0.77 hours, p < 0.01), increased sit to stand transitions/day (7.1 ± 10.5 vs −1.4 ± 5.71, p < 0.01) and increased daily step counts (2814 ± 1753 vs 742 ± 1321, p < 0.01). Compared to the AC group, the PASR group also increased steps/day accumulated within specific cadence bands 61 to 80 steps/min, (1252 ± 447 vs 177 ± 359, p < 0.01), 81 to 100 steps/min band, (919 ± 511 vs −98 ± 697, p < 0.01), and within the 101 to 120 steps/min band (415 ± 625 vs −327 ± 467, p < 0.01). PAT-RHI significantly increased in the PASR group only (0.179 ± 0.180 vs 0.044 ± 0.101, p = 0.02). CONCLUSIONS: Modest improvements in microvascular reactivity, physical activity, and sedentary behavior were demonstrated following a 12-week intervention targeting sedentary behavior reduction and increased lifestyle physical activities in individuals with APAD. CLINICAL RELEVANCE: Increasing evidence demonstrates functional benefits from walking interventions on individuals with both symptomatic and asymptomatic PAD. The results of this study suggest promoting the use of twice daily low to moderate intensity lifestyle-based walking bouts may benefit microvascular endothelial function in older sedentary individuals with APAD. While current physical activity guidelines involve participation in moderate or vigorous level physical activity, recommending twice daily walking bouts to increase physical activity levels appears to be beneficial. Self-paced moderate intensity lifestyle walking bouts in sedentary individuals with APAD should be encouraged to both decrease functional decline and as a potential mechanism to help improve vascular health.


Alexis C. Coval, Bobbi Lynn Bailey, Diana Bonilla, Christina Bridget Haddican, Dana Rose Maida, Janette Marie Scardillo

PURPOSE/HYPOTHESIS: Experts in the field have questioned the continued use of standard sternal precautions due to the impact on functional outcomes. The purpose of this systematic review was to determine the functional impact of standard sternal precautions (SSP) compared to modified sternal precautions (MSP) on mobility in adults following median sternotomy. NUMBER OF SUBJECTS: N/A. MATERIALS AND METHODS: A literature search using PubMed, CINAHL, ScienceDirect, and APTA EBSCOhost was conducted using search terms: (“coronary artery bypass graft” OR CABG OR sternotomy) AND (function OR ADL OR “activities of daily living") AND (modified OR restrictive) AND precaution. Search limits: Human subjects, peer reviewed, English language. Selection criteria: adult (18+), median sternotomy. Two reviewers independently assessed each study for methodological quality and came to a consensus based on OCEBM Levels of Evidence (2011). RESULTS: Twenty-one reports were assessed for eligibility. After detailed appraisals, 4 studies met selection criteria. All articles ranked as OCEBM Level 2 evidence (1 RCT, 1 quasi-experimental design, 1 observational study and 1 cross-sectional design). Sample size ranged from 72 to 1104 (n = 1744; avg age 64.96 yrs). SSP prohibited lifting, pushing, pulling >5 lbs (4), driving (2), reaching behind back (2), reaching overhead (2), leaning forward with head below heart (1), arm use with sitting or standing (1) and required splint chest during coughing (2). MSP was defined as “keep your move in the tube” (3) or “less restrictive” (1). Function was assessed through Short Physical Performance Battery (SPPB), Health Assessment Questionnaire (HAQ), level of assistance for bed mobility and transfers, and functional self-report. Two studies concluded no statistically significant differences between groups (SPPB at 4 weeks MD 1.0 point, 95%, CI –0.2–2.3; at 12 weeks MD 0.4 point, 95% CI –0.9–1.6; and self-report with P = .14). Two studies found significant improvements for MSP groups with greater return to function (HAQ P < .001) and decreased functional assistance required (P < .001). Two adverse events unrelated to sternal precaution adherence occurred in both the SSP (1) and MSP (1) groups. CONCLUSIONS: Moderate levels of evidence indicated either equally effective or more favorable outcomes with use of MSP as compared with SSP. Limitations included non-standardized and varied functional outcome measures, and multiple sternal precaution protocols. Future research should include standardization of functional outcome measures and well-defined precautions to justify the use of MSP as a means to improve functional outcomes. CLINICAL RELEVANCE: Experts suggest SSP may inadvertently impede recovery when compared to patient-specific sternal precautions, which may facilitate more favorable outcomes. Inconsistencies in reported sternal precaution protocols contribute to insufficient evidence in support of their universal use. With a lack of evidence to support adherence to SSP, clinicians should advocate to the medical team for incorporating MSP in standard sternotomy care. Permitting activity with MSP may improve functional outcomes and optimize discharge destination.


