Cardiopulmonary Physical Therapy Research Articles

International Survey of Cardiopulmonary Physical Therapy Management of Adult Intensive Care Unit Patients and the Impact of COVID-19

Objectives: The aim of this study was to report on the cardiorespiratory assessments, interventions, and outcome measures used by physical therapists with critically ill patients and the impact of COVID-19. Design: An anonymous international online survey of practice (through Google Forms) of physical therapists was conducted. Setting: The study was conducted in adult intensive care units. Participants: A total of 309 physical therapists participated in the study. Interventions: A survey was used to determine current cardiopulmonary physical therapy practices in ICU. Results: Predominantly participants were female (74%), aged 31 to 40 years (40%), having worked in intensive care unit (ICU) for either 0 to 5 years (38%) or 11 to 20 years (28%), and worked full time (72%). Most participants worked in the United Kingdom (36%), Europe (21%), or Australia/Oceania (18%). The 3 most frequently reported assessment indicators for cardiopulmonary physical therapy interventions were lobar collapse/atelectasis, audible secretions, and decreased/added lung auscultation sounds. The 3 most commonly used outcome measures included lung auscultation, arterial blood gas analysis, and transcutaneous arterial saturation. The 3 most commonly used physical therapy interventions (“very often” in a descending order) included patient mobilization, repositioning to optimize gas exchange, and endotracheal suctioning. For the COVID-19 cohort, participants reported similar use of patient repositioning to optimize gas exchange and postural drainage, and lower use of patient mobilization and endotracheal suctioning, deep breathing exercises, active cycle of breathing technique, and oropharyngeal suctioning. Conclusion: This survey reports on the characteristics of physical therapists who work in ICU, and their cardiopulmonary physical therapy assessments, interventions, and outcome measures most commonly used, inclusive of patients with COVID-19. There were some differences in interventions provided to the COVID-19 cohort compared with the non–COVID-19 cohort.

INSPIRATORY MUSCLES TRAINING: AN EFFECTIVE WAY TO IMPROVE POST-OPERATIVE OUTCOMES AFTER CORONARY ARTERY BYPASS GRAFTING

Cardiovascular diseases (CVD) are the leading cause of death worldwide. It is a multifactorial disease and has many risk factors including hypertension, diabetes mellitus, physical inactivity and smoking. Coronary artery disease (CAD) is one of the consequences of CVD.1 If we talk about CAD, it is a really common heart disease in our country, also known as ischemic heart disease and develops when coronary arteries or its sub-branches which are the blood supply of the heart become narrowed or blocked due to accumulation of plaque leading to an impaired supply of oxygen rich blood to the heart and thus cause retrosternal chest pain typically known as angina that is accompanied by dyspnea.2 Coronary artery bypass grafting (CABG) is generally the ideal treatment option for the individuals suffering from CAD. In this procedure, an auto-graft of vessel is taken and the commonly used vessels are left internal thoracic artery and great saphenous vein. The graft is sutured in such a way that the blocked coronary artery is bypassed and the blood supply to the heart is restored.3 Although medical sciences have advanced a lot, yet the prevalence of post-operative complications, specifically the respiratory ones pose an immediate threat to the survival and are the aiding factors to mortality and morbidity.4 Physical therapy after any surgery plays a pivotal role in improving the post-operative outcomes and helps the patient fight the effects of surgery. It makes a patient return to his or her normal life and helps in the early discharge of patients from hospitals thus preventing the chances of hospital acquired infections and reducing the financial load on masses.5 Respiratory rehabilitation, which is the specialty of physical therapy, have tremendous positive effects on the pulmonary compliance and function by preventing the post-operative pulmonary atelectasis.6 Moving further towards the components of respiratory rehabilitation, a group of breathing maneuvers conjointly known as inspiratory muscles training (IMT), if applied pre-operatively to the patients who are scheduled to undergo the coronary artery by-pass grafting displayed healthy post-operative outcomes.7 To conclude, it is the dire need of today to raise awareness among the health care professionals especially cardiologists and cardio-thoracic surgeons; and the general public regarding the pre-operative respiratory physical therapy for the patients planned to go through CABG. So, in the light of supported evidence, it is proved that respiratory physical therapy, particularly pre-operative IMT has positive outcomes in post-operative state. Moreover, the authors would also like to shed light on the facts about the healthcare policies and physical therapy services in Pakistan. Contrary to public sector hospitals, the rehabilitation departments in private sector hospitals are properly managed, substantially equipped and well established, leading to enhanced quality of physical therapy practices that result in better prognosis of the patients. The health department of our country should also emphasize on the public sector hospitals to make necessary arrangements for logistics of sufficient equipment and the hiring of physical therapists that are qualified and specialized in the field of cardiopulmonary physical therapy.

