Background and Purpose: Lung transplantation presents unique rehabilitation challenges, particularly in the acute postoperative phase where formal physical therapy guidelines are limited. Evidence supporting their use in this setting, however, remains limited. The purpose of this case report was to describe the implementation of a standardized battery of outcome measures and the physical therapy management of a medically complex patient in the acute phase after bilateral lung transplantation (LT). Case Description: A 66-year-old man with end-stage COPD underwent bilateral LT with left diaphragm plication. Postoperatively, the patient presented with significant deconditioning, impaired functional endurance, and required assistance of 2 individuals for all mobility. Intervention: Physical therapy was provided once daily, 6 days per week, progressing from early mobilization and upright tolerance to pregait activities, progressive ambulation, lower extremity strengthening, and endurance training. Outcomes: The AM-PAC 6-Clicks score improved from 11 to 23, the 6-Minute Walk Test from 23.77 to 246.58 m, the Short Physical Performance Battery from 3/12 to 10/12, and the Five Times Sit-to-Stand from 90 to 16.62 seconds. The patient was discharged home on hospital day 21 at a supervision level without an assistive device and on room air. Discussion: This case demonstrates that implementing a standardized outcome measure battery during acute inpatient LT rehabilitation is both feasible and clinically valuable. These tools facilitated data-driven decision-making, supported interdisciplinary communication, and informed discharge planning, establishing a foundational protocol for future LT rehabilitation.
Purpose: The Johnson & Johnson MedTech Impella 5.5 ® is a temporary mechanical circulatory support (tMCS) device that supports cardiac output in the setting of cardiogenic shock. Older Impella ® models provide less cardiac output and limit mobility because of femoral insertion sites. It is widely accepted that early mobility is important in the ICU setting, but there is a lack of mobility-specific guidelines for patient selection or procedural interventions with the Impella 5.5 ® . This study describes a framework that was created to aid in patient selection for mobility, discusses procedures for those who are appropriate to mobilize, and provides single-center mobility data in patients with an Impella 5.5 ® temporary ventricular assist device. Methods: Retrospective chart review was performed on all 49 patients who had an Impella 5.5 ® device between April 2023 and September 2024. Variables retrieved from electronic medical records included mobility-related data (highest level of mobility, number of mobility events, device performance level (P-level) and pressors/inotropes at time of mobility), patient data (age, gender), and device data (placement location, duration of device, and concurrent/previous devices). Statistical analysis included percentages to understand data trends and frequency of mobility. Results: Twenty-four out of 49 (49%) of patients with an Impella 5.5 ® were deemed appropriate to mobilize based on the decision-making guideline, for a total of 62 mobility events. A vast majority (98%) of mobility events occurred with physical therapy or occupational therapy, with nursing accounting for the remaining 2%. There were no adverse events noted during mobility. Conclusions: The Johnson & Johnson MedTech Impella 5.5 ® provides up to 5.5 liters per minute of cardiac output, which allows the heart to recover from cardiogenic shock. When paired with interprofessional communication and training, a decision-making algorithm can aid in safe and effective mobilization of medically complex patients with an Impella 5.5 ® mechanical assist device.
Purpose: There is sufficient evidence supporting the benefits of respiratory muscle training in patients with a wide variety of health conditions. The BREATHS framework is a 7-step evidence-based knowledge translation framework designed to support the implementation of inspiratory muscle training into clinical practice. In this Knowledge Translation project, the BREATHS framework was used to implement respiratory muscle assessment and training, inclusive of both inspiratory and expiratory training, among an outpatient neurologic multidisciplinary therapy team consisting of physical, occupational, and speech therapists. Methods: The BREATHS framework was used to structure a knowledge translation project consisting of educational in-services and clinician resources development. A pre, during, and post-survey model with descriptive statistics was used to assess for baseline and changes among clinicians regarding knowledge, confidence, and behaviors after dissemination of the knowledge translation project. Results: Participants demonstrated confidence related to assessment and training of respiratory muscles as well as increased implementation in clinical care of respiratory muscle assessment and training. Conclusion: The BREATHS framework can serve as a practical model for implementing knowledge translation of respiratory muscle assessment and training into physical therapy practice. Further work is needed to understand stakeholder perspectives on utilization of respiratory muscle training and to measure change in practice.
