Cardiopulmonary exercise test indices of respiratory buffering before and after aerobic exercise training in women with pulmonary hypertension: Differentiation by magnitudes of change in six-minute walk test performance.

While aerobic exercise training (AET) has generally been shown to improve 6-min walk test (6MWT) distance (6MWD) in patients with pulmonary hypertension (PH), a substantial number of patients appear to adapt differently, with minimal or even negative changes in 6MWT distance being reported. PURPOSE: To compare post-aerobic exercise training adaptations in cardiorespiratory functional capacity across three groups of patients with PH: those with high (HI), low (LI) and negative (NEG) post-training increases in 6MWD. METHODS: Participants were 25 females (age 54 ± 11 years; BMI 31 ± 7 kg/m2) who completed a vigorous, 10-week, thrice weekly, supervised treadmill walking exercise program. Cardiopulmonary exercise tests (CPET) and 6MWT were completed before and after training. Ten of the 25 participants were classified as HI (range = 47-143 m), 11 were classified as LI (range = 4-37 m) and 4 were classified as NEG (range = -17 to -53 m). RESULTS: Peak CPET duration, WR and time to anaerobic threshold (AT) were significantly higher (p < 0.05) after training in both the LI and HI groups but not in the NEG group. There was a significant improvement in VE/VCO2 (p = 0.042), PETCO2 (p = 0.011) and TV (p = 0.050) in the HI group after training, but not in the NEG or LI group. CONCLUSION: These findings suggest that sustained ventilatory inefficiency and restricted respiratory buffering may mediate exercise intolerance and impede the ability to adapt to exercise training in some patients with PH.

The development of an instrument to measure satisfaction with physical therapy.

BACKGROUND AND PURPOSE: Patient satisfaction continues to receive attention as a measure of the outcome of physical therapy intervention. However, a great deal more attention has been paid to the topic outside of, rather than within, physical therapy. This article describes the development of an instrument that measures patient satisfaction among physical therapists' patients and clients. METHOD: A 26-item instrument designed to measure the domains of patient satisfaction among patients was developed by the authors in preparation for this study and field tested on patients from several sites comprising a large clinical operation. Descriptive statistics and estimates of reliability of measurements obtained with the instrument were computed. Reliability and validity were assessed. A total of 289 individuals completed the instrument. RESULTS: The coefficient for reliability (Cronbach alpha=.99) obtained for the instrument was clearly within a desired range. Different types of validity were established as well. CONCLUSION AND DISCUSSION: Instruments typically used by physical therapists to measure patient satisfaction have undergone little psychometric analysis. This instrument appears to meet the criteria required to make it a useful tool for measuring patient satisfaction.

Regaining functional independence in the acute care setting following hip fracture.

BACKGROUND AND PURPOSE: Factors that predict functional recovery in the first few days following hip fracture and that may facilitate discharge to the home directly from the acute care setting have not been identified. This study investigated the attainment of key functional milestones by patients and discharge status from an acute care hospital following hip fracture. SUBJECTS: Subjects were 162 community-based individuals (59 men, 103 women) aged 60 years or older who were admitted to an acute care hospital following unilateral hip fracture. METHODS: Data on personal, medical surgical, hospital course, and acute rehabilitation factors as well as functional status and placement at the time of discharge were collected. Adjusted odds ratios were calculated to determine predictors of independence in seven types of transfers and ambulation activities and discharge directly to the home. RESULTS: Subjects who ambulated independently prior to fracture, stayed longer in the acute care setting, and received physical therapy on average more than once a day had improved odds of regaining independence in bed mobility, transfers, and ambulation. Subjects who regained independence and received physical therapy on average more than once a day had improved odds of discharge directly to the home from the acute care setting. Increasing age and postoperative complications reduced the odds of discharge directly home. CONCLUSION AND DISCUSSION: A substantial proportion of patients with hip fracture achieve independence in bed mobility and transfers and in ambulation with a walker during the early postoperative phase, although few progress to a higher level during a short-term stay in the acute care setting. Frequency of physical therapy, among other factors, appears to improve the odds of regaining functional independence and discharge directly to the home from the acute care setting.