Samantha Baker, Justin Hwang, Alison Ede, Hsiang-Ling Teng, Ayla Donlin, Jacqueline Kiwata Dawson

PURPOSE/HYPOTHESIS: Cardiometabolic disease is the leading cause of death of adults in the United States1, with regular exercise that follows American College of Sports Medicine guidelines recommended as a first approach to prevention and treatment2. For physical therapists, home exercise program (HEP) prescription can help manage musculoskeletal conditions and is useful in mitigating cardiometabolic disease risk factors3. However, patient adherence to HEPs is a constant challenge and poor participation is common over time4. Technology-enhanced HEPs are increasingly available for clinicians to use with their patients, yet more information is needed on factors that may affect HEP adherence, particularly in patients with cardiometabolic risk factors5. We hypothesized that self-reported moderate-to-vigorous physical activity (MVPA) at baseline would be associated with exercise participation in an 8-week digital HEP. NUMBER OF SUBJECTS: 30. MATERIALS AND METHODS: Three male (46.0 ± 34.2 yr) and 27 female (29.9 ± 8.8 yr) sedentary adults (<60 min of MVPA/week) were randomized to receive an 8-week home exercise program as part of a larger 3-arm randomized trial (n = 84). Participants were given a chest strap (Myzone MZ-3) for exercise monitoring and 3 35-min videos per week of high-intensity functional training designed to meet ACSM guidelines for reducing cardiometabolic risk. Participants completed the International Physical Activity Questionnaire (IPAQ)6 at baseline and following the 8-week intervention. Exercise effort was captured by the tracker as a physical activity score = % maximum heart rate (HRmax) x duration. Moderate-to-vigorous exercise time (MVET) was calculated as the time spent in effort >64% HRmax. Multiple linear regression was used to investigate the association between self-reported baseline MVPA and exercise participation during the 8-week intervention, analyzed as 1) weekly exercise sessions, 2) weekly exercise effort and 3) weekly MVET, adjusted for sex and age. RESULTS: Self-reported MVPA was 25.1 ± 69.4 min/week at baseline and 174.3 ± 391.3 min/week post-intervention. Baseline MVPA was associated with number of exercise sessions/week (P = .013, β = 0.45, F = 7.03) and exercise effort/week (P = .023, β = 0.42, F = 5.83), but not MVET/week (P = .123, β = 0.29, F = 2.52). Neither sex nor age were found to influence any of the regression models. CONCLUSIONS: Our data from a small sample of primarily female adults suggests that higher levels of baseline physical activity can positively influence participation and exercise effort in a digital HEP. Further research is needed to examine if demographic factors such as race/ethnicity and socioeconomic status influence exercise compliance when the program is digitally delivered. CLINICAL RELEVANCE: Digital home exercise programs have the potential to streamline continuity of care from the clinic to the home and improve overall patient experience. Therefore, an understanding of factors that influence exercise behavior can help overcome barriers to physical activity, improve compliance and ultimately lead to greater, long-term therapy intervention outcomes.


Gavin E. McBride, Natalie Hagen

PURPOSE/HYPOTHESIS: The shift towards patient-centered care emphasizes the need to understand differences between patient and clinician perspectives of health. In acute care clinician perceptions are used to assess physical function for safety (i.e. falls risk), treatment, and discharge planning. Patient perceived AM-PAC versus clinician perceived AM-PAC have shown general agreement, however, AMPAC may capture physical function at lower levels than many patients' desire. The objective this analysis was to determine the strength of the correlation and offsets between patient perceptions of physical function with respect to the US average and the clinician scored AMPAC measure of physical function. NUMBER OF SUBJECTS: 22. MATERIALS AND METHODS: Twenty-two patients with a primary cardiopulmonary diagnosis were recruited from the acute care rehab department at a VA facility. Patient functional status was assessed using the Patient Reported Outcome Measurement Information Systems (PROMIS) Physical Function Short Form 10a (PF10a), with t-scores ranging from 13.5 to 61.9, where a norm of 50 equals the US average, and 10 points is 1 standard deviation. A licensed Physical Therapist completed the AMPAC-6 Clicks Basic Mobility (BM) short form to assess patient functional status, with t-scores ranging from 23.5 to 61.1, where 50 equals the mean of a post-acute rehabilitation population, and 10 points is 1 standard deviation. Pearson correlation assessed correspondence between the measures and a paired-sample T test was used to confirm expected differences between the means for each measure. RESULTS: There is a significant, positive correlation between patient (PROMIS PF10a) and clinician (AMPAC-6 BM) assessment of physical function (r = 0.68, P = <0.01). However, patients viewed their physical function significantly lower, relative to the US average, versus the clinician AM-PAC score (PROMIS PF = 33.2 [±6.9], AM-PAC = 52.3 [±8], P < .001). CONCLUSIONS: While our patient and clinician assessment of physical function is positively correlated, patients reported their physical function significantly lower compared with the clinician perspective (AMPAC-6) which suggested higher levels physical function. This data reinforces the utility for clinician-based measurements of physical function to be paired with patient perceptions of function that are person centered. CLINICAL RELEVANCE: The addition of a simple, patient self-report measure of functional status, such as PROMIS-PF, may help identify patients with physical function impairments. In-line with patient-centered care, these patients could benefit from the unique skill set of an advanced practice cardiopulmonary physical therapist while admitted to an acute hospital, and potentially further home health or cardiac and pulmonary rehabilitation referrals at discharge.