Introduction: Lobar collapse in patients in the intensive care unit is traditionally diagnosed via chest radiography (CXR). Case Report: This patient had a recent CXR that suggested a new-onset, left, lower lobe collapse and no collapse of the right lower lobe. However, physiotherapy-led ultrasound identified a more significant right lower lobe collapse than left lower lobe collapse. Physiotherapy that included only left-side-lying repositioning resulted in full right lobe reexpansion, confirmed by repeat lung ultrasound (LUS). No additional lung recruitment techniques or invasive interventions were required. Discussion: LUS enabled a more accurate diagnosis than CXR, guided effective physiotherapy treatment, and confirmed a real-time response to positioning alone, supporting the need for broader integration of LUS into physiotherapy practice. However, challenges faced to implement broadly include access to training, supervision/mentoring, and appropriate governance and support.
Background and Purpose: Improving physical activity is a central goal of pulmonary rehabilitation (PR), and emerging programs now incorporate physical activity targeted interventions to enhance patient outcomes. Existing reviews on this topic lack rigor and are limited. Therefore, this review synthesized literature on the effectiveness of physical activity interventions added to traditional PR programs to change physical activity levels in individuals with chronic obstructive pulmonary disease (COPD). Methods: Using PubMed, Web of Science, Cochrane Library, and Embase, 4 researchers screened 463 articles with the search terms: (pulmonary or respiratory rehab*) AND (daily physical activity or activity level or physical activit* and sedentary*). Seven articles were finalized with predetermined eligibility criteria. Reviewers extracted information and appraised the articles using the Physiotherapy Evidence Database (PEDro) scale. Results: A pooled analysis (n = 587) showed that the addition of physical activity interventions to PR produced a statistically significant increase in daily steps per day compared with group with only PR. Analyses of moderate-to-vigorous physical activity, walking time, sedentary time, endurance, and quality of life showed no significant between group differences. The PEDro scores of the studies ranged from 4 to 7. Discussion and Conclusions: Our findings suggest that adjuvant physical activity interventions added to PR provided small improvements in steps per day compared with usual care in individuals with COPD. Risks of bias, heterogeneity of interventions, and differences in participant characteristics should be considered while interpreting our data. Clinical Pearls: These findings may guide clinical decision making regarding incorporating physical activity interventions with traditional PR for patients with COPD.
Background and Purpose: Pulmonary embolism (PE) is a life-threatening condition that rarely occurs in high altitude (HA) environments. Typically PE does not present as musculoskeletal (MSK) pain. The purpose of this case report is to describe successful physical therapist (PT) management of a patient who presented with low back pain (LBP) during a HA expedition, where further evaluation and imaging identified primary impairment due to PE. Case Description and Intervention: A standardized clinical examination was conducted inside a tea house along the Everest Base Camp trek with limited resources. The patient complained of an intermittent “dull ache” at the left lumbar spine and left costovertebral angle, but the MSK examination was unremarkable. Initial differential diagnosis was acute mountain sickness (AMS) versus kidney stones. Fingertip oxygen saturation (SpO 2 ) was 68% at the PT evaluation but deteriorated to 45% after climbing to higher altitudes. Thus, helicopter evacuation to Kathmandu was coordinated to expedite emergency department evaluation. Outcomes: Radiographs showed left pleural effusion, laboratory results noted elevated D-dimer, and computed tomography (CT) scan revealed segmental bilateral PE. The patient recovered in the hospital for several days before flying home. At 3-month follow-up, the symptoms resolved, and follow-up testing was negative for PE. Discussion: Pulmonary embolism may present as referred LBP in conjunction or independent from AMS. Further research is recommended to investigate the incidence of PE presenting as MSK pain, and clinical signs that could be used as screening criteria to categorize risk for those planning high altitude expeditions.