Home FES: An Exploratory Review.

This review of literature focuses on the multiple uses of Functional Electrical Stimulation (FES) and how this modality may be a valuable home-based therapy. Papers pertaining to home FES exercise were collected using the Web of Science, Google Scholar databases and collegial hints. In our opinion, the following statements summarize the results. FES may be used to induce health benefits in populations with paralysis, and in persons with musculoskeletal, cardiorespiratory and renal pathology. The EU Project Rise showed how FES could have a variety of encouraging outcomes for patients with denervated muscles following traumatic injuries. As suggested by recent literature, FES has proven to be a viable form of exercise for elderly individuals. Thus, Home FES may be an option for patients looking for an additional form of muscle and cardiopulmonary physical therapy.

The Current Status of Cardiovascular and Pulmonary Physical Therapy: An Update of the Description of Specialty Practice

Purpose: Cardiopulmonary physical therapy (PT) was one of the first 4 specialty areas recognized within the PT profession in 1978 and was the first to certify specialists in 1985. Physical therapy practice in general and specifically cardiovascular and pulmonary (CVP) PT has expanded over these past 40 years. To maintain currency in this specialty, the American Board of Physical Therapy Specialties (ABPTS) requires that a practice analysis be performed at least every 10 years. Summary of Key Points: This article reports the findings of the 2017 practice analysis in CVP PT, resulting in the 2018 version of the Description of Specialist Practice: CVP. Statement of Conclusion: This report will serve as the foundation for the examination blueprint for ABPTS board certification in CVP PT, curricula in CVP PT residency programs, activities related to specialist certification, and maintenance of specialist certification.

The effect of positional changes on oxygenation in patients with head injury in the intensive care unit.

Background:Following head injury, cardiopulmonary functions are impaired and this disturbs the oxygenation transport pathway. Expanding cardiopulmonary physical therapy to encompass the oxygen transport system as a whole has implication for treatment as well as assessment and treatment outcome. Therefore, the aim of the study is to assess the oxygenation level in head injury patients with relation to body positioning in the intensive care unit (ICU).Methodology:Thirty consecutive patients with head injury with hemodynamically stable were included from the surgical ICU, ages ranging from 15 to 50 years. Noninvasive vital parameters (oxygen saturation [SpO2], pulse rate [PR], respiratory rate [RR], and blood pressure [BP]) were observed and recorded in different body positions at regular intervals of 5 min for 15 min in each position.Results:There was increment in SpO2 value in all positions from 0 min to end of 15 min in supine (98.63 ± 0.36–98.73 ± 0.30), right-side lying (98.77 ± 0.30–98.93 ± 0.20), left-side lying (98.73 ± 0.29–99.03 ± 0.24), and recline sitting (30°–70°) (99.03 ± 0.24–99.50 ± 0.22). However, there was statistically significant increment in recline sitting (30°–70°) compared to other positions (P = 0.036) while other parameters (PR, RR, and BP) were getting stabilized at lower values at end of 15 min in every positions tested.Conclusion:We conclude that upright position bring about significant increase in arterial SpO2 compared to any other positions. Other vital parameters were seen to stabilize at lower values at the end of 15 min in every position tested.

New Year, New Look, New Opportunities!