Jessica Wulke, Katelyn Brown, Jordan Teel, Megan Reynolds, Taylor Gilliland, Evan McShan, Jared Louis Gillespie, Simon Driver

BACKGROUND AND PURPOSE: Firefighting is a demanding and hazardous profession requiring optimal physical and cognitive health. Occupational risk factors associated with firefighting (contact with the public, pulmonary damage from repeated exposure to fire) may place firefighters at an increased risk of contracting SARS-CoV-2 as well as for suffering complications resulting from fulminant COVID-191, which can result in impaired physical2 and cognitive3 performance. Current recommendations for rehabilitation following COVID-19 may be insufficient to address the unique physical and cognitive demands required to perform fire suppression tasks.4 The purpose of this case report is to describe the efficacy of a high-intensity, occupation-specific physical therapy (HIOS-PT)5 program to improve aerobic capacity, muscular strength, and cognitive performance sufficient to return a firefighter to full duty within 6 months following hospital discharge for critical COVID-19. CASE DESCRIPTION: A 36-year-old firefighter completed 30 sessions of HIOS-PT with hopes of returning to his strenuous occupation as a firefighter following a 70-day complicated hospitalization for critical COVID-19 pneumonia and acute respiratory distress syndrome requiring invasive mechanical ventilation. Initial evaluation revealed impaired aerobic capacity of less than the first percentile for age and sex on cardiopulmonary exercise testing6, impaired muscular strength on isokinetic testing, and impaired cognitive performance as assessed by an app-based information processing task (reaction time and accuracy). The HIOS-PT program was symptom-limited simulated real work activities based on previous literature describing the effect of similar programming with first responders in cardiac rehabilitation5, while improving strength, cognition, and aerobic capacity sufficient to meet fitness standards required to return to work. Additionally, the patient performed 3 simulated candidate physical ability tests each increasing in intensity which consisted of 9 fire suppression activities required by his department7. Follow-up assessments were performed after completion of 30 HIOS-PT sessions. OUTCOMES: Aerobic capacity increased 54% from a VO2 = 25.4 mL/kg/min (7.3 METs) to VO2 = 39.2 mL/kg/min (11.2 METs). Muscular strength increased from 59% to >96% body weight. Cognitive performance on an information processing test increased 175% from a score of 556 to 1530. Upon discharge from the HIOS-PT program, the patient returned to full duty as a firefighter. DISCUSSION: HIOS-PT was well tolerated and effective in rehabilitating a firefighter to return to work following a prolonged hospitalization for critical COVID-19. Rehabilitation guidelines for occupational athletes, such as firefighters, following critical COVID-19 is limited and may be insufficient to adequately prepare these individuals for return to strenuous work duties. This case supports the exploration into using HIOS-PT for individuals required to perform heavy work following critical COVID-19.