Physical therapy for musculoskeletal syndromes.

Judgments about the effectiveness of physical therapy in the treatment of musculoskeletal syndromes depend on the findings of the physical therapist's examination and the fit between the clinical problem and the intervention. Using a model of the process of disablement, this article outlines the theoretical basis for a physical therapist's role in remediating the impairments and functional limitations associated with musculoskeletal conditions. The research basis for the application of particular physical therapy procedures, including physical agents and mechanical modalities, to typical patient problems is presented.

The correlates of health perceptions in rheumatoid arthritis.

OBJECTIVE: Although measures of health perceptions have been routinely incorporated into assessments of individuals with rheumatoid arthritis (RA), the relationships of other characteristics of these individuals to their health perceptions is not fully understood. We describe the cross sectional associations of sociodemographic, disease, and functional status characteristics with perceived health in individuals with RA. METHODS: This description was generated through a 2-phase secondary data analysis using 2 statistical approaches: recursive partitioning of the sample and standard multivariate logistic regression techniques. RESULTS: Both methodological approaches identified education, race, depression, and physical activity as important correlates of self-assessed health in RA. Each approach, in its own way, also identified an interactive effect between physical activity and education and between depression and race in these models. CONCLUSION: An individual's sociodemographic, disease, and functional status characteristics form a complex model of the correlates of health perceptions of individuals with RA.

Arthritis and the process of disablement.

Rheumatoid arthritis and osteoarthritis are two medical conditions that broadly alter the musculoskeletal system and influence a person's ability to perform the functional activities and tasks expected of an independent adult. A burgeoning literature depicts the process of disablement in arthritis and details the relationships among disease, impairments, and functional limitations. There is, however, a substantial gap in the physical therapy literature regarding the relationship among arthritis, musculoskeletal impairment, and physical function. Furthermore, the search for the most effective ways to remediate musculoskeletal impairment and improve function remains a challenge for clinicians and researchers alike.

The effects of specific medical conditions on the functional limitations of elders in the Framingham Study.

OBJECTIVES: The purpose of this study was to identify associations between specific medical conditions in the elderly and limitations in functional tasks; to compare risks of disability across medical conditions, controlling for age, sex, and comorbidity; and to determine the proportion of disability attributable to each condition. METHODS: The subjects were 709 noninstitutionalized men and 1060 women of the Framingham Study cohort (mean age 73.7 +/- 6.3 years). Ten medical conditions were identified for study: knee osteoarthritis, hip fracture, diabetes, stroke, heart disease, intermittent claudication, congestive heart failure, chronic obstructive pulmonary disease, depressive symptomatology, and cognitive impairment. Adjusted odds ratios were calculated for dependence on human assistance in seven functional activities. RESULTS: Stroke was significantly associated with functional limitations in all seven tasks; depressive symptomatology and hip fracture were associated with limitations in five tasks; and knee osteoarthritis, heart disease, congestive heart failure, and chronic obstructive pulmonary disease, were associated with limitations in four tasks each. CONCLUSIONS: In general, stroke, depressive symptomatology, hip fracture, knee osteoarthritis, and heart disease account for more physical disability in noninstitutionalized elderly men and women than other diseases.

AIMS2. The content and properties of a revised and expanded Arthritis Impact Measurement Scales Health Status Questionnaire.

