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.

Loss of lean body and muscle mass correlates with androgen levels in hypogonadal men with acquired immunodeficiency syndrome and wasting.

The acquired immunodeficiency syndrome (AIDS) wasting syndrome (AWS) is a devastating complication of human immunodeficiency virus infection characterized by a disproportionate decrease in lean body mass. The pathogenesis of the AWS is unknown, but recent data suggest that endogenous secretion of the potent anabolic hormone, testosterone; is decreased in 30-50% of men with AIDS. However, it is unknown whether decreased androgen levels are associated with decreased lean body mass and/or functional decreases in muscle strength and aerobic capacity in hypogonadal men with the AWS. In addition, testosterone is known to have stimulatory effects on GH secretion, and the loss of these effects on the GH-insulin-like growth factor I (IGF-I) axis may be an additional mechanism of decreased lean body mass in this population. Twenty hypogonadal subjects (free-testosterone < 12 pg/mL) with weight loss > 10% of preillness weight or absolute weight < 90% ideal body weight (IBW) were enrolled in the study. None of the subjects were receiving Megace. Lean body mass and fat-free mass were determined by potassium-40 isotope analysis (40K) and dual-energy x-ray absorptiometry, respectively, and analyzed with respect to gonadal function by linear regression analysis. Muscle mass was determined by urinary creatinine excretion, and exercise functional capacity was assessed by a 6-min walk test, a sit-to-stand test, and a timed get-up-and-go test. Results also were compared with gonadal function by regression analysis. IGF-I and mean overnight GH levels, determined from frequent sampling (q20 min from 2000-0800 h), were compared with results obtained from age- and sex-matched normal controls. Subjects were 26-58 yr of age (39 +/- 7 yr, mean +/- SD) with a CD4 cell count of 150 +/- 186 cells/mm3. Serum levels of FSH were elevated in 30% of the subjects. Muscle mass was significantly reduced, compared with expected mass for height (23.3 +/- 5.5 vs. 29.3 +/- 1.7 kg, P = 0.0001) and was decreased disproportionately to weight (77% of expected value for muscle mass vs. 93% of expected value for weight). Free-testosterone levels were correlated with total body potassium (R = 0.45, P < 0.05) and muscle mass (R = 0.45, P < 0.05). Total-testosterone levels were correlated with exercise functional capacity (R = 0.64, P = 0.01 for the sit-to-stand test and R = 0.53, P < 0.05 for the 6-min walk test). Mean GH levels were significantly increased (3.03 +/- 1.76 vs. 0.90 +/- 0.37 ng/mL, P < 0.001) and IGF-I levels decreased (167 +/- 66 vs. 225 +/- 69 ng/mL, P < 0.01), compared with age- and sex-matched eugonadal controls. GH levels were inversely correlated with caloric intake (R = -0.60, P = 0.02) and percent fat mass by dual-energy x-ray absorptiometry (R = 0.58, P = 0.02). Six additional hypogonadal subjects receiving Megace for AIDS wasting were analyzed separately. Nutritional status and parameters of body composition were compared in the Megace and non-Megace-treated subjects. No significant differences in caloric intake, lean body mass, fat mass, or muscle mass were demonstrated. These data demonstrate that changes in body composition, including loss of lean body and muscle mass, and deterioration in exercise functional capacity are highly correlated with androgen levels in hypogonadal men with the AWS. Furthermore, our data demonstrate significantly increased GH levels and decreased IGF-I in association with low weight in this population. These data suggest that androgen deficiency combined with classical GH resistance may contribute to the critical loss of lean body and muscle mass in hypogonadal men with the AWS. These data are the first to link muscle and lean body wasting with progressive gonadal dysfunction among the large percentage of men with AIDS wasting who are hypogonadal. This demonstrates the need for additional studies to determine the efficacy of gonadal steroid replacement to increase lean body mass in this population.

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.

Intracranial hypotension syndrome: neuroimaging in five spontaneous cases and etiopathogenetic correlations.

Intracranial hypotension (IH) is essential or, more frequently, secondary. This syndrome is characterized by severe postural headache and low opening cerebrospinal fluid (CSF) pressure; although other symptoms may exist. In this study five patients are investigated. Neuroimaging showed: on computerized tomography scan (CT), poor visualization of the cerebral sulci with small ventricles; on magnetic resonance imaging (MRI), subdural fluid collections with enhancement on the convexity, along the tentorium and in the upper cervix after administration of contrast medium and downward displacement of the brain. Radionuclide cisternography was normal in the two patients who underwent this treatment as well as the meningeal biopsy in another patient. In all patients the opening CSF pressure was low or unmeasurable. The clinical syndrome spontaneously recovered contextually to normalization of neuroradiological findings. The possible pathogenesis (dural border cell layer tear) was discussed and the importance of diagnostic confirmation with MRI and measurement of CSF pressure when IH is thought to be present was underlined.