Aaron Heisey Thrush, Emma Steenbergen

PURPOSE/HYPOTHESIS: To report PT utilization and outcomes among patients on ECMO support, with and without COVID-19 (COV). NUMBER OF SUBJECTS: All patients supported on ECMO for ≥3 days and receiving PT while on ECMO were included. MATERIALS AND METHODS: Retrospective review of medical records to collect required data, from 2015 to June 30, 2022. Descriptive analysis was used to summarize data. RESULTS: From 156 patients on ECMO for ≥3 days, 36 underwent PT while on ECMO - 15 patients without COV and 21 patients with COV. Five patients had veno-arterial configuration. The non-COV group included 15 patients with 142 PT sessions, and the COV group included 21 patients with 270 PT sessions. Non-COV and COV groups had a median age of 40 and 43 years, were 73% and 43% male, and had BMI of 25.3 and 35.1 kg/m2. Mean Sequential Organ Failure Assessment and Respiratory ECMO Survival Prediction scores were higher in the non-COV group, while Lung Injury Scores were similar. Non-COV and COV groups had similar hospital length of stay (60, 54 days), ICU length of stay (53, 50 days), and were cannulated for similar duration (24, 26 days). PT evaluations occurred soon after admission for both groups (4, 5 days). Non-COV and COV groups received a median of 2.5 and 2.6 sessions/week. Sixty-seven percent of non-COV sessions, and 86% of COV sessions, were done with ≥1 femoral cannula in situ. Thirty-five percent and 50% of sessions were in-bed passive or active exercises in the non-COV and COV groups, respectively. Sitting at edge of bed (EOB) or passive transfers to chair, standing or marching, and ambulation were achieved in 20%, 24%, and 21% of non-COV sessions; and in 27%, 16%, and 7% of COV sessions. The non-COV group had a mean first ICU Mobility Scale score (IMS) of 2.23, and improved by 0.31 points. The COV group had a mean first IMS of 1.13, and improved by 1.29 points. The median duration of PT sessions (minutes) with supine interventions, sitting EOB or passive chair transfer, standing or marching, or ambulation were achieved were 30, 45, 55, and 60 in the non-COV group, and 30, 44, and 60, and 55 in the non-COV group. Patient who discharged home from the hospital received the greatest frequency and minutes of PT (3.5 sessions/week, 118 minutes/week) while on ECMO, followed by those discharged to long term or acute rehabilitation settings, acute hospital transfers, and death during admission. CONCLUSIONS: These findings are the first report of PT utilization and outcomes comparing patients with and without COVID-19. The results suggest that PT provision and clinical profiles were similar in both groups. However, the COV group started with lower mobility levels and made larger mobility gains while on ECMO. Our data quantifies the duration of PT sessions according to mobility goals that were achieved, and also shows an association between the frequency and duration of PT sessions and more optimal discharge destination. CLINICAL RELEVANCE: This investigation may assist in allocating resources to ECMO patients, and provide a benchmark for mobility achievements at a time when ECMO utilization is increasing and as a reflection of practice in the response to the ongoing COVID-19 pandemic.


Heidi A. Tymkew, Masina Scavuzzo, Melissa Gerson, Sandra Hooper, Mark Jackson, Padmavathi Kunta, Chelsea Clayton, Cassandra Arroyo MS, PhD

PURPOSE/HYPOTHESIS: Patients undergoing a lung transplant evaluation at our facility complete a 6-minute walk test (6MWT) to assess aerobic capacity and the Short Physical Performance Battery (SPPB) to assess physical function. Based on the SPPB score a patient is considered frail (SPPB < 7), pre-frail (SPPB 8–9) or not frail (SPPB > 10). The purpose of this study is to evaluate if there is a difference in post-transplant outcomes in patients who are considered frail/pre-frail compared to those considered not frail via the SPPB. NUMBER OF SUBJECTS: 72 lung transplant recipients. MATERIALS AND METHODS: Retrospective chart review of all lung transplant recipients between September 2019 and March 2021. Patients were excluded if a pre-transplant SPPB was not documented. The following data was collected: general demographics, initial transplant evaluation data (6MWT, SPPB), general post-transplant hospital information (mobility milestones, physical therapy data, length of stay, discharge location) and post-transplant pulmonary rehab (PR) data (6MWT, Timed Up and Go [TUG], number of PR sessions). Patients were divided into 2 groups based on their initial SPPB score (Frail/pre-frail < 9; Not frail 10–12). Then differences between groups were determined by independent samples t-tests. RESULTS: Based on the initial SPPB score there were 20 (27.8%) patients considered frail, 30 (41.6%) pre-frail and 22 (30.6%) not frail with the mean SPPB of 8.6 + 2 points (range 3–12). After dividing the patients into 2 groups frail/pre-frail versus not frail, there was no difference in the age, gender, BMI or underlying lung disease. The patients who were considered physically frail/pre-frail had higher lung allocation scores (P = .007) and walked shorter distances during the pre-transplant 6MWT (P = .004). There were no differences between groups in intensive care unit/hospital length of stay, duration of mechanical ventilation, discharge location or 30-day readmissions. There were no differences in mobility milestones post-transplant except for those patients who were not frail were able to walk on the treadmill earlier than the frail group (10.5 vs 16.2 days, P = .036), both groups received similar number of PT visits and treadmill sessions. The non-frail group was able to walk longer distances than the frail group during the 6MWT at hospital discharge and at discharge from pulmonary rehab (P = .016 and P = .019). The non-frail group also had a lower TUG score at hospital discharge (10.3 vs 12.7 seconds, P = .03). CONCLUSIONS: Patients who are considered non-frail during the pre-transplant evaluation were able to initiate treadmill walking earlier post-transplant, walk longer distances and had a lower TUG score at hospital discharge than those patients who were considered frail/pre-frail. CLINICAL RELEVANCE: Pre-lung transplant frailty may impact early post-transplant physical function outcomes. Lung transplant recipients who were considered physically frail/pre-frail by the SPPB prior to transplant often exhibit lower exercise capacity and increased TUG scores which places them at a higher fall risk at hospital discharge.