and Purpose: Women living with obesity have increased work of breathing due to adiposity on the chest wall and higher metabolic demands. Consequently, dyspnea is a major deterrent to physical activity. This study aimed to determine the effects of inspiratory muscle training (IMT) compared with usual care on respiratory muscle function, physical fitness, and dyspnea. Thirty women were randomly assigned to IMT (IMTG) or usual care (control group [CG]). IMT consisted of 2 sets of 30 inspiratory efforts at 55% of maximum inspiratory pressure (MIP), adjusted weekly, 5 days a week for 4 weeks. IMT was home-based and supervised. CG did not receive any IMT or intervention. The primary outcomes were MIP, sustained maximum inspiratory pressure (SMIP), distance walked in the Incremental Shuttle Walking Test, and dyspnea intensity. Secondary outcomes included maximum expiratory pressure, predicted peak oxygen consumption (VO 2 peak ), the thirty-second Sit-to-Stand test (STS), and rating of perceived exertion. Outcomes were measured at baseline and after 4 weeks. IMTG improved MIP ( P = .01), SMIP ( P = .01), distance walked ( P = .03), predicted VO 2 peak ( P = .01), STS ( P = .01), and decreased Borg dyspnea ( P = .03), whereas these outcomes did not change in the CG. Improvements in respiratory muscle strength and endurance likely contributed to the enhanced physical fitness and reduced dyspnea, suggesting a potential pathway for IMT to positively affect exercise capacity and well-being. IMT increased strength and endurance of the respiratory muscles, physical fitness, and decreased dyspnea in women living with obesity.
Early mobility and rehabilitation in the intensive care unit (ICU) setting is a well-established component of physical therapist (PT) practice. Despite this, there is variability between institutions and disciplines regarding perceived barriers to early mobility. The purpose of this study was to examine perceptions of the interprofessional team regarding the safety of early mobility in the ICU across disciplines with regard to specific devices and insertion sites. This survey study used a convenience sample of professionals who staff the ICUs at a level 1 trauma academic medical center. The survey included questions regarding profession, primary ICU of practice, years of experience, level of agreement with statements related to early mobility, and perceived risk-to-benefit ratio of early mobility for specific clinical scenarios. Across items related to ICU interventions and perceived risk-to-benefit ratio, internal consistency was excellent with α = .94. Statistically significant differences were noted between professions for each device and insertion site. Concern for femoral insertion across all devices was apparent in the lower percentage of non-PT respondents perceiving a favorable risk-to-benefit ratio across professions for femoral compared to nonfemoral insertion sites. Despite existing research regarding the safety and benefits of early mobilization and rehabilitation of patients in the ICU, members of the interprofessional team have concerns regarding the risk-to-benefit ratio for various monitoring and interventional devices. This overall unfavorable perceived risk-to-benefit ratio contrasts with team members' reported general support for and participation in early mobilization, and with the routine, daily practice at our institution.
Extracorporeal membrane oxygenation (ECMO) is crucial in the management of severe cardiopulmonary dysfunction. Although early rehabilitation in the intensive care unit (ICU) has been shown to reduce ICU-acquired weakness and improve patient outcomes, there is limited evidence on structured rehabilitation programs for patients on veno-venous ECMO (VV-ECMO) for the treatment and management of their disease process. Herein, a case of a multidisciplinary progressive rehabilitation program with a focus on resistance training that enhanced functional improvement in a patient on VV-ECMO after lung transplantation is reported. A female in her sixties with a history of idiopathic pulmonary fibrosis underwent lung transplantation but subsequently developed acute respiratory distress syndrome requiring VV-ECMO on postoperative day 13. A high-intensity rehabilitation protocol, which included ambulation, passive through active range of motion exercises, physical/occupational therapy, and resistance training, was implemented on postoperative day 16. The patient demonstrated progressive improvement in exercise tolerance, resistance training duration, gait distance, and functional strength. This case highlights the potential benefits of high-intensity rehabilitation to enhance physical function and mobility in patients on VV-ECMO. Further research is warranted to evaluate the effectiveness of the high-intensive rehabilitation and to establish standardized rehabilitation protocols in VV-ECMO settings.