Welcome to the inaugural issue of the Cardiopulmonary Physical Therapy Journal, as published by Wolters Kluwer! As the Journal begins its 26th volume, we begin a new era. As you see, there have been wonderful changes in the look and layout of the print version, as well as a new website (www.cardioptjournal.com). The Associate Editors, Editorial Board, and I have been busy behind the scenes for months in preparation for this transition, and we hope you are as excited as we are. As I begin my sixth year as Editor-in-Chief, I marvel at the progress that has led us to this point. That is a reflection of advances in the art and science of cardiovascular and pulmonary physical therapy, both in the United States and around the world. There have been steady increases in the number and quality of submissions, expertise of reviewers, and a support team that has taken my vision and brought it to fruition. I can't express adequately my appreciation for all who are involved in creating the Journal that you receive each quarter. I have learned so much from each of them and am so proud to represent them all. With this new year and a new publisher comes new opportunities that I hope many of you will take part in developing. We are always looking for new authors and ideas. We represent a society that has very diverse interests and settings, from critical care practice to community-based wellness to basic science explorations of physiology that underpin practice. We also represent the next generation of cardiovascular and pulmonary physical therapists and value innovations in the science and art of education for these eager young professionals. So, I hope you hear a call to submit manuscripts related to education and practice issues, as well as more traditional research topics. One area of growth in the Journal's content has been from outside the United States. Cardiovascular and pulmonary content is a very large part of physical therapy around the world, and our international colleagues bring a great perspective to our areas of expertise. I continue to welcome authors from outside the United States to submit their work to the Journal and to teach us Americans some new ideas and perspectives. As has been said by most of us, “every patient has a heart and lungs, so every patient is a cardiovascular/pulmonary patient” and that is true no matter where in the world that patient lives. I'd also like to take this opportunity to invite new reviewers to join our ranks. Now that we have a fully online submission and review system, it is easier than before to coordinate invitations, reminders, and feedback to reviewers. The only requirements to be a reviewer are to have successfully published in a peer-review journal (so you understand the process) and to be willing to give timely, balanced, and constructive feedback to authors about their work. Our Associate Editors work very closely to foster new reviewers and help them learn the process. Please contact me ([email protected]) if you would like to nominate yourself as a reviewer for the Journal. In conclusion, I am very excited about this new year and all the possibilities that are before us to continue to raise the quality and visibility of the Cardiopulmonary Physical Therapy Journal and our unique and wonderful part of the physical therapy profession. I hope you will join us in this new adventure, whether as an author, a reviewer, or an engaged reader. There is room for all!

Cardiopulmonary Physical Therapy: Management and Case Studies

Cardiopulmonary Physical Therapy provides a comprehensive overview of the essential competencies of cardiopulmonary physiotherapy and is applicable to a wide variety of practice settings, including acute care and outpatient rehabilitation. A great resource for new or experienced physiotherapists working with clients with cardiopulmonary conditions, this book would also make a good tool for teaching physiotherapy students and new graduates the essentials of this area of practice. The book is divided into three parts. Part 1 begins with a basic review of anatomy, physiology, and the pathophysiology associated with common acute and chronic respiratory and cardiovascular conditions, then breaks down the essential components of cardiopulmonary physiotherapy assessment and treatment techniques into concise chapters that together provide the foundational knowledge to manage people with these conditions. Part 2 consists of 24 cardiopulmonary cases covering a wide range of common cardiopulmonary conditions, and Part 3 provides a handy answer guide to each case—making this book an ideal choice for the academic setting. Cardiopulmonary Physical Therapy offers several great teaching resources, and thus would make an excellent textbook for an entry-to-practice physiotherapy programme. Individual chapters on the core competencies for cardiopulmonary physiotherapy are supplemented by chapter 6, which provides a useful overview of the clinical decision-making process. It is particularly helpful in outlining the steps involved in this process and applying these basic principles to the essential components of cardiopulmonary physiotherapy assessment and treatment. It would be a useful tool for introducing students to this complex process and giving them several possible frameworks to assist in integrating all of the necessary components. For new graduates and clinicians, the chapters on interpreting arterial blood gases, chest X-rays, and laboratory values may be of particular interest. These chapters helpfully review the basic concepts associated with these investigations. Individual chapters on a variety of treatment techniques—including airway clearance, exercise prescription, positioning, and early mobility—are tailored to students or new clinicians, in that they provide a detailed overview of the basic concepts of these techniques and organize large amounts of information into appendices, figures, and tables that concisely highlight important clinical implications for physiotherapy practice—making it a great quick reference tool for clinicians! Written for physiotherapists by physiotherapists, Cardiopulmonary Physical Therapy is a complete resource for the essentials of this area of practice. The authors collectively have a wide range of both academic and clinical experience, and they have done a great job of synthesizing very large and complex concepts into manageable, concise, clinically focused chapters. Moreover, the realistic cases allow for an integrative approach to learning and consolidating essential competencies. I would recommend this book to educators as a teaching tool, to new graduates, and also to clinicians wanting a comprehensive resource to consult in their daily cardiopulmonary practice.