Robert L. Dekerlegand, Allison Guengerich, Emma Hoffman, Hannah Lynn Schied, Devon Williams

PURPOSE/HYPOTHESIS: Coronavirus disease 2019 (COVID-19) may result in hypoxemic respiratory failure and death similar to acute respiratory distress syndrome (ARDS). Based on its known efficacy in ARDS, prone positioning (PP) was used to manage intubated patients with severe COVID-19 lung disease. Though less supported by evidence, awake prone positioning (APP) was also trialed in non-intubated patients with COVID-19 to preserve resources and optimize outcomes. The primary available evidence included in recent reviews on APP in COVID-19 were the resultant retrospective single group studies that showed mixed findings. While such designs expedite results, a risk of bias weakens their application. With emerging research, this focused review evaluated APP in COVID-19 based on prospective trials that included a comparison group. NUMBER OF SUBJECTS: Not applicable. MATERIALS AND METHODS: PubMed and CINAHL databases were searched through June 10, 2022 with the following strategy: [(SARS-COV-2) OR (COVID-19) OR (coronavirus)] AND [(prone) OR (proning) OR (prone positioning)]. Prospective studies investigating APP in non-intubated adults with COVID-19 compared to usual care were included. Quality of evidence was determined by the Cochrane Risk of Bias tool with recommendations made using the GRADE approach. RESULTS: Seven articles evaluating APP in a combined total of 2604 participants (66% male, mean age: 59.8 yrs, BMI: 29.0) with mild to moderate hypoxemic respiratory failure were included. Participant characteristics were heterogeneous and the duration of proning ranged from 4 to 16 hrs/d. APP was associated with improved oxygenation; however, only one study reported a lower incidence of intubation. No effect was noted on mortality or length of stay (LOS). Adverse events were rare but APP was associated an initial worsening outcome in one instance. Lack of blinding and protocol heterogeneity were identified risks of bias. CONCLUSIONS: APP may improve oxygenation in non-intubated individuals with mild to moderate COVID-19 lung disease as compared to usual care; however, prospective controlled trials do not support a positive effect on intubation, LOS, or mortality. The lack of transference in contrast to PP in intubated patients suggests that the primary benefit of PP may be minimizing ventilator-induced lung injury. Alternatively, benefits of APP may be reserved in select individuals as patient characteristics and proning protocols may influence the response. Though serious adverse events were not reported, the potential for skin breakdown and brachial plexus injuries are noted in ventilated patients with the proning times necessary for benefit. Given these findings, the value of “immobilizing” awake patients in prone should be questioned and alternate active interventions investigated. CLINICAL RELEVANCE: The routine application of APP in COVID-19 lung disease to improve clinical outcomes is not supported by current literature. Based on the GRADE approach, a weak recommendation against using APP was determined. Future studies should investigate if optimal protocols matched to potential responders improve the value of APP in COVID-19.


Aaron Heisey Thrush, Emma Steenbergen

PURPOSE/HYPOTHESIS: To compare mobility, medical complexity, and adverse events in patients without COVID-19 (non-COV) and with COVID-19 (COV) while on extracorporeal membrane oxygenation (ECMO) and undergoing physical therapy (PT). NUMBER OF SUBJECTS: All patients on ECMO for ≥3 days and receiving PT while on ECMO were included. MATERIALS AND METHODS: Retrospective collection of data from records from 2015 to June 30, 2022. Descriptive analysis was used to summarize data. RESULTS: From 156 patients on ECMO, 36 underwent PT while on ECMO. Five patients had veno-arterial configuration. The non-COV group included 15 patients with 142 sessions, and the COV group included 21 patients with 270 sessions. Non-COV and COV groups had a median age of 40 and 43 years, were 73% and 43% male, and had BMI of 25.3 and 35.1 kg/m2. Mean Sequential Organ Failure Assessment and Respiratory ECMO Survival Prediction scores were higher in the non-COV group, while the Lung Injury Scores were similar. Non-COV and COV groups had similar hospital and length of stay (60 vs 54 days; 53 vs 50 days) and were cannulated for similar duration (24, 26 days). PT evaluations occurred soon after admission for both groups (4, 5 days). Non-COV and COV groups received a median of 2.5 and 2.6 sessions/week, and 45- and 40-minutes/session, respectively. Sixty-seven percent of non-COV sessions and 86% of COV sessions were done with ≥1 femoral cannulas in situ. The COV group was supported on significantly higher pump flow (4.3 vs 3.6 L/min), pump speed (3200 vs 2675 rpm), and sweep settings (6 vs 4 L/min), however, blender fraction of inspired oxygen was the same (100%). Sessions in the COV group more often had simultaneous sedative infusions (20% vs 4%), abnormal blood gases (91% vs 71%), and hypertension or desaturation. Sessions in the non-COV group more often had simultaneous continuous renal replacement therapy (26% vs 1%), mechanical ventilation (68% vs 38%), and severe anemia (49% vs 37%). Vasoactive infusions presence and lactate levels were similar in both groups. Thirty-five percent and 50% of sessions were in-bed exercises in the non-COV and COV groups. Sitting at edge of bed or passive transfers to chair, standing or marching, and ambulation were achieved in 20%, 24%, and 21% of non-COV sessions; and in 27%, 16%, and 7% of COV sessions. The non-COV group had a mean first ICU Mobility Scale score (IMS) of 2.23, and a mean improvement by 0.31 points. The COV group had a mean first IMS of 1.13, and a mean improvement by 1.29 points. Safety events were categorized as minor or major according to whether interventions were required. The safety event rate in the non-COV and COV sessions were 5% (4 minor, 3 major) and 4% (5 minor, 1 major). CONCLUSIONS: This investigation describes patients on ECMO with and without COVID, with detail on medical condition, mobility, and adverse events. While ECMO settings were higher during COV sessions, other measures did not indicate a clear disparity in disease severity or fragility. The COV group started with lower mobility but made larger gains while on ECMO. CLINICAL RELEVANCE: PT provided to patients with and without COV and on ECMO can result in safe and effective mobility outcomes.


