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RESEARCH REPORT

The Physiological and Psychological Effects of the First Year of an Entry-Level Physical Therapist Education Program on Students

Douris, Peter C. PT, DPT, EdD; D'Agostino, Nick A. DPT; Mathew, Seena K. DPT; Anderson, Robert P. DPT; Bauman, Kevin M. DPT; Tiangtham, Sattha A. DPT; Greco, Tom DPT; Pizow, Adam DPT; Hall, Cheryl A. PT, DHSc

Author Information
Journal of Physical Therapy Education: September 2020 - Volume 34 - Issue 3 - p 186-191
doi: 10.1097/JTE.0000000000000143
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Abstract

INTRODUCTION/REVIEW OF LITERATURE

Approximately 10,000 new students begin an entry-level physical therapist educational program in the United States every year.1 Pursing health careers by attending these programs should be a positive learning experience; however, the journey can be overwhelming for many students. Managing multiple courses, assignments, and examinations compels many students to think that they must choose prioritizing academics over healthy lifestyle behaviors. Previous studies involving medical students have shown that students prioritize academics over healthy lifestyle choices.2,3 The quality of life of medical students in Brazil that was most affected was found to be in the mental health domain, particularly emotional and social functioning categories.2 In addition, there was a significant change in health habits, including an increase in alcohol consumption and a decrease in exercise and socialization for first-year medical students.3

Research shows that medical students who decrease their recreation, on average, are more likely to perform poorly on examinations compared with their peers who engage in recreational activities.4 Positive correlations between physical activity habits and high academic achievement in medical students have been documented.5 A retrospective study reviewed physical fitness trends, body composition, and cardiorespiratory endurance changes over a 2-year period for military medical students. It was reported that these students were able to maintain their muscular endurance and body composition; however, their cardiorespiratory endurance declined significantly, in the timed 1.5-mile run.6 Stephens et al7 also studied military medical students and discovered significant decreases in the number of timed push-ups and sit-ups, and an increase in the time they took to run 1.5 miles over the 4 years of school. Both theorized that the decrease in fitness seen in medical students may occur because students are forced to adapt to numerous new situations, leading to a high level of stress. Another study also reported that students demonstrated a significant decline in aerobic fitness over the 4 years of medical school.8 The results of these studies support the hypothesis that physical therapy students may also experience a decline in physical fitness because of the challenging entry-level physical therapy education curriculum while adjusting to the demands of novel experiences and situations.

Stress is defined as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.”9 Research has shown that 70% of medical students felt moderate stress and over 20% felt severely high stress levels, resulting in a negative correlation between academic performance and levels of stress.10 Chiropractic students also reported having moderate to high levels of stress and fatigue, and stress was strongly correlated with psychological health, relationships with family members, mood, and the need for learning accommodations.11 Fatigue was found to be strongly correlated with psychological health, academic demands, and conflicts between studies and other activities.11 It has been reported that 88% of undergraduate Pakistani physiotherapy students reported feeling stress throughout their first 4 semesters of a physical therapist educational program.12

Physical therapy students face a challenging, highly demanding curriculum that often leads to high levels of stress and burnout.13 These students report that they do not sleep the night before a practical, eat poorly, and complain of stomach issues, lightheadedness, and headaches.13 In addition, physical therapy students are generally more academically stressed than the general college student population.14 Although our review of the literature has thoroughly documented the effects of medical school on students' fitness and stress, it is clear that there is a gap in the knowledge on the effects of a physical therapy curriculum on changes in the students' physical fitness, exercise habits, stress, sleep, and quality of life. To the best of our knowledge, there does not appear to be similar studies performed on physical therapy students. Therefore, the purpose of our study is to assess the changes in anthropometric parameters, exercise levels, physical fitness, stress, sleep, and quality of life in students during their first year of an entry-level physical therapist education program.