The Effect of Heart Rate Variability on Exercise Training Post-Cardiac Surgery

Purpose: the purpose of this study was to investigate heart rate variability on exercise training post-cardiac surgery. Method: the data collection was from the Chia-yi Christian Hospital Cardiac Surgery implementation of beating heart coronary artery bypass surgery and valve replacement patients. There were a total of 10 patients included in this study. Cardiac patients after discharge from hospital were the participation of exercise training groups (n=5), and no receiving cardiopulmonary physical therapy of patients was the home-based group (n=5). Statistics: Data analysis was conducted using the SPSS statistical software for Windows 20.0. Analysis of covariance (ANCOVA) was used as the statistical method at a significance level (α) of .05. Through statistical analysis and comparison, the results were obtained as below: In HRV time domain portion, SDNN, CV%, results were significant difference. In frequency domain portion, indices such as LF and VHF, results were significant difference. Conclusion: According to the experimental results, the heart rate variability on exercise training better than patients did not participate in sports training after cardiac surgery patient.

Cardiopulmonary Physical Therapy Practice in the Paediatric Intensive Care Unit

Physical therapists play an important role in the pediatric intensive care setting. The purpose of this study was to describe current cardiopulmonary physical therapy (CPT) practices in a pediatric cardiac critical care unit (CCCU) and a pediatric intensive care unit (PICU), as well as to determine the feasibility of obtaining clinically relevant outcome measures in this setting. We obtained reasons for admission, CPT treatment patterns, and availability of chest X-rays interpretation via a retrospective chart review of children who received CPT while in the PICU and CCCU (n=111). Congenital cardiac conditions (34.2%) and primary respiratory deterioration (27.9%) were the most common reasons for admission; 50% of the children had associated diagnoses (e.g., developmental delay). Manual hyperinflation with expiratory vibration was the most common CPT treatment. Chest X-ray interpretation was available in 72% of the charts. Manual hyperinflation with expiratory vibration was used across diagnostic groups in the CCCU and PICU; its effectiveness therefore requires further study. Chest X-ray is an important clinical outcome and therefore needs to be recorded in a standardized manner to be useful for future clinical research studies.

The Linda Crane Lecture From Silos to Bridges: Preparing Effective Teams for a Better Delivery System

Good afternoon and thank you for attending this session. It is an honor to be this year's recipient of the Dr. Linda Crane Memorial Lecture Award. When this award was created about 15 years ago, I served as the Editor for the Cardiopulmonary Physical Therapy Journal and was very pleased when the decision was made to publish these lectures in the Journal. I knew this would bring some meaningful contributions to our publication and I remember thinking there were many deserving recipients in the cardiopulmonary, pediatric, and education sections. I truly did not expect to be one of them. Before beginning, I would like to thank the selection committee and Drs. Michael Puthoff, Jane Eason, Ellen Hillegass, and Dianne Jewell for their respective roles in nominating me. Also, I would like to extend a special thank you to my colleagues, alumni, and current students from St. Ambrose University who are here today. My work with these individuals, in some cases for over 20 years, was an inspiration for the topic I chose to discuss. Like many of the past Linda Crane Award recipients, I had the honor of knowing Dr. Linda Crane. I remember the very first time I met Linda. It was back in the late 1980s and I was attending one of my first Combined Sections Meetings. A doctoral student at the University of Iowa, I came to CSM to present a poster and found myself at the cardiopulmonary research platform presentations one afternoon. I really did not know many people at that time but came in and sat on the end of one of the rows. I think Linda recognized me as a newcomer and slid down several empty spaces between us to introduce herself to me. As we talked, she inquired about my interest in cardiopulmonary physical therapy. It was great to meet someone who was so excited about cardiopulmonary physical therapy. She encouraged me to come to the Section business meeting later that day and then proceeded to introduce me to others in the Section. I remember feeling as though someone had just opened a door for me. If Linda was here with us today, I doubt these generous actions would stand out to her but, her kindness certainly made a positive impact on me. I have listened to almost every Linda Crane Lecture given since the first one by Meryl Cohen in 2000.2 The speakers have covered a wide range of topics important to physical therapy practice and education. They have also provided an opportunity for us to learn more about Linda. She has been described as passionate, outgoing, someone who lived her life to the fullest and someone many physical therapists enjoyed working with … she was the type of person you want on your team. Some of my colleagues are worried that I will be using this opportunity to talk about common structures in the Iowa landscape. While it is true we have many silos and bridges in Iowa, including the famous Bridges of Madison County,3 that is not my intended focus. As I proceed, I hope the purpose of the title becomes more obvious. I'd like to begin by talking about teams.