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

PURPOSE/HYPOTHESIS: Skeletal muscle dysfunction plays a role in exercise limitation of multiple chronic lung diseases, including idiopathic pulmonary fibrosis (IPF). A thorough assessment of volitional lower extremity muscle performance that includes the parameters of force, power, and fatigue has not been performed in IPF, nor has this been examined since the widespread adoption of antifibrotic therapy. The purpose of this study was to characterize muscular performance in individuals with IPF who are stable on antifibrotic therapy and to examine relationships to simultaneously-measured clinical indicators of disease progression and health-related quality of life (HRQL). NUMBER OF SUBJECTS: 15 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: Computerized dynamometry (Noraxon MRv3.14) was used to assess lower extremity muscular strength & endurance in isometric knee extension (at 70 deg) and muscular force & power in force platform bilateral jump test (normalized to body mass). Administered at the same study visit were pulmonary function tests (PFTs), 6-minute walk test (6MWT), maximal treadmill cardiopulmonary exercise test (CPET), and St. George's Respiratory Questionnaire for IPF (SGRQ-I). Relationships were analyzed using Pearson correlations. Data are presented as means ± SD. RESULTS: Peak force and power in jump test were 1464 ± 283 N/kg (range 1009–2185 N/kg) and 24 ± 4 W/kg (range 18.8–30.6 W/kg), respectively. Peak knee extension force was 327 ± 77.9 N (range 195–435 N) and impulse of hold time in endurance dynamometry was 7273 ± 3912 N*sec (range 2418–14181 N*sec). Significant relationships were observed for multiple dynamometry values with clinical indicators of disease severity, including in PFTs and exercise testing. Patients with lower lung diffusion capacity in DLCO (ml/min/mm Hg) had worse muscular power (r = 0.53, P = .05) and worse muscular endurance (r = 0.52, P = .05). Lower muscular endurance was correlated with lesser distance in 6MWT (r = 0.69, P = .006), and lower VO2max (r = 0.69, P = .006), max METS (r = 0.69, P = .007) and max treadmill speed (r = 0.70, P = .005) in CPET. Lower VO2max (r = 0.53, P = .04), max treadmill speed (r = 0.70, P = .005), and max METS (r = 0.53, P = .05) were also observed in those with lower muscular power. Finally, the SGRQ-I indicated that patients with lower muscular endurance reported worse symptom impairment (r = 0.77, P = .001). CONCLUSIONS: Lower extremity muscle performance is related to clinical indicators of disease severity and exercise capacity in IPF, as well as to their self-reported HRQL. More muscle function impairment in those with lower lung diffusion capacity may suggest a unique muscle phenotype in IPF that is, in part, related to chronic hypoxia. More research is needed to characterize pathophysiology and direct therapies for skeletal muscle weakness in IPF. CLINICAL RELEVANCE: Muscle strength, power, and endurance may be predictive of exercise tolerance in patients with IPF. Physical therapists that treat patients with IPF should screen for and prescribe therapeutic exercises to address impairments in muscle performance.