SUBJECTS

Students included the first-year Doctor of Physical Therapy (DPT) class at the New York Institute of Technology (NYIT). Subjects were selected based on the following inclusion/exclusion criteria. Inclusion criteria of the study required that the subject had to be a student in the first-year physical therapy student cohort. We excluded any student from the physical fitness testing arm of study if they had any of the following: (1) cardiopulmonary conditions including asthma within the past 6 months,(2) major musculoskeletal injuries (ie, torn ligaments, bone fractures) over the past 6 months, and (3) other health issues that would interfere with a subject's safety during exercise. All 38 students in the first-year DPT cohort volunteered to participate in the study. Although this study included a single cohort of students, the investigators offer that this group is representative of a typical physical therapy class in the United States, according to the aggregate program data provided by CAPTE.1

METHODS

The study was approved by the NYIT Institutional Review Board (BHS #1342). The subjects were informed of the methods, procedures, and risks and were asked to sign the approved consent form before taking part in the study. The research design was a prospective longitudinal study. The independent variable was the first year of an entry-level physical therapist education program, covering 3 semesters (summer, fall, and winter), from May 2018 to March 2019. The dependent variables were the various outcome measures that were taken at specific intervals throughout the academic school year.

Procedures

Thirty-eight first-year DPT students were assessed using outcome measures (Table 1) at specific intervals during the first 3 semesters of the didactic phase of the first academic year. Table 1 outlines the pre- and post-timeline measurements for baseline anthropometric and physical fitness values assessed at the start of the summer semester, in May 2018, with the final measurements taken at the end of the winter semester before the final examinations in, March 2019. The physical fitness outcome measures, with the exception of the exercise log, are described in detail according to the American College of Sports Medicine's (ACSM).15 The outcome measures of stress, sleep, and quality of life were measured 6 times throughout the first year, at the beginning and the end of each of the 3 semesters before the final examinations, as presented in the timeline in Table 2. The summer semester began in May 2018 and ended by August 2018, for a total of 12 weeks. The fall semester began in September 2018 and ended in December 2018, for a total of 15 weeks, and the winter semester began in January 2019 and ended in March 2019, for a total of 12 weeks. Subjects were also instructed to keep an exercise log, in calendar format, to track the exercise performed during each semester. Each entry would consist of the date of activity, the total time they spent exercising and a brief description of the activity performed. The intensity of exercise was not quantified; only the total time spent exercising was recorded. Exercise logs were handed out at the beginning of each semester and collected at the end of each semester. The total time per week that the student performed exercise during each semester was calculated and used for the subsequent data analysis.

Table 1. - Timeline for Anthropometric and Physical Fitness Testing
Outcome Measures Pre Test Post Test
Height (cm) X
Weight (kg) X X
Cooper test (mL/kg/min) X X
Push-ups X X
Sit-ups X X
Body composition (%) X X
Grip strength (kg) X X
Waist (cm) X X
Sit and reach (in) X X

Table 2. - Timeline for Questionnaires During the First Year
Questionnaires Summer Semester Fall Semester Winter Semester
Pre Post Pre Post Pre Post
PSQI X X X X X X
SF-36 X X X X X X
PSS X X X X X X
Ex log X X X
Abbreviations: Ex Log, Exercise Log; PSS, Perceived Stress Scale; PSQI, Pittsburgh Sleep Quality Index; SF-36, The Rand.

All subjects were tested for physical fitness outcome measures between 9 am and 11 am. Height, weight, waist circumference, and body composition were measured before fitness testing. The subjects were instructed to perform the physical fitness tests to the best of their abilities as described by the ACSM.15 These specific physical fitness tests were chosen for this study because they represent the most important health-related physical fitness components, according to the ACSM.15

Three questionnaires were administered, twice per semester, throughout the school year, the Perceived Stress Scale (PSS), the Pittsburgh Sleep Quality Index (PSQI), and the Rand (SF-pair wise). The PSS is used as a psychological instrument designed to measure the perception of stress in individuals.16 Items in this measure are designed to focus on how unpredictable, uncontrollable, and overwhelmed the subject feels at certain times; the higher the score, the greater the stress.16 The PSS scores were tabulated and then used in the subsequent data analysis. The PSQI is an effective instrument used to measure the quality and patterns of sleep in adults.17 It differentiates “poor” from “good” sleep quality by measuring 7 areas: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the past month.17 There are a total of 9 questions which can be scored from 0-3 and rated as follows: not during the past month (0), less than once a week (1), once or twice a week (2), and 3 or more times (3). The overall score used for the data analysis was based on the results from the quality of sleep data and responses to question 4 separately, which asks, “During the past month, how many actual hours of sleep did you get at night?” The lower the score, the poorer quality of sleep. The Rand (SF-36) is the health-related quality of life questionnaire.18 The Rand analyzes 8 scales representing various health concepts, which include: Physical functioning (PF), Role limitations because of physical health (RPH), Role limitations because of emotional problems (REM), Energy/fatigue (ENE), Emotional well-being (EMO), Social functioning (SOC), Pain, and General health (GHTH). Each item is scored from 0 to 100, with a higher score indicating a more favorable health state. The score for each of the 8 scales was used for the data analysis. All questionnaires were answered with directions for subjects to report on how they felt during the past month.