Risk Factors for the Development of Late Pulmonary Complications Following Pediatric Heart Transplant

Purpose Survival following pediatric heart transplant (PHTx) continues to improve, however the development of late pulmonary complications (LPC), of multifactorial etiologies, poses a threat to quality of life and function. The purpose of this study was to describe development of LPC and use of cardiopulmonary physical therapy (CPT) interventions in PHTx recipients. Methods and Materials Single centre retrospective review of PHTx recipients transplanted between January 1997 and June 2010. Results 128 subjects (71 males) met inclusion criteria with a median age at transplant of 2.2 years (range 0-17). Sixty-five (51%) had an underlying diagnosis of congenital heart disease (CHD). Seventy-six patients (59.4%) had ≥1 comorbidity at time of Tx, most commonly developmental delay (29.7%). Fifty subjects (39%) developed LPC: recurrent pneumonia (n=37, 28.9%), bronchiectasis (n=9, 7.0%), pleural effusion/chylothorax (n=6, 4.7%), asthma (n=13, 10.2%), interstitial lung disease (n=5, 3.9%), or other (n=20, 15.6%). Facters associated with increased risk of developing LPC included age Conclusions LPC develop in a significant portion of PHTx recipients. Risk factors include young age, CHD, comorbidities, phrenic nerve damage, prior pneumonias and longer need for mechanical ventilation. CPT for LPC is indicated to assist with impaired airway clearance, however the impact on long term outcomes remains to be determined.

Guest Editorial: Physical Therapy in Critical Care

The role of physical therapists in critical care has been evolving. Of interest to this section, traditional PT care in the ICU focused on interventions for respiratory conditions, using techniques such as percussion, manual hyperinflation, suctioning, and bed exercises. As our knowledge of the importance of early mobilization has evolved, as evidenced by changes in how quickly patients are out of bed following cardiac surgery, the interventions in physical therapy have changed. The physiologic rationale for early mobilization has been discussed since the early 1990s in papers written in part by leaders in cardiovascular and pulmonary physical therapy.1 What has been lacking is strong evidence of the benefits of early mobilization in critically ill patients. In the past few years, the number of poster and platform sessions at the Combined Sections Meetings focused on physical therapy in critically ill patients has increased. Similarly, the number of published articles on this topic is growing. The topic for this special issue developed in response to these trends. Our call for papers resulted in a variety of manuscripts. We have a systematic review of mobilization in the ICU, which focuses on both safety and effectiveness outcomes. There is good evidence to support the effectiveness of early mobilization, even in patients on mechanical ventilation. Several interesting case examples are included that will be very useful in helping clinicians determine the types of interventions and outcomes most relevant to treating patients in ICU environments. One paper also addresses what can be done in the academic environment to prepare students for work in these complex practice environments. And, we benefit from the expertise of our colleagues in other countries; in this edition, we have examples from Turkey and Australia as well as the United States. The articles chosen for this issue illustrate several treatment trends that will help advance the work of PT in the critical care environment. One of our articles discusses the barriers to treatment of patients in the ICU. This shows us that some barriers, such as timing of medication administration, could be easily addressed, but will require the physical therapist to be committed to active mobilization of patients and demonstrate ability to communicate effectively with other members of the ICU team. Overall, there are relatively few adverse effects of early mobilization, particularly when therapists are observing the physiologic response of patients by monitoring vital signs during treatment sessions. A number of articles discussed in the systematic review provide guidelines for discontinuing treatment based on vital sign responses. This reminds us that we need increasing focus on one of the key tenets of cardiopulmonary physical therapy practice; that we are treating the patient's physiologic deficits in conjunction with movement and functional abnormalities. There is much work to be done in advancing the practice of PT in these critical care environments. What an exciting time of practice to be able to shape the interventions and influence better health outcomes for our patients!