Respiratory muscle training can improve strength, endurance, and ventilatory function. Although the rectus abdominis is considered the primary muscle of forced expiration, limited research has been conducted to explore whether adding external oblique (EO), internal oblique (IO), and transverse abdominis (TA) training could improve key components of exhalation. The purpose of this study was to explore whether the addition of 7 exercises primarily targeting the obliques and TA in trained female athletes would change the expiratory component of pulmonary function. The participants in this pretest–post-test study were female Division I track and field middle and long-distance runners (n = 22). The participants had 7 exercises added to their in-season training regimen 3 times a week for 8 weeks. Spirometry measured forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, and peak expiratory flow rate (PEFR) before and after the intervention. Surface electromyography was recorded during maximal voluntary contractions of core muscles to monitor desired muscle recruitment and assess pre- and post-training activation levels. The data analysis revealed findings indicating statistical insignificance based on our predetermined confidence interval. However, 3 of the 4 pulmonary function metrics had strong effect sizes. The surface electromyography outputs were lower than the preintervention results and showed no correlation with the pulmonary function results. The spirometry raw data from this study showed that strengthening the EO, IO, and TA muscles can minimally increase the mean difference in aspects of expiratory pulmonary function compared to others. Surface EMG revealed that muscle activity did not improve with low repetition exercises, performed 3 times per week for 8 weeks. The strong effect size for 3 of the 4 tests supports repeating the study with a larger sample size to enhance power and include a control group. In addition, developing an intervention with increased exercise repetitions is necessary to fully appreciate any measurable changes. The introduction of 7 anterolateral abdominal muscle exercises to an established training regimen presented nonstatistically significant increases in FEV1, concomitantly the FEV1/FVC ratio, and PEFR. Observation of the data showed that most participants in 3 of the 4 tests presented with a mean increase in their post-testing effort. Due to the statistical findings and unique traits of the study participants, no clinical links can be extrapolated until further research is conducted.
Urinary incontinence (UI) affects an estimated 53% of women and negatively affects quality of life. Stress UI (SUI), involuntary leakage of urine with activities that increase intra-abdominal pressure, is the most prevalent subtype. Chronic lung disease is a suggested risk factor based on studies in obstructive disorders reporting association with cough. SUI has not been examined in interstitial lung disease (ILD) where cough is less prevalent. This study investigates SUI in lymphangioleiomyomatosis (LAM)– a rare, progressive ILD typically diagnosed in otherwise healthy women of childbearing age. In this cross-sectional study, a questionnaire assessing urinary and respiratory symptoms, lung function, fatigue, UI reporting, and health status was completed by 167 women with LAM plus 218 healthy controls matched for major SUI risk factors (CON). Analysis was performed with Welch t-test (continuous data) and chi-square and Mann–Whitney U tests (ordinal data), and risk differences using linear regression determined risk factors for SUI. The prevalence of SUI was higher in LAM (72%) compared with matched CON (48%). LAM with SUI had more dyspnea, phlegm production, and fatigue-related symptoms, but not more cough or lung impairment. Less than a third of LAM with SUI reported symptoms to medical providers, and prescribed treatments were commonly inconsistent with current recommendations. A higher prevalence and underreporting of SUI in women with LAM suggests need for targeted SUI screening and management to address a potentially overlooked complication of the disease with known impact on QoL. Future research should investigate how respiratory sequelae may contribute to greater SUI in LAM and other chronic lung diseases.