Data Analysis

Mean values and standard deviation were calculated for all descriptive and outcome measures. Data analysis was completed using SPSS version 25.0 (Chicago, IL). Repeated Measures analysis of variance (ANOVA) was calculated for all the outcome measures of stress, sleep, and quality of life, measured 6 times, with post hoc analysis performed in the event of a significant F test. Post hoc analysis consisted of paired t-tests adjusted with a Bonferroni correction. Paired t-tests were performed on all anthropometric and fitness measures that were measured at the beginning and end of the first year. An alpha level of P < .05 was used for all statistical comparisons.

RESULTS

A total of 38 DPT students (20 men and 18 women) in the first-year cohort participated in this study. Summary statistics of subject anthropometric and physical fitness outcome measures are displayed in Table 3. One subject was unavailable for the pre- and post-testing for the anthropometric and physical fitness measures and another 6 were unable to undertake the Cooper12 Minute for a variety of orthopedic conditions. According to the paired t-tests, there was no significant difference from the beginning to the end of the school year in the data collected for weight, push-ups, sit-ups, body composition, grip strength, and waist circumference. However, aerobic endurance, as measured with the Cooper test, displayed a significant difference (P = .001). These findings reveal that there was a decline in students' aerobic endurance during the first academic year of the DPT program.

Table 3. - Subject Anthropometric and Physical Fitness Outcome Measure Resultsa
Outcome Measure n Pre Post P
Age (y) 38 23.5 (3.1)
Height (cm) 37 166.8 (18.2)
Weight (kg) 37 72.0 (16.5) 73.5 (17.0) .13
Cooper test (mL/kg/min) 31 40.8 (8.6) 35.5 (8.9) .001*
Push-ups 37 34.5 (15.3) 35.8 (12.8) .69
Sit-ups 37 43.3 (14.3) 45.2 (12.5) .38
Body composition (%) 37 21.7 (6.2) 21.6 (6.3) .76
Grip strength (kg) 37 37.8 (12.1) 38.8 (10.7) .25
Waist (cm) 37 83.3 (10.0) 83.7 (12.4) .70
Sit and reach (in) 37 19.7 (14.4) 19.9 (4.7) .46
aData are mean (SD). Paired t tests (P < .05) were performed on all variables as appropriate with significant differences indicated by an asterisk.

Table 4 contains the exercise log data for all the students. The exercise logs measured the number of hours per week a subject reported performing planned exercise. There were significant differences when comparing the fall to the summer semester and the fall to the winter semester (P = .001). However, when comparing the winter to the summer semester, there was no significant difference (P = .981). These results indicate that the students change the amount of exercise performed at different points throughout the academic year.

Table 4. - Exercise Log Resultsa
Sum Fall Win P Sum vs Fall Fall vs Win Sum vs Win
Ex log 2.2 (1.8) 1.2 (1.1) 2.2 (2.4) .001* 0.001* 0.001* 0.981
Abbreviations: ANOVA, analysis of variance; Ex Log, Exercise Log in hours/week; Sum, Summer; Win, Winter.
aData are mean (SD). Repeated measures ANOVA were performed between the 3 semesters followed by Paired t tests (P < .05) to determine significant pair wise comparisons that were indicated by an asterisk.