Using Simulation and Patient Role Play to Teach Electrocardiographic Rhythms to Physical Therapy Students

THE AIMS OF THE STUDY WERE TO DIFFERENTIATE: (1) physical therapy (PT) students' preferred method for learning electrocardiographic (ECG) recognition utilizing standardized patient (SP) and human patient simulation (HPS) approaches, (2) the impact of HPS or SP on confidence in interpreting ECG, and 3) the effect of HPS or SP on students' ability to make clinical decisions based upon ECG interpretation. "Three educational methods were employed to teach ECG recognition to two different years of novice PT students enrolled in a cardiopulmonary physical therapy class. First, all students had a traditional lecture on ECG. Following the lecture, two problem-based learning (PBL) approaches were utilized. One approach used a SP and paper ECG strips, and the second approach utilized HPS with simulated ECG monitoring."(1) Following the two PBL approaches, a post instructional survey regarding the learning experiences was conducted. Following instruction, each cohort (n = 24, n = 29) of PT students was given a mixed methods survey about their experience. Survey return rate amongst both cohorts was 77%. Independent sample of individual cohort and paired t-tests of combined data comparing HPS to SP revealed a strong preference for HPS (p = 0.003 (2008 cohort) and p = 0.0001 (2010 cohort)) and combined cohort (p = 0.0001). There were no significant differences in responses between cohorts or preference between the HPS method and the use of SP and HPS combined. Additionally, 75% of respondents either strongly agreed or agreed that they felt confident with their skill in ECG interpretation as presented with HPS or SP. 90% either strongly agreed or agreed that they understood how the ECG relates to patient treatment. Summative assessment utilizing HPS revealed that students were competent in their performance in ECG recognition and clinical decision making related to patient treatment.(1) Data support that HPS was the preferred method to improve student confidence in ECG recognition and interpretation.

A Cardiopulmonary Instructorʼs Perspective on a Standardized Patient Experience: Implications for Cardiopulmonary Physical Therapy Education

Standardized patients (SP) in Doctor of Physical Therapy (DPT) curricula are increasingly used for students to practice developing clinical reasoning, communication, and professional skills in an authentic learning environment. The purposes of this article are to: (1) describe an instructional model that synthesized SPs, Internet-based communities of practice, and reflection to teach clinical reasoning in DPT students; and (2) a cardiovascular and pulmonary physical therapy (CPPT) instructor's perspective on the educational process and student clinical skill development. The model, employed in a course: "Integrative Physical Therapy Practice," enabled the instructor to document student clinical performance and reasoning during an SP interaction. For students, clinical reasoning was illuminated through the model's assessment process. Data collected through the assessment process provided important feedback to the instructor on classroom instructional effectiveness. Examination of student learning experiences enabled the instructor to consider: (1) key aspects of examination and management for persons with cardiovascular or pulmonary disorders, (2) methods for visualizing clinical reasoning, (3) the impact of teaching on student learning, and (4) strategies for teaching CPPT. More research is indicated to investigate pedagogy for the development of clinical reasoning in DPT students.

INVITED COMMENTARY: Rating the Quality of Trials in Systematic Reviews of Physical Therapy Interventions

Physical therapists seeking to use evidence to guide their practice may have limited time to read research reports. One way to reduce the time required to identify and read about the research that is relevant to a particular clinical question is to read a systematic review that summarizes multiple studies. This paper explains the process that is used to conduct systematic reviews, which includes the establishment of a protocol, comprehensive searching, appraisal of the quality of the included studies, data extraction and metaanalysis, and consideration of the clinical and research implications of the findings. We also consider how the reader of a systematic review can determine whether the review is likely to provide an unbiased (believable) estimate of the treatment effect. A systematic review of randomized trials of a cardiopulmonary physical therapy intervention is used as an example. The issue of appraisal of quality is then discussed further, with a demonstration of how one validated tool for quality appraisal-the PEDro scale-can be used to evaluate a randomized trial in cardiopulmonary physical therapy.

ASSOCIATE EDITORʼS COMMENTARY: Using Stop & Go to Get Going!