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.

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.

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.

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.

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.

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.

Simon's model of rural-urban migration: a proof of Johansen's conjecture.

"In Simon's 1947 model, rankings of industries by income elasticities and by technologically induced changes in input quantities were proven identical. Johansen's conjecture that this does not extend to more than two sectors is confirmed by counter-example."

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.

[The assessment of nursing workload]. / I carichi di lavoro infermieristico.

The measurement of nursing workload first began in the 1970s, because of the need for determining severity of illness and cost-effectiveness in the intensive care unit. In the following decades, the need for more specific tools for assessing nursing workload brought to the development of scoring systems more focused on nursing activities. We will briefly review the scoring systems validated since 1974. TISS-Therapeutic Intervention Scoring System elaborated by Cullen in 1974 is based on 57 therapeutic procedures and was designed to assess the severity of illness in the ICU. Each intervention scores 1 to 4. Patients are grouped in 5 classes. It was not sufficiently validated and was abandoned. However it first introduced the idea of "patient point managed per nurse". TISS update was elaborated by Keene in 1983. The therapeutic procedures were increased to 76. It was assumed that a single nurse can manage 40/50 points per day. Though not validated, it became the most used tool to assess complexity of treatment and nurse/patient ratio. However many of these items are obsolete and frequently related to the severity of illness rather than to specific nursing interventions. PRN-Project Research of Nursing was elaborated by EROS during 1980-1987. Points are assigned to each nursing activity according to their frequency, duration, need for more than one nurse, etc. It results quite time consuming, thus unsuitable for routine use. OMEGA elaborated in 1986 describes 86 therapeutic interventions, grouped in 3 categories, measured at the end of ICU stay, thus representing a measure of global workload and use of resources. TOSS-Time Oriented Score System was elaborated by GIRTI in 1991. This score was studied and tested in Italy. It represents a direct temporal evaluation of nursing workload. The score is expressed in minutes. It is reliable and relatively simple, and has been validated on over 2 700 ICU patients. TISS 28 was elaborated by Miranda in 1996. It represents a simplified and updated version of the original TISS, proposed to assess the nursing workload. The authors stated that a nurse can deal with 46 points over the 24 hours. NEMS-Nine Equivalents of nursing Manpower use Score was elaborated by Miranda in 1997. It was derived from TISS and TISS28. Only 9 items, related to specific organ support, nursing and diagnostic/therapeutic interventions inside or outside the ICU, are considered. These items were weighted by multivariate analysis, obtaining a score comparable to the TISS28 score. Each nurse can deal with 45/50 points per day. NAS-Nursing Activity Score was elaborated by Miranda in 2003. It was derived from TISS28, aiming at the description of nursing activities not necessarily correlated to the severity of illness. It describes 81% of the nursing time, compared to 43% of TISS 28. In conclusion, many scoring systems have been proposed to describe nursing workload, both directly (as with TOSS and PRN) or through severity and complexity of treatment (TISS, TISS 28, NAS and NEMS). These scores represent the instruments to assess the correct use of ICU resources.

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.

Effects of dopamine and dobutamine on skeletal muscle oxygenation in normoxemic rats.

The effects of two vasoactive drugs, dopamine and dobutamine, on skeletal muscle tissue oxygenation were studied in a normoxemic rat model. It is usually claimed that drugs may increase or decrease oxygen delivery to tissues. However, this claim is only valid on the global level. Our interest is directed towards individual organs. Two groups of rats (n = 7 each) were studied. One group received dopamine, the other dobutamine. Blood gases, hematocrits, and mean arterial blood pressures were measured in addition to tissue pO2. Infusion of dopamine 2.5 micrograms/kg/min resulted in a statistically significant decrease in skeletal muscle pO2. Higher doses of dopamine, and all doses of dobutamine, did not influence pO2 at all. The results raise the question of whether blood flow to vital organs may be negatively affected by dopamine 2.5 micrograms/kg/min. Direct measurements of tissue oxygenation are warranted in, e.g., the liver and gut.