Table 5 presents the results of the self-reported questionnaires, the PSS for stress, the PSQI for sleep, and the Rand (SF-36) for quality of life. All 38 subjects completed the questionnaires. Repeated measures ANOVA's were used to determine the statistically significant differences between the 6 measures, pre and post for each of 3 semesters. There were significant differences (P < .05) for the following: PSS, global sleep, hours of sleep, and each of the 8 domains of health on the Rand. This allowed us to perform the paired t-tests adjusted with the Bonferroni correction factor for all specific pair-wise comparisons of interest. The difference between the beginning (pre) and the end of each semester (post) for all qualitative outcome measures was compared. Analysis showed that stress increased significantly, and global sleep or quality of sleep and hours slept per night decreased significantly for each separate semester, as each semester progressed. Although there was an overall significant F for PF and Pain, the pair-wise comparisons within each semester were not significant. Therefore, there were no significant changes within each semester. There was a significant difference (P < .05) for RPH for the summer and winter semesters, a significant difference (P < .05) for REM the summer semester only and significant differences (P < .05) within each of the 3 semesters for the domains of ENE, EMO, SOC, and GHTH, all scores decreasing, as the semester progressed.

Table 5. - Results of Questionnaire Outcome Measuresa
Outcome Sum Pre Sum Post Fall Pre Fall Post Win Pre Win Post P Sum Fall Win
Stress 10.3 (4.6) 14.5 (7.5) 12.4 (8.0) 18.7 (6.3) 13.3 (7.7) 16.9 (7.8) .001* .001* .001* .002*
Sleep 7.2 (1.0) 6.3 (1.1) 7.0 (1.3) 5.7 (0.8) 7.0 (1.5) 6.0 (0.8) .001* .001* .001* .001*
G-sleep 4.8 (2.4) 6.1 (3.1) 5.0 (3.3) 7.2 (3.0) 4.9 (3.0) 5.9 (2.8) .001* .001* .001* .001*
PF 97.2 (6.0) 95.3 (7.9) 95.3 (7.4) 93.6 (8.8) 97.0 (5.6) 96.5 (5.0) .012* 0.15 0.36 0.26
RPH 93.9 (20.7) 77.0 (35.5) 85.8 (32.0) 77.0 (36.0) 83.7 (33.4) 73.0 (41.8) 008* .01* 0.17 .01*
REM 87.4 (30.8) 58.1 (42.6) 76.8 (38.4) 68.6 (42.9) 69.6 (40.4) 62.2 (44.6) .001* .004* 0.18 0.26
ENE 66.5 (12.1) 48.3 (20.5) 62.7 (17.2) 37.3 (17.3) 57.8 (21.2) 41.9 (24.3) .001* .001* .001* .001*
EMO 81.3 (10.3) 65.0 (19.2) 75.8 (18.7) 57.7 (19.0) 75.9 (16.9) 63.1 (20.8) .001* .001* .001* .001*
SOC 89.5 (13.7) 70.6 (26.6) 84.1 (21.2) 66.2 (28.2) 83.9 (19.2) 73.3 (29.0) .001* .001* .001* .011*
Pain 86.7 (16.4) 81.2 (19.8) 84.7 (19.1) 82.4 (21.7) 90.6 (14.4) 87.9 (17.4) .02* .120 .57 .17
GHTH 75.5 (14.7) 70.6 (18.0) 69.7 (15.8) 62.8 (17.7) 71.5 (17.1) 63.8 (17.7) .001* .021* .001* .003*
Abbreviations: ANOVA, analysis of variance; EMO, emotional well-being; ENE, energy/fatigue; Fall, Fall Pre- and Post-comparison; GHTH, general health; G-Sleep, global sleep score; PF, physical functioning; REM, role limitations due to emotional problems; RPH, role limitations due to physical health; Sleep, hours/night; SOC, social functioning; Sum, Summer Pre- and Post-comparison; Win, Winter Pre- and Post-comparison.
aData are mean (SD). Repeated measures ANOVA were performed between the Pre- and Post-data for all 3 semesters followed by Paired t tests (P < .05) to determine significant pair-wise comparisons that were indicated by an asterisk.

DISCUSSION AND CONCLUSION

In the present study, we attempted to quantify the changes in anthropometric parameters, fitness, exercise levels, stress, sleep, and quality of life in students during their first year of an entry-level physical therapist education program. There were no significant changes for the anthropometric measures, body composition, the number of push-ups and sit-ups performed, or in flexibility and grip strength. The findings in this study were consistent with a similar study in medical students, which also found no differences in body composition or in the number of push-ups and sit-ups.6