It is with great pleasure that the Cardiopulmonary Physical Therapy Journal publishes an invited paper on the effectiveness of and practical suggestions for interval training in patients with chronic obstructive pulmonary disease.1 This paper makes a significant contribution to cardiopulmonary physical therapy for areas of further research as well as for immediate clinical practice related to exercise prescription. In fact, the paper highlights an area of intersection between research and practice of exercise prescription that deserves more attention. Empirical research can only inform us of the mean trend of a sample; whereas in clinical practice we are interested in an effect on one particular person–the patient who is seeking our suggested interventions. Estimated effects in a particular study reflect the mean and variance of the sample being studied; in clinical practice, we are estimating a particular effect on a particular person based on several indicators. Researchers must select inclusion and exclusion criteria that help produce a sample that represents the population in which they anticipate an effect and to which they want to generalize. Clinicians, in making decisions about exercise prescription, must make informed decisions based on the empirical evidence (generated by empirical studies and inductive reasoning); but must vet the empirical evidence through a process of deductive reasoning as they take general understanding and apply it very specifically to a case. Kortianou and colleagues have captured this balance in the following paper.1 Despite the fact that mean effects of interval training that have not been demonstrated to be superior to continuous training in patients with COPD, the authors appropriately use deductive reasoning. The expected benefits of interval training are based on accumulating a higher intensity of exercise for longer durations, leading to greater total work. In past studies in patients with COPD, the total work between interval training and continuous training were not different. Hence, the superiority of interval training has not actually been tested in these studies. The authors then rightly refer to studies that demonstrate improved tolerance of interval training–lending support to the hypothesis that these patients can accomplish greater total work. With greater total work it is hypothesized that patients would gain greater improvements. This is a major consideration for the interpretation of studies on interval training in patients with COPD, for the development of additional studies, and when considering incorporation of interval training in the exercise prescription of patients with COPD. Kortianou and colleagues also suggest that interval training may have a unique role to play in the training of two particular subpopulations of patients with COPD.1 They ask us to consider the benefits for these two groups based on the two proposed mechanisms. The two subpopulations include: (1) those with known ventilatory limitation prevents sustained exercise, and (2) those with known peripheral muscle dysfunction. As we continue to develop our understanding in this area we should attempt to delineate at least one of the rationales outlined by Kortianou and colleagues as the reason to study or prescribe interval training. To do this, we need to determine whether ventilation or peripheral muscles are the primary limitation to sustained work. I suspect that with improved understanding of these issues we will develop greater specificity of prescription parameters in these two groups of patients, as well as improved estimation of benefits to be expected from interval training interventions. One step would be to analyze responder subgroups in future interval training studies.2

Reaching the Masses: Physical Therapist Students Learn to Use YouTube to Share Clinical Information with Patients and the Public

Purposes: This pilot study (1) assessed physical therapist students’ attitudes toward using YouTube to share health-related videos on the Internet, and (2) determined whether a cohort of physical therapist students would use YouTube, or similar technologies, to share educational information with other health care providers and health care consumers once they enter practice. Methods: A cohort of 28-second-year Doctor of Physical Therapy students completed a project to produce and share educational videos on YouTube. Students, working in small groups, selected a clinical skill introduced and practiced during the Cardiopulmonary Physical Therapy course as the focus of their videos. A survey completed at the conclusion of the project collected data about students’ attitudes and experiences regarding the use of YouTube. Results: Tabulation of students’ responses revealed that 85% of the students enjoyed making videos and 96% of the students felt that physical therapists should share physical therapy-related information with the largest possible audience. Nineteen percent of the students reported that they are likely to share additional videos online. Conclusion:YouTube and other online video sites allow physical therapists to reach a large audience of people interested in the services and education they provide. However, some students may be reluctant to take advantage of this relatively new technology. Future research may focus on the relationship between the obligation students feel to produce educational videos and their reported reluctance to produce educational videos once they enter clinical practice.

Research Corner Outcome Measures in Cardiopulmonary Physical Therapy: Focus on the Late Life Function and Disability Instrument (LLFDI)

Research Corner Outcome Measures in Cardiopulmonary Physical Therapy: Focus on the Late Life Function and Disability Instrument (LLFDI)

Overview of Telehealth and Its Application to Cardiopulmonary Physical Therapy

Advances in telecommunication technology provide unique opportunities for the provision of medical services to underserved and geographically displaced patients. Health care professionals currently use voice and video systems to communicate with patients and colleagues in a variety of clinical venues. Unfortunately, such systems have limited presence in physical therapy settings. A variety of factors, including lack of familiarity with existing devices and perceived system purchase and operation costs, appear to be limiting its use. Even the terminology is confusing with such terms as telehealth, telemedicine, and telerehabilitation often used interchangeably. The purpose of this paper is to present an overview of this technology and to provide a clinical perspective regarding the use of telehealth in cardiopulmonary physical therapy practice.

Research Corner: Outcome Measures in Cardiopulmonary Physical Therapy: Focus on the Glittre ADL-Test for People with Chronic Obstructive Pulmonary Disease

The primary goal of physical rehabilitation for people with chronic lung disease, including chronic obstructive lung disease (COPD), is to improve function. In terms of the International Classification of Functioning, Disability and Health (ICF),1 physical therapy typically focuses on improving activity, which may result in increased participation in pursuits that are meaningful to the individual. A commonly used and related concept is functional status. Keith2 described functional status as “physical function including activity restrictions and fitness; psychological function including affective and cognitive functioning, social function including limitations in usual roles or major activity, social integration, social contact, and intimacy.” There are 2 primary methods of assessing functional status—questionnaires and performance-based tests. The most frequently used tools are questionnaires. Generic questionnaires such as the Functional Status Questionnaire,3 Extended Activities of Daily Living scale,4 and the SF-365 are available. However, disease specific questionnaires such as the Chronic Respiratory Questionnaire,6 the St. George's Respiratory Questionnaire,7 and the Pulmonary Functional Status and Dyspnea Questionnaire8 are commonly used for people with chronic lung disease. Questionnaires are generally inexpensive, quick to administer, and allow patients to express their perception of their function. However, there are a number of disadvantages associated with the use of questionnaires.9–12 Specifically, patients' responses may be affected by social and personal expectations of the purpose of the questionnaire. Also, responses may change depending on a patient's cognition or psychological status. In some circumstances, patients may state that they are capable of completing a task but do not consider the time required to complete the activity. Without additional information that is difficult to quantify, a patient may appear to function well when this is not the case. Another difficulty associated with the use of questionnaires is that disease progression in people with a chronic disease may result in activity limitation that could decrease the symptoms of interest. Such a change could erroneously be interpreted as an improvement in health status. For instance, people who experience dyspnea while climbing stairs may stop doing this activity and take the elevator instead. When questioned, this person may no longer report dyspnea when climbing stairs. The person may not be trying to hide the truth, but may have forgotten the discomfort once it no longer occurs. Objective, performance-based tests avoid many of the difficulties noted above. The six-minute walk test (6MWT) is the most frequently used objective test of functional capacity for people with respiratory disease.13 Patients are told to walk as far as possible, in 6 minutes, over a 100 foot, level, indoor course. The psychometric properties of the test have been examined in detail and the test has been shown to be a reliable measure of the distance walked in people with COPD when it is conducted according to standardized guidelines.13,14 The length of the hallway used for the walk,15 the instructions given to the subject,16 the type and amount of encouragement given,16 and the number of learning trials17 have all been shown to affect test performance and reliability. The test is simple to administer and generally well accepted by patients but it does not assess how walking ability affects functional status or participation, as it is defined in the ICF model. Furthermore, it does not assess how dyspnea during unsupported arm activities8,18,19 such as making beds, shelving dishes and doing the laundry affects functional status. As the prevalence of COPD in women increases20–23 the definition and assessment of function will likely need to expand to include more of these activities of daily living (ADL). Most objective tests of physical performance, like the 6MWT, focus on mobility dysfunction or on people having severe limitations.24–27 In contrast, the Assessment of Motor and Process Skills (AMPS) is a 26 item test that measures the quality of a person's activities of daily living (ADL).28 Unfortunately, the test is time consuming to conduct and it would be exhausting for many people with COPD. Furthermore, the assessment of process ability that is an integral part of this test is not usually relevant for people with COPD. The AMPS has not been validated in people with COPD in whom dyspnea plays a significant role in limiting function. Thus the Glittre ADL test was developed to address the need for a more representative, objective assessment of function in people with COPD.12