OBJECTIVE: The goal of this project was to develop a more comprehensive and sensitive version of the Arthritis Impact Measurement Scales (AIMS). METHODS: AIMS scale items were revised, and 3 new scales were added to evaluate arm function, work, and social support. Sections were also added to assess satisfaction with function, attribution of problems to arthritis, and self-designation of priority areas for improvement. The new instrument was designated the AIMS2. A pilot test of format and content and a performance test of reliability and validity were carried out. RESULTS: Questionnaire completion times in a pilot study of 24 subjects averaged 23 minutes, and evaluations were positive regarding the instrument's length and ease of completion, and the subjects' willingness to complete serial forms and return them by mail. Measurement performance was tested in 408 subjects: 299 with rheumatoid arthritis (RA) and 109 with osteoarthritis (OA); 45 of these subjects completed a second AIMS2 within 3 weeks. Internal consistency coefficients for the 12 scales were 0.72-0.91 in the RA group and 0.74-0.96 in the OA group. Test-retest reliability was 0.78-0.94. All within-scale factor analyses produced single factors, except for mobility level in OA. Validity analyses in both the RA and the OA groups showed that patient designation of an area as a problem or as a priority for improvement was significantly associated with a poorer AIMS2 scale score in that area. Reliability, factor analysis, and validity results were consistent in age, sex, and education subgroups. Satisfaction was moderately correlated with level of function in the same health status area, and the satisfaction items formed a reliable scale. Responses to the arthritis attribution items showed that most dysfunction in this sample was due to arthritis. CONCLUSION: The AIMS2 is a revised and expanded health status questionnaire with excellent measurement properties that should be useful in arthritis clinical trials and in outcomes research.

Physical therapy diagnosis and the relationship between impairments and function.

Physical therapy diagnosis refers to both a process and a particular label within a classification scheme. This article reviews the development of the concept of diagnosis in physical therapy and evaluates the clinical utility of using the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps (ICIDH) as a taxonomy for physical therapy. In place of the ICIDH, a model developed by Nagi is suggested. If this model is applied to physical therapy, the relationship between impairments and functional limitations is identified as the primary diagnostic focus of physical therapy. Exploration and expansion of this model may best serve the development of a classification scheme for physical therapy diagnosis.

Defining arthritis and measuring functional status in elders: methodological issues in the study of disease and physical disability.

This study explores the degree to which the association of knee osteoarthritis with physical disability changes with different definitions of osteoarthritis in 1,416 Framingham Study elders. When all categories of radiographic osteoarthritis were aggregated into a single "arthritis" variable and dependence upon human assistance in one or more functional activities combined into a single variable, elders with osteoarthritis had only moderately increased odds for dependence after controlling for age or sex (OR = 1.25). A definition of osteoarthritis based only upon symptoms produced larger odds for dependency (OR = 1.85). Elders with mild osteoarthritis and infrequent knee pain had no significantly elevated risk for dependence in any of the seven functional activities. Elders with infrequently symptomatic, moderate to marked radiographic osteoarthritis were at increased risk for dependence in stair climbing, walking a mile, housekeeping, and carrying bundles. Elder with radiographic osteoarthritis accompanied by frequent pain had an increased odds of dependence in stair climbing, walking a mile, and housekeeping. Using a generic definition of "arthritis" and aggregating functional activities may underestimate the impact of osteoarthritis on physical disability in the elderly and obscure the task-specific nature of that relationship.

Arthritis in nursing home residents. A validation of its prevalence and examination of its impact on institutionalization and functional status.

We studied nursing home residents to validate the method used in national surveys for estimating the prevalence of arthritis, and to examine the impact of arthritis on institutionalization and on the physical function of residents. Five homes were studied using a 3-phase approach. Directors of nursing in each home classified residents (n = 629) with respect to the presence of arthritis and senile dementia. The presence of osteoarthritis or rheumatoid arthritis and their impacts on a resident's initial placement were separately assessed by a physician through a chart review of a stratified subsample. The physician also rated a resident's likelihood of returning to community living. Finally, the functional impact of arthritis was assessed by a physical therapist. The nurses' estimate of the prevalence of arthritis in this population was 23.33%, while the physician estimate was 23.03%. These results are consistent with the 24.6% prevalence found in a 1977 national survey. Arthritis itself was a major cause of nursing home placement in 15% of all residents without dementia. Among those without dementia who also had arthritis, arthritis was a major cause of institutionalization in 31%. None of the residents without dementia showed substantial potential for reintegration into the community. Controlling for age, residents with arthritis had more pain, were more likely to require assistance in functional tasks, and were more likely to use a wheelchair daily than were their fellow residents. Nevertheless, our results suggest that arthritis, despite its impact on function, in and of itself is not a major cause of nursing home placement or ongoing institutionalization.