Although muscle strength, muscle endurance, and flexibility did not change over the first year, we did document a significant decline in aerobic fitness, consistent with recent studies.6,7 Significant changes in aerobic fitness were documented as the first academic year progressed, with V̇o2max decreasing 13% from 40.8 to 35.5 ml/kg/min. The minimal clinical important difference (MCID) for MaxV̇o2 is 3.5 ml/kg/min.19 The decline in aerobic fitness may be related to less time spent engaged in physical activity during intense periods of academic study, especially during the longest semester (fall). This decline may also be because of a lack of prioritization of fitness-related activities while managing the numerous demands of a first-year physical therapy student. The decline in aerobic fitness for these students (an average of 5 ml/kg/min, which is greater than the MCID) is harmful to their overall health, particularly to their cardiorespiratory system, significantly increasing their risk of cardiovascular disease.20-22

Stress levels showed a significant increase, whereas hours of sleep and global quality of sleep, and quality of life demonstrated a significant decrease throughout the progression each semester. High levels of stress were prominent in students during the first year of a physical therapist education program. Stress scores on the PSS were below the normative mean of 14.2 for their age group at the beginning of each semester, and then increased significantly by the end of each semester. The highest mean stress score of 18.7 was reported at the end of the fall semester.16 The results of this study are in agreement with other studies performed with medical, chiropractic, and undergraduate physiotherapy students.10-12 Higher levels of psychological stress are associated with elevated blood pressure and cortisol levels and with sleep disruption; all of which are risk factors for cardiovascular disease.16,23

Data from the PSQI showed that the first-year DPT students demonstrated poor sleep quality throughout the first year, and subsequently, sleep quality and hours of sleep per night decreased as each semester progressed. The largest decrease from the baseline measure on the PSQI occurred in the fall semester. A score greater than 5 on the PSQI denotes a poor quality of sleep, which was a consistent finding in all subjects by the end of each semester.24 After each semester concluded, and the students were able to relax, their amount of sleep and sleep quality improved. Students reported sleeping an average of 5.7 hours a night during the fall semester, consistent with the findings that the fall semester provided the greatest challenge to the students as evidenced by poorer sleep, greater stress, and decreased physical activity. Of note, the summer semester consists of 2 consecutive 6-week classes, taken one at the time, for a total of 9 credits over 12 weeks, whereas the fall semester consists of 5 concurrent classes for a total of 15 credits over 15 weeks. The first fall semester represented a novel experience because of the increased number of classes relative to the summer, with increasing study demands and time management issues. As students learned to adapt to the challenges of the fall semester, they were able to return to their previous level of exercise the following (winter) semester. However, students still reported stress and decreased sleep quality during that 12-week, 16-credit winter semester.

Quality of life reflects students' ability to enjoy their normal life activities. As measured by the 8 domains of the Rand, analysis of student data found that students reported their quality of life decreased significantly during the first year of school in the physical therapist education program, which was consistent with the findings in a study of medical students.2

There are several key limitations to the study that should be addressed when interpreting the results. First, although this student cohort appears to be representative of a typical class composition, as per the CAPTE aggregate data, the results are compiled from students who constitute a single, physical therapist education program cohort and, therefore, may not be broadly generalizable.1 The qualitative measures of aerobic fitness and body composition were not measured using the “gold standard” of measuring maximal oxygen consumption, that is, using the open-circuit spirometry or hydrostatic weighing for body composition. The availability and cost of the equipment and time required to test individual subjects were prohibitive for the time constraints of this study. In addition, several of the responses from students reported on the qualitative questionnaires may have been compromised because of recall bias. Based on these limitations, it is recommended that future work expound on the information in this study by considering the following: (1) the need for a multicohort study by expanding the data collection to include other physical therapist education programs from various regions of the United States, (2) expanding the data collection over the entire curriculum, and (3) using the “gold standards” of measurement, if feasible.

The entire cohort was able to maintain their grade point average and maintain academic standards for each course as per the requirements of the program. In conclusion, the cohort of students succeeded academically, despite the reported adverse effects on their physical health and psychological well-being. These findings may suggest that stress management courses and wellness resources should be available to students while enrolled in a physical therapist education program. Physical therapy faculty should also be aware of the potentially harmful effects of the curricular demands on the students' health and well-being and exercise vigilance in engaging in regular assessment of the physical and mental health of their students. Physical therapy students should be given strategies to learn to prioritize self-care and wellness so that they will be able to better serve their patients in the future, by first, taking care of themselves.

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Keywords:

Fitness; Stress; Sleep; Quality of life

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