Cytoreduction and heated intraperitoneal chemotherapy is the standard of care for selected patients with peritoneal malignancies. By nature, these procedures are maximally invasive and are associated with high rates of postoperative complications and prolonged hospital stay. Although preoperative prehabilitation with respiratory muscle training (RMT) has demonstrated benefits in various surgical populations, its impact in patients undergoing CRS/HIPEC remains understudied. We conducted a retrospective review of a prospectively maintained database at a high-volume CRS/HIPEC center. Patients scheduled for CRS/HIPEC who received a preoperative prehabilitation program with RMT were identified and matched 2:1 to control patients based on (age, completion of cytoreduction, primary site, and year of CRS/HIPEC). Univariable comparisons were performed using chi-squared and Kruskal–Wallis tests. Multivariable linear regression was used to assess the association of prehabilitation on hospital length of stay (LOS), adjusting for age, grade 3 to 5 complication, and receipt of prehabilitation. Kaplan–Meier survival analysis was conducted to explore differences in overall survival. A total of 38 patients who underwent curative intent CRS/HIPEC during the study period received preoperative prehabilitation with RMT. After matching, 98 patients were included in the final analysis, with 38.8% (38/98) receiving prehabilitation. There were no significant differences in demographics or rates of postoperative complications, including pulmonary complications, between groups. Median LOS was significantly shorter in the prehabilitation group (8 days [IQR 7–8]) compared with controls (9 days [interquartile range (interquartile ranges) 7.5–12]; P = .002). Multivariable regression showed prehabilitation was associated with a 2.8-day reduction in LOS ( P = .01). No significant difference in overall survival was observed (156.0 vs 57.0 months; P = .097). Preoperative prehabilitation with RMT in patients undergoing CRS/HIPEC is feasible and associated with reduced hospital length of stay. Although no significant differences were observed in postoperative complications or survival rates, these suggest a potential role for prehabilitation in optimizing perioperative recovery reducing health care utilization in this high-risk population.
Purpose: Reduced cerebral blood flow (CBF) may play a role in the pathophysiology of postexertional malaise (PEM) in myalgic encephalomyelitis (ME). This case report aimed to determine the feasibility of measuring differences in blood flow to the head occur during PEM induced by 2-day cardiopulmonary exercise testing (CPET). Methods: One individual with ME and 1 nondisabled individual underwent a 2-day CPET to induce PEM. Blood flow was assessed using a novel in-ear device (Lumia Health), using photoplethysmography to estimate a relative flow index while participants were supine and during a 10-minute standing test before CPET. The person with ME showed a 34% decrease in work at the ventilatory anaerobic threshold (VAT), confirming PEM on day 2. During PEM, flow index decreased by 17% while supine and 23% during orthostasis compared to day 1. The nondisabled individual did not exhibit subjective or objective PEM (1% reduction in work at VAT) and experienced less than a 5% reduction in flow index while supine. Results and Conclusions: Reduced blood flow to the head during PEM may partially explain ME symptomatology. The novel in-ear device shows promise as a diagnostic and biofeedback tool, warranting further research in larger studies.
Purpose: Maximal inspiratory pressure (MIP) is a simple measure that reflects inspiratory muscle strength, which is often impaired in individuals with chronic obstructive pulmonary disease (COPD). This study aimed to assess the test–retest reliability, minimal detectable change (MDC) of MIP in persons with COPD, as well as to revisit its relationship with the 1-minute sit-to-stand test (1STST). Methods: Individuals with stable COPD were recruited. The study protocol included 2 visits. During the first visit, participants performed the MIP measurement and the 1STST with a 30-minute interval. The second visit was repeated within 10 days to assess between-day test–retest reliability. Results were reported as mean and SD. Results: The MIP measurement demonstrated excellent test–retest reliability (intraclass correlation coefficients [ICC] = 0.94, 95% CI: 0.89, 0.97, P = .001). Bland–Altman plots revealed a mean bias in the MIP measurement of 3.3 cmH 2 O, with limits of agreement ranging from −17.7 to 24.3 cmH 2 O. The MDC for MIP was estimated to be 7.3 cmH2O, respectively. A weak positive correlation (r = 0.29, P = .03) was observed between MIP and 1STST performance. Conclusions: This study demonstrated excellent between-day test–retest reliability of MIP measurement in persons with mild to moderate COPD. In addition, a weak positive correlation was found between 1STST and MIP in this population.
Clinical reasoning (CR) is a critical skill in cardiovascular and pulmonary (CVP) physical therapy that enables therapists to navigate complex patient situations and make informed decisions. This process involves cognitive and noncognitive elements such as data analysis, hypothesis testing, active listening, and critical evaluation. Mastery of CR improves with practice, feedback, and reflection, but errors can still occur without a systematic approach to evaluation and intervention. One strategy to minimize errors in CR is the SINSS construct—Severity, Irritability, Nature, Stage, and Stability. Although traditionally used in orthopedics, SINSS has potential applications in CVP therapy, helping clinicians better assess the characteristics of a patient's symptoms and guide the vigor and extent of examination and treatment. The systematic use of SINSS enables therapists to better understand specific CVP conditions and symptoms presented by patients, allowing for a more individualized and well-tolerated physical examination and intervention plan. This clinical perspective aims to provide a detailed definition of the terms within the SINSS construct and their relevance to managing patients with CVP conditions. Current research on the application of SINSS in clinical practice and educational settings is also discussed, highlighting its potential to reduce diagnostic, prognostic, and interventional CR errors. Future recommendations for the use of SINSS in CVP physical therapy are provided to advance the study of CR and improve patient outcomes.
Effective translation of knowledge to rehabilitation practice requires disseminating relevant resources in accessible locations that meet the needs of clinicians. This study explored rehabilitation providers' perceived challenges in managing Long COVID and their strategies used to optimize the quality of care delivered. A cross-sectional sample of 2700 rehabilitation providers (900 PTs, 900 OTs, 900 SLPs) were randomly selected from the state with the highest prevalence of Long COVID according to the Centers for Disease Control and Prevention Household Pulse Survey within each of the US geographic divisions. Participants were invited to complete a survey exploring their clinical challenges and methods utilized to obtain resources to support the rehabilitation needs of individuals with Long COVID. A total of 296 providers (11.6% response rate) were included in the final analysis, with 97 (32.7%) indicating they treat people with Long COVID frequently or occasionally. Across the sample, lack of knowledge (60.1%) and lack of experience (59.0%) regarding the condition were identified as the primary challenges to rehabilitation. Professional networking (33.4%) and federal government websites (29%) were used to support knowledge, with noted differences in the forums accessed. Challenges exist in providing quality rehabilitation to individuals with Long COVID that can be addressed with evidence-based resources. However, rehabilitation providers may not be effectively accessing or utilizing these resources in practice, which may perpetuate these challenges. Targeted interdisciplinary initiatives that enhance clinicians understanding of Long COVID may increase the ability to identify individuals with this condition and either provide, or refer them to, quality rehabilitation to optimize outcomes.
Cardiogenic shock with biventricular failure has no durable mechanical circulatory support (MCS) options. The Heartmate III left ventricular assist device (LVAD) can support the right ventricle. In difficult cases, a durable biventricular (BiVAD) configuration is used. With LVAD rehabilitation literature flourishing, there is little evidence regarding rehabilitation progression after durable, BiVAD placement. This report aimed to describe the progression of physical therapy interventions for a patient with a temporary to durable BiVAD implant. The patient is a 33-year-old woman with chemotherapy-induced cardiomyopathy placed on temporary MCS support for cardiogenic shock. Eventually, the patient received a durable, BiVAD implant. This case describes the evidence-based interventions for a physical therapy plan of care. A rehabilitation plan of care proved feasible and effective, with the patient completing 22 sessions for approximately 38 minutes per session. With an emphasis on interdisciplinary collaboration and supplemental nursing led mobility, no adverse events occurred. By extrapolating MCS literature, physical therapy interventions improved identified impairments in preparation for and after BiVAD implant to facilitate discharge home. Further research is required to determine optimal exercise prescription parameters and mobility screening guidelines for BiVAD patients in larger studies.