Needs of the elderly and the politics of health care. The social context of changes in the delivery system.

The emergence of the elderly as a substantial subgroup within the population has been identified as signaling a crisis for the health care system. This article places recent changes in health care financing for the elderly in the context of biomedical, demographic, and social factors. These factors, in turn, are related to the larger economic and political structures that have shaped our national health care policies and programs. Current policies and programs are inadequate in meeting the needs of the elderly because they provide a limited array of services. This article also examines how the needs of the elderly have been portrayed to support age-based entitlements to limited health care coverage, irrespective of need across age strata. Physical therapists can use their understanding of the genesis of particular public policies to assist in developing a health care system that is responsive to the needs of all members of society.

Interpersonal skills education in entry-level physical therapy programs.

The purpose of this study was to determine the current status of interpersonal skills (IPS) education in entry-level physical therapy programs with respect to content, course work requirements, and evaluation strategies. The disciplines of faculty members who teach IPS and their materials and methods also were explored. Using a 32-item questionnaire, we surveyed in 1984 all accredited baccalaureate (BS), certificate (CERT), and entry-level master's degree (MS) programs (N = 107) in physical therapy. Seventy-two responses (67.2%) were received, reflecting returns from 57 BS (64.7%), 5 CERT (83.3%), and 10 MS (76.9%) program respondents. Nearly all (97.2%, n = 70) of the respondents explicitly taught IPS in the classroom, but fewer of them evaluated learning (74.3%, n = 52). Overall, respondents teaching in MS programs consistently reported including a greater concentration of IPS content than the other two types of programs. All of the MS programs required specific IPS course work, compared with 50 (87.7%) of the BS programs and 3 (60%) of the CERT programs. Predominantly, faculty members who teach IPS are academically based physical therapists who use an extensive variety of methods and materials.

Regional differences in physical therapists' incomes.

This investigation examines regional differences in the incomes of full-time employed members of the American Physical Therapy Association. The study was undertaken specifically to test the assumption that the gross earned incomes of therapists in New England were less than their peers in other regions. Data came from the 1982 APTA membership survey, based on a random sample of 20 percent of the APTA membership (response rate = 62.8%). Results indicate that in 1981 a significantly greater proportion (women, p less than or equal to .0001; men, p less than or equal to .01) of APTA members in New England had a lower income compared with peers in six other regions. Significant income differences persist even when controlling for age, experience, primary activity or responsibility, entry-level education, and highest earned academic degree.

Ethical issues in physical therapy practice. A survey of physical therapists in New England.

This survey was an attempt to identify which ethical decisions are most frequently encountered and are most difficult to make for practicing physical therapists. A questionnaire that described 30 situations with an ethical dimension was sent to 450 American Physical Therapy Association members practicing in New England. A total of 187 (41.5%) usable questionnaires was returned. Issues raised by items were designated as primary, secondary, or nonpriority. Seven primary and 11 secondary ethical issues were identified. In brief, these issues involve the decision about which patients should be treated, what obligations are entailed by that decision, who should pay for treatment, and what duties derive from the physical therapist's relationship; with other health professionals, including physicians. Some of these decisions are more frequent in certain types of employment facilities than in others. Sources of ethical conflict and the role of the professional organization in defining moral values for the profession are discussed in this paper, and implications for education are presented.