Sheryl Maureen Flynn, Sharon Cornelison RT, William Pu, Kim Metzler RT, Connie Paladenech RT, Jill Ohar MD

PURPOSE/HYPOTHESIS: Despite the demonstrated benefits of Pulmonary Rehabilitation (PR) such as improved exercise capacity, and quality of life, and reduced mortality, breathlessness, and anxiety, fewer than 3% of adults with COPD receive PR. Furthermore, adherence to clinic-based PR (CPR) is low. Telehealth-based PR (TPR) with remote therapeutic monitoring (RTM) may be a feasible and effective alternative. The purpose of this study was to evaluate the feasibility and efficacy of TPR + RTM to improve access and adherence to PR. We hypothesized that TPR + RTM is feasible, and effective. NUMBER OF SUBJECTS: n = 18 adults participated in the study. Inclusion criteria: physician permission, diagnosed with COPD, FEV1 >30%-80%, and ability to perform the 6 Minute Walk Test (6MWT). Exclusion criteria: desaturation <88% during 6MWT on room air or supplemental O2, excess of 4LPM oxygen use, coronary artery disease with unstable angina, and presence of acute neurological or cardiovascular condition. MATERIALS AND METHODS: Adults with COPD self-selected to participate in either an 8-wk CPR program or an 8-wk home-based TPR + RTM program. The CPR group exercised 3x/wk and completed 25 lesson topics. The TPR + RTM group used a downloadable app specifically designed with features aligned with PR clinical practice guidelines to track their daily symptoms, exercise 3x/wk, and complete 47 digitized educational modules at home. Clinicians used the web-based RTM tool to monitor progress. Participants were called weekly to adjust the program. RESULTS: The n = 8 CPR group was 75% male, aged 72.5 (6.5) range 61 to 83; the n = 11 TPR + RTM group was 36% male, aged 67.9 (9.3) range 54 to 89. Outcomes for Usability, Exercise Adherence and Education Adherence are shown in Table 1. Test Outcomes are shown in Table 2. CONCLUSIONS: Preliminary data supports the feasibility of a TPR + RTM program for adults with COPD. When combined, all participants achieved statistically significant improvement in all outcomes at 8 weeks, and there was no difference between groups. More than 50% of all participants surpassed MCID thresholds in all outcomes. Adherence and usability scores were high. CLINICAL RELEVANCE: These preliminary results support that a software enabled TPR + RTM program is feasible and effective in improving exercise capacity, quality of life, and may improve access to the 97% of adults living with COPD who are unable or unwilling to attend in-clinic PR.

Table 1 -
Group Exercise Education Usability (SUS)
Expected total Completed Expected total Completed
CPR 24 39 (163%) 25 22 (88%) N/A
TPR 24 29.18 (122%) 47 44.18 (94%) 86.4 = exceptional (95th percentile)

Table 2 -
Outcome All Participants % Reaching MCID Threshold MCID Threshold
Pre Post Change Score P CPR TPR + RTM
6 minute walk test 324.8 (24.8) 392.9 (19.8) +68.1 (11.6) .004 85.7% 77.7% +30 m
COPD assessment test 18 (1.75) 14.4 (1.46) −3.63 (1.34) .01 62.5% 54.5% −2
St. George respiratory questionnaire 50.08 (3.01) 36.46 (3.00) −13.97 (2.3) <.001 71.4% 72.7% −8.3
Lung information needs questionnaire 8.5 (0.85) 3.33 (0.56) −5.28 (0.98) <.001 87.5% 72.7% −1
Veteran rand 12 physical 33.16 (2.02) 39.39 (2.02) 6.22 (1.54) <.001 62.5% 90.9% +1


Cristiane C. Meirelles, Arianna Farnsworth, Mrs. Sidra L. Petit, Brent William Baertsche

BACKGROUND AND PURPOSE: Pulmonary rehabilitation offers substantial benefits in improving lung function, reducing symptoms, and improving quality of life for people with cystic fibrosis (CF) and patients after lung transplantation (LTX) 1. Inspiratory muscle training (IMT) has shown to be beneficial in addressing deficits in respiratory muscle function, 2 but the benefits of IMT in CF patients requiring a redo LTX is unclear 3. To the best of our knowledge, no studies have investigated the use of IMT in addition to physical therapy (PT) intervention immediately after lung transplantation in patients with CF that require a second LTX. This case series describes the addition of IMT to physical therapy interventions in the acute care setting followed up by a home exercise program in 3 patients with cystic fibrosis following redo double lung transplantation. CASE DESCRIPTION: Two males (33 ± 8 yrs.; BMI 20.1 ± 6.7 kg/m2) and one female (34 yr.; BMI 14.5 kg/m2), were admitted to the hospital with a diagnosis of CF and prior history of double LTX, attained a redo double LTX during admission, and participated in PT following surgery to improve general strength, balance, functional mobility, and endurance. In addition, the patients performed IMT (2 sessions/day; 30 breathes per session) at 50% of maximal inspiratory pressure (MIP), for 5 days/week commencing immediately following surgery. Patients received an exercise log to continue and self-track IMT upon discharge from the hospital. AM-PAC basic mobility 4 were assessed at evaluation and upon hospital discharge. MIP, perceived dyspnea (Modified Borg Dyspnea Scale, MBS) 5 and physical performance (4-meter walking speed and 5 times sit to stand) 6 were assessed at baseline and upon completion of IMT. Length of hospital stay (LOS) was 23 ± 7 days and all patients were discharge home. All patients participated in a 12-week Pulmonary Rehab Program upon hospital discharge. Length of IMT was 13 ± 9 weeks. OUTCOMES: The IMT intervention was safe with no adverse events. AM-PAC scores improved from 15.6 ± 2.5 at evaluation to 22 upon discharge. MIP improved from −21.9 ± 1 cmH2O to −73.7 ± 23 cmH2O (21% to 75% of predicted normal value). MBS improved 3 to 0 (classified as a moderate to nothing at all). Baseline physical performance: 4-meter walking speed and 5-time sit to stand test were 0.51 ± 0.1 m/s and 35.5 ± 0.1 21 secs and improved to 1.31 ± 0.2 m/s and 8.3 ± 1.9 secs, respectively, after IMT. The physical performance tests stratified the patients as safe community ambulators with no risk for falls. DISCUSSION: All patients were able to achieve clinically significant improvements in outcomes including MIP, perceived dyspnea, AM-PAC and physical performance. To our knowledge, this is the first case series that has explored the benefits of adding IMT to PT intervention and Pulmonary rehab following redo double lung transplant in cystic fibrosis patients. The results demonstrate the potential benefit of the use of IMT to assist in improving respiratory muscle function and physical performance in lung transplantation across the continuum of care.


Simon K. Ho, Kelly E. Rock, Victoria Gocha Marchese

PURPOSE/HYPOTHESIS: Diaphragm function has been associated with exercise tolerance1 and perceived exertion.2 However, the underlying mechanisms for how the diaphragm affects breathing during exercise is not fully understood. Furthermore, these relationships have not been well-studied in children. Thus, the objective of this study was to explore the relationship between diaphragm function and ventilatory parameters during the six-minute walk test (6MWT) in healthy children and adolescents. NUMBER OF SUBJECTS: This was an observational study using a sample of convenience. Ten healthy children and adolescents were enrolled. MATERIALS AND METHODS: Respiratory muscle strength was measured via respiratory mouth pressures (maximal inspiratory pressure [MIP] and maximal expiratory pressure [MEP]). Diaphragm thickness was measured via two-dimensional B-mode ultrasonography as described by Spiesshoefer et al.3 using a 7.5 to 10 MHz frequency 45-mm linear transducer (SonoQue C4PL Dual Head Probe, O2 Lifecare, Inc., Yorba Linda, CA, USA). The right hemidiaphragm was imaged in supine by placing the transducer on the right lateral chest wall at the zone of apposition of the diaphragm. Images were obtained during deep inspiration at total lung capacity (TLC) and quiet breathing at functional residual capacity (FRC). Ventilatory parameters (respiratory frequency [fR], tidal volume [VT], minute ventilation [V'E], oxygen uptake [V'O2], and ventilatory equivalent for oxygen [V'E/V'O2]) during the 6MWT were measured via breath-by-breath expired gas analysis (VO2 Master Health Sensors Inc., Vernon, BC, Canada). Rate of perceived exertion (RPE) was measured by the Borg Category Ratio 0 to 10 scale. Correlation analysis was performed using Pearson's product-moment correlation coefficient (r) with significance set at P ≤ .05. RESULTS: Diaphragm thickness at TLC was negatively correlated with fR (r = −0.70, P = .03) and V'E/V'O2 (r = −0.79, P = .01). Similarly, the change in thickness was negatively correlated with V'E/V'O2 (r = −0.78, P = .01). RPE was negatively correlated with thickness at both TLC (r = −0.72, P = .03) and FRC (r = −0.76, P = .01). Neither MIP nor MEP were correlated with ventilatory parameters or RPE. CONCLUSIONS: These findings suggest that greater diaphragm thickness was associated with lower ventilatory demand and better breathing efficiency, yet diaphragm strength was not related. Greater diaphragm thickness might be related to changes in chest wall mechanics, potentially altering the sensation of dyspnea and the control of breathing. Thus, the structure and function of the diaphragm muscle may have mechanistic roles that affect the regulation of respiratory rhythm and ultimately exercise performance. CLINICAL RELEVANCE: Given the negative impact of exertional dyspnea on participation and quality of life in children, 4,5 a better understanding of potential mechanisms for the control of breathing during exercise may lead to promising interventions.

Copyright © 2022 Cardiovascular and Pulmonary Section